Every finding on record at Citrus Grove Post Acute

Based on interview, and record review, the facility failed to ensure the resident's medical records were accurate and complete in accordance with the accepted professional standards and practices, for one of three sampled residents (Resident 1), when: The staff did not document according to the physician's order for oxygen use and the oxygen saturation (SpO2 - a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) documentation did not reflect the residents condition for use for the month of July 2026. These failures could negatively impact patient care and prevent staff or representative parties from being aware of the potential deterioration of Resident 1's condition.Findings: On June 16, 2026, at 10:30 a.m., an unannounced visit was conducted to investigate a quality-of-care concern.On July 16, 2026, at 12:50 p.m., Resident 1 was observed to be lying in bed, alert. A nasal cannula (NC - a device applied to the nasal passage that provides a low level of supplemental oxygen, typically at flow rates [FR] of 2 to 4 liters per minute (L/m), allowing patients to breathe comfortably) was observed to be resting on the lower jaw just below the chin away from the nasal passage. Resident 1 denied pain or discomfort. Resident 1's mouth was open with normal breathing. An oxygen concentrator (Battery-powered devices pull in room air, separate and compress oxygen, remove nitrogen, and deliver purified air to breathe) was observed to have the NC attached with a FR of 0.5 L/m with a low volume alarm sounding which could be heard from the hallway outside of Resident 1's room.On July 16, 2026, at 1:32 p.m., an observation of Resident 1's room was conducted. Licensed Vocational Nurse (LVN 1) was observed to be at the bedside and the upper torso including the head of Resident 1 could not be observed. The oxygen concentrator was observed to be active with a setting of 0.5 liters. The machine was heard to be making the low volume alarm beeping sound.On July 16, 2026, at 2:35 p.m. an interview was conducted with Resident 1. Resident 1 was observed to be calm resting in bed. The NC was observed to be resting on the lower jaw just below the chin away from the nasal passage. Resident 1 denied pain or discomfort. Resident 1's mouth was open with normal breathing. An oxygen concentrator was observed to have the NC attached with a FR of 0.5 L/m with a low volume alarm sounding.On July 16, 2026, at 2:47 p.m. the Director of Nursing (DON), LVN 1, and two additional staff members walked past Resident 1's room and did not respond to the beeping of the oxygen concentrator nor were observed to check the application of the nasal cannula. A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, Parkinsons's disease (neurological disorder that affects the central nervous system) and Diabetes Mellitus type two (chronic metabolic condition where the body cannot use insulin properly).The History and Physical dated June 15, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.A review of the physicians orders dated June 14, 2026, indicated, .Oxygen Therapy via nasal cannula 2-5 L/min PRN for SpO2 <90% or respiratory distress. RT/RN to assess and initiate; determine flow within range. LVN to notify RN/RT when indicated. Adjustments per RT/RN only. LVN may place nasal cannula after RN/RT direction. Order date.every shift for SOB.The progress note dated July 14, 2026, at 1:12 p.m. indicated, .zero shortness of breath.O2 (oxygen) saturation.RA (room air).96% .zero distress.The change in condition (COC) dated July 13, 2026, at 6:51 p.m. indicated.oxygen saturation 97% oxygen via nasal cannula.The progress note dated July 7, 2026, indicated, .resident on 2 lpm (liters per minute) via nasal cannula tolerating well, vitals within normal limits saturation 95% .no distress noted.There were no additional notations in the progress notes indicating the use and application of oxygen for the month of July 2026 in accordance with the physicians order.A review of the vital signs (blood pressure, oxygen status, pulse rate, pain level, and respiratory rate) from July 2, 2026, to July 16, 2026, indicated:July 15, 2026, at 4:15 p.m., 97% oxygen via NCJuly 14, 2026, at 6:21 p.m., 96% oxygen via NCJuly 14, 2026, at 1:17 p.m., 98% oxygen via NCJuly 13, 2026, at 11:29 a.m., 97% oxygen via NCJuly 9, 2026, at 11:07 a.m., 98% oxygen via NCJuly 8, 2026, at 11:49 a.m., 98% oxygen via NCJuly 7, 2026, at 10:40 a.m., 95% oxygen via NCJuly 6, 2026, at 10:43 a.m., 98% oxygen via NCJuly 3, 2026, at 10:21 a.m., 98% oxygen via NCJuly 2, 2026, at 1:57 p.m., 98% oxygen via NC(There was no consistent documented evidence that the nursing staff applied oxygen to Resident 1 during the month of July 2026, according to the physicians order.)A review of the electronic medication administration record (eMAR) for July 2026, was conducted. From July 1, 2026, to July 16, 2026, the physicians order for oxygen therapy displayed a check mark which indicated, .administration . There were no additional notations on the administration order which indicated the SpO2 levels or the L/min of oxygen administered.On July 16, 2026, at 3:10 p.m. a concurrent interview and record review was conducted with LVN 1. LVN 1 indicated they initially could not recall if Resident 1 required oxygen therapy but upon record review indicated Resident 1 had an order for PRN (as needed) oxygen at 2-5 L/m for SpO2 <90% or respiratory distress, to be initiated and adjusted by RT (respiratory therapist)/RN (Registered nurse); LVN to notify RN/RT and may apply nasal cannula after direction. LVN 1 observed Resident 1's nasal cannula was improperly positioned and oxygen concentrator settings were incorrect; she was unaware of the meaning of the beeping alarm, turned off the concentrator, and removed the cannula from Resident 1. LVN 1 reported assessing Resident 1 with normal vital signs but did not have SpO2 readings on hand and acknowledged documentation was lacking for oxygen use on July 16, 2026. LVN 1 indicated the last documented SpO2 was 97% on July 15, 2026, with a nasal cannula used for oxygenation had been applied and that the use of oxygen had been sporadic between June and July 2026. LVN 1 stated oxygen should only be applied per physician order with documented baseline SpO2 to justify use and proper application per facility policy.On July 16, 2026, at 4:01 p.m. an interview and record review was conducted with Registered Nurse Supervisor (RNS) inside the room of Resident 1. RNS reported no known behaviors of Resident 1 removing oxygen. Reviewed care plan and physician orders, noting oxygen was PRN with SPO2 to be maintained above 90%. RNS explained certified nursing assistants (CNAs) and LVNs were responsible for reporting oxygen issues and changes in breathing; LVNs should assess residents and record SPO2 levels during shifts. RNS indicated Resident 1 wore the nasal cannula at some point during the shift but was not aware it did not remain applied to the resident; noting no SPO2 vital signs were documented for July 16, 2026. RNS emphasized LVNs should intervene if oxygen was off, perform assessments, and record vital signs as indicated, which was not done. RNS further stated all SPO2 levels must be charted per physician orders to establish baseline for oxygen use.On July 16, 2026, at 5:39 p.m. an interview and record review was conducted with the Director of Nursing (DON). DON stated that when a NC was applied to Resident 1, a baseline oxygen saturation should have been documented to confirm compliance with physician orders. The DON indicated the physician orders specify PRN oxygen use at 2 to 5 liters if SpO2 is below 90%. DON emphasized that baseline SpO2 should verify the need for oxygen, with ongoing monitoring per the order. After a review of the eMAR the DON indicated the check mark would indicate the nurse followed the physician order but that no additional notations were found. The DON indicated incorrect application or FR of the NC had the potential for inadequate oxygen delivery. The DON stated oxygen concentrator should be off and the NC should not remain applied if SpO2 is above 90% and the resident was not in distress and that the oxygen concentrator settings must be in place according to the physician's order. A review of vital signs indicated oxygen use was documented on multiple days in July 2026 with SpO2 above 90%, but it was unclear if oxygen was removed or applied as ordered. The DON further stated documentation was inconsistent with the physician's order and should be corrected.A review of the facility policy and procedure titled, Vital Signs, Weights, Height dated November 2017, indicated, .the residents vital signs shall be recorded as the physician's order indicates, or as frequently as the resident's condition warrants.this shall vary according to various factors.vitals signs.shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician.the physician shall be notified promptly when the vital signs are out of range from the acceptable parameters provided.A review of the facility document titled, Job Description Licensed Practical (Vocational) Nurse (LPN/(LVN), dated May 2022, indicated, .provide nursing services in accordance with facility policies, and professional standards of care.document resident vital signs as needed.maintain documentation of all nursing care and services provided to the residents; use nurse's notes, flow sheets and electronic records according to facility protocols.ensure each resident receives adequate supervison.

Based on interview and record review, the facility failed to notify the resident's representative (RP), when one of three sampled residents (Resident 2) was found to have Interdisciplinary team meetings (IDT) on a quarterly basis and multiple changes in condition (COC) from January to July 2026. This failure resulted in the responsible party being unaware of Resident 2's COC and IDT meetings Findings: On July 16, 2026, at 1:43 p.m. an interview was conducted with Resident 2. Resident 2 was alert and calm. Resident 2 indicated he had been in and out from the hospital over the course of this year 2026 but was doing well. Resident 2 stated he believed he established his sister as a healthcare decision maker and believed that the sister had been made aware of his condition changes and meetings about his healthcare needs. Resident 2 stated he had not heard from his sister in approximately two months and wanted to know if his sister was not aware that she would be made aware of his updated health condition.Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis (Hemiplegia is a severe or complete loss of strength, whereas hemiparesis refers to a mild loss of strength) and Chronic respiratory failure with hypoxia (improper airway gas exchange).A review of the resident profile indicated, .contacts.(name of sister).responsible party (RP - healthcare decision maker).emergency contact number one.next of kin.(contact phone number).The history and physical, dated March 31, 2026, indicated, Resident 2 has the capacity to understand and make medical decisions.A review of Resident 2's COC's from January to June 2026, indicated the following:May 27, 2026.RP notified.self-responsible.April 10, 2026.RP notified.self-responsible.March 25, 2026.RP notified.self-responsible.January 28, 2026.RP notified.self-responsible.There was no documented evidence the facility informed the RP of four changes in Resident 2's condition on four separate occasions.A review of Resident 2's IDT from January to June 2026, indicated the following:April 15, 2026, .name of attendees.(DON, and multiple staff names in attendance).There was no documentation Resident 2's RP was made aware of or in attendance for the IDT meeting on April 15, 2026.A review of the care plan title, Resident is Long Term placement until a safe discharge plan can be established, indicated, .interventions.invite resident/family/support person to care plans meetings as planned/and requested.On July 16, 2026, at 2:08 p.m. a concurrent interview and record review was conducted with the Social Services Assistant (SSA). SSA stated Resident 2 was able to make decisions and that his sister was involved with Resident 2's care. SSA indicated that a resident who designates an RP to be the healthcare decision maker should be made aware of and involved with healthcare changes and decisions such as COC and IDT meetings. SSA indicated nursing should update representative parties regarding healthcare changes and services. SSA further stated RP's should be made aware of and involved with IDT meetings and that the IDT for April 2026 did not appear to include the RP for Resident 2 and it should have.On July 16, 2026, at 5:39 p.m. a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON identified Resident 2's sister as the RP for medical decisions. The DON stated although Resident 2 could make healthcare choices, the RP should have been informed of COCs and IDT meetings. The DON identified from January to July 2026, Resident 2 had four COCs, but the RP was not listed as notified; Resident 2 was. IDT meetings from November 2025 to July 2026 showed no RP attendance in April 2026, and it was unclear if the RP was informed. The DON further stated the RP should have been notified of COCs and IDT meetings to assist with medical decisions.A review of the policy and procedure titled Change in a Resident's Condition or Status, dated February 2021, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status.A significant change of condition is a major decline.that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.impacts more than one area of the resident's health status.a nurse will notify the residents representative when.there is a significant change in the resident's physical, mental, or psychosocial status.the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to report an allegation of injury of unknown origin within 24 hours to California Department of Public Health (CDPH) after the allegation was made, for one of seven residents (Resident 1). This failure had the potential to result in further injury for Resident 1, affecting the resident's physical, emotional, and psychosocial well-being. On June 16, 2026, at 10:30 a.m., an unannounced visit was conducted to investigate a quality-of-care concern.On July 16, 2026, at 2:35 p.m. an interview was conducted with Resident 1. Resident 1 was observed to be calm resting in bed. Resident 1 denied pain or discomfort.A review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included, Parkinsons's disease (neurological disorder that affects the central nervous system) and Diabetes Mellitus type two (chronic metabolic condition where the body cannot use insulin properly).The History and Physical dated June 15, 2026, indicated Resident 1 did not have the capacity to understand and make decisions.A review of the progress note titled SBAR/COC (Situation, Background, Assessment, and Recommendation/Change in Condition) dated, April 2, 2026, at 6:34 a.m., indicated, .Nursing observations, evaluation, and recommendations are: While nursing assistant was performing pericare resident began to scream and cry when nursing assistant went to move her leg to turn her over on her side. nursing assistant notice swelling and notified LVN (licensed vocational nurse). Swelling noted to right knee. no discoloration noted at this time. Recommendations. Dated and time reported to primary physician April 2, 2026, 4/2/2026 at time listed as 0000.awaiting for order family (name of representative party) notified. 0645.A review of the assessment document titled, SBAR/COC dated April 2, 2026, at 9:47 a.m. indicated, .Nursing observations, evaluation, and recommendations are: While nursing assistant was performing pericare resident began to scream and cry when nursing assistant went to move her leg to turn her over on her side. nursing assistant notice swelling and notified LVN. Swelling noted to right knee. no discoloration noted at this time.Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: awaiting for orders.Pain scale: Numerical.0.(0-10 scale).Follow-Up Documentation Type: Other change in condition.Swelling to R (right) knee.Observation, Evaluation, Recommendation: Resident is AOx1 (alert and oriented to self), resident is unable to make needs known. Resident doing routine timely checks and rounds to ensure safety, resident is currently on monitoring and documentation for swelling to R knee. Resident RP (representative party) is aware. Resident is currently spending the day in bed to rest knee. No Signs or symptoms of pain when at rest laying down. Continue with plan of care.(name of daughter) notified at 0645.A review of the nursing note dated April 2, 2026, at 3 p.m., indicated, .Informed at beginning of shift of COC done during previous shift r/t swelling of right knee. Assessed resident during morning rounds and noted swelling to right knee as reported from previous shift. No redness, discoloration, or open skin noted and resident laid in bed comfortably with equal rise and fall of chest. Alerted by LVN towards end of morning shift of noting an increase in swelling to resident's RLE. Entered resident's room to assess. Resident noted laying in bed comfortably with equal rise and fall of chest. Respirations even and unlabored. Assessed resident and noticed increase in swelling to upper RLE. No redness, discoloration, or open skin noted at this time. RLE warm to touch. Attempted to flex resident's knee but resident grimaced and verbalized ow, ow. Immediately stopped knee flexion. Resident again verbalized ow, ow when attempted to abduct RLE and immediately stopped RLE abduction. Resident kept in a comfortable position and no more grimacing noted. Bed in lowest position, call light with in reach. MD notified of findings and ordered xray of RLE. Informed oncoming shift of findings and endorsed xray order. Plan of care ongoing.A review of the progress note dated April 2, 2026, at 5:33 p.m., indicated, .Resident alert non-verbal. Comfortably resting in bed with eyes closed. Reassessed Rt lower extremity, still noted with swelling from above the knee up to thigh area. Skin intact, no bruising. Noted facial grimacing during assessment on the affected area. Writer asked resident's roommate in bed B, denies any incident or fall. Furthermore, roommate stated that resident gets up daily and staff brings her to the dining room and back to bed after lunch except today. Keep comfortable in bed. Call light placed within reach.A review of the radiology results report dated April 2, 2026, at 6:42 p.m. indicated, .report date April 2, 2026 at 8:30 p.m.right femur (leg bone) examination.bones.acute (sharp, severe, or sudden in onset ) impacted and angulated distal femoral fracture (broken bone just above the knee joint) .diffuse osteopenia is seen (bone mineral density is lower than normal).osteoarthritis is identified (degenerative joint disease).no concerning soft tissue. Impressions.acute distal femoral fracture.A review of the interdisciplinary team (IDT) care conference note dated April 2, 2026, at 10 p.m. indicated, .attendees, DON (director of nursing).While nursing assistant was performing peri care resident began to scream and cry when nursing assistant went to move her leg to turn her over on her side, nursing assistant notice swelling and notified LVN. Swelling noted to right knee. no discoloration noted at this time, swelling increased Md notified again ordered for X-ray right leg/knee/hip. Resident unable to verbalize what happened no evidence of abuse, neglect, or environmental hazards identified.Resident transferred out to hospital.Interventions: Resident on bed rest; affected leg immobilized, Right lower extremity elevated, Apply cold compress, Pain medication as ordered, Neurovascular checks initiated to right lower extremity (circulation, sensation, movement, pulses), Reinforce safe transfer, Ensure proper Hoyer-lift use with two staff assist.A review of the progress note dated April 2, 2026, at 10:48 p.m., indicated, .Charge nurse called daughter, RP (name of RP) to inform her of x ray results.A review of the progress note dated April 3, 2026, at 1:12 a.m., indicated, .Resident left with two escorts via gurney to (name of acute hospital). Resident was alert and awake during transfer.A review of the progress note dated April 3, 2026, at 7:12 p.m., indicated, .Return from hospital with diagnosis acute comminuted angulated fracture of the distal femoral.resident remains on monitoring for readmission from hospital with Knee brace to immobilized. will monitor for pain, swelling and bruising. Res with right Leg elevated to reduce swelling. Res (resident) with no s/s (signs and symptoms) of pain, no facial grimacing noted at this time. Res handle with extra care. PO (by mouth) fluids encouraged as tolerated. will continue to monitor. call light within reach.A review of the interdisciplinary team (IDT) care conference note dated April 4, 2026, at 10:06 a.m., indicated, .attendees.DON.IDT review following resident's return from the hospital April 3, 2026 with diagnosis of acute comminuted angulated fracture of the distal femoral (non-surgical management). Resident has significant risk factors including advanced age, dementia, osteopenia, immobility, and inability to report symptoms. Resident is also noted to have uncoordinated movements during care, including flailing of extremities and scooting toward edge of bed, increasing risk for injury.April 6, 2026.met with resident and daughter who is present in the facility.From April 2, 2026, to April 4, 2026 after an injury of unknown origin was identified to the right knee of Resident 1, there was no documented evidence the facility reported an injury of unknown origin according to the facility policy and procedures regarding investigating injuries.On July 16, 2026, at 4:01 p.m. an interview and record review was conducted with the Registered Nurse Supervisor (RNS). RNS remembered the incident which occurred on April 2, 2026, after reviewing the records. RNS stated in the morning, she learned that Resident 1's right knee was swollen, and that the certified nursing assistant (CNA) observed there was swelling to the right knee during routine care but no fall or injury happened and no struggle or combative behaviors from Resident 1. RNS stated the physician was made aware but did not give any orders by 10 a.m. on that same day. RNS indicated between 10 a.m. and 3 p.m., the swelling worsened. At 3 p.m., the RNS called the physician and received an order for an x-ray of the right knee. RNS said she did not know the cause of the swelling and could be related to factors such as, fluid, infection, a broken bone, a fall, or a blood clot. RNS stated she attempted to move the knee gently, but the resident felt pain, so she stopped. She told the next nurse when her shift ended at 3:30 p.m., that an order for the x-ray was placed and left for her shift. A review of the records with the RNS indicated the x-ray was done at 6:42 p.m. and reported at 8:30 p.m. on April 2, 2026, which showed an acute fracture in the right knee. The RNS said she didn't think she needed to check or call the physician again until she heard the knee got worse in the afternoon. She only reported the situation to the next shift's RN supervisor.On July 16, 2026, at 5:39 p.m. an interview and record review was conducted with the Director of Nursing (DON). The DON reviewed the medical record for Resident 1 and could recall the incident reported on April 2, 2026, regarding a fracture to the right knee. DON was asked what the protocols were for reporting injuries. DON indicated if an injury was found and substantiated, they would not report it such as a fall with known injury or resident to resident abuse with known physical altercation. DON stated if they could not substantiate the injury or abuse, they would report it according to their facility policy for injury of unknown origin. DON indicated Resident 1's fracture was identified later in the evening after the x-ray had confirmed the injury and that they were not able to substantiate any cause of the injury until after the result was received. DON indicated the roommate and the staff at the time indicated no fall or observed injuries or behaviors that would have contributed to a knee injury. The DON stated she was unsure if the incident would be considered reportable according to the injuries of unknown origin investigation policy. The DON stated the family was made aware and the physician responded with interventions after the swelling to the knee was noted to get worse. The DON further stated any worsening of an injury would be considered a change in condition and reportable to the physician and responsible party and that they did not report the injury to the state after the IDT meeting was conducted on the evening of April 2, 2026.A review of the policy and procedure titled, Investigating Resident Injuries, dated April 2021, indicated, .If an incident/accident is suspected, a nurse or nurse supervisor completes the facility-approved accident/incident form.if nursing determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines.injury of unknown source is defined as an injury that meets both the following conditions.the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of: the extent of the injury.the location of the injury.A review of the policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .All reports of resident.injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management.reporting.all alleged violations.including injuries of an unknown source will be reported by the facility Administrator, or his/her designee, to the following persons or agencies.the State licensing/certification agency responsible for survey/licensing the facility.An alleged violation including injuries of unknown source will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed, for two of four residents reviewed for foot care (Residents 1 and 2), to ensure:1. For Resident 1, the facility arranged and completed a follow-up consultation with the podiatrist, as the resident was last seen on September 5, 2025; and2. For Resident 2, the facility arranged follow-up with the podiatrist and appropriately addressed the resident's repeated refusals of podiatry care since October 2024. Additionally, the facility did not initiate or develop a care plan to address Resident 1's multiple refusals of podiatry care.These failures resulted in Residents 1 and 2 going on an extended period without having their toenails clipped and/or monitored, resulting in untrimmed toenails and increasing their risk of complications such as injury and infection from inadequate monitoring of foot care and services. Findings:1. On July 8, 2026, at 8:45 a.m., an observation with a concurrent interview was conducted with the Assistant Director of Nursing (ADON) and Resident 1.Resident 1 was observed in bed, alert, with no signs of distress. Resident 1's feet were observed to be uncovered in bed. Resident 1's toenails on bilateral feet appeared thickened and untrimmed with uneven edges, suggesting they had not been cut or trimmed for an extended period.In a concurrent interview, the ADON stated the following:- Resident 1's bilateral feet toenails were long and she did not know when was the last time he was seen by a podiatrist;- The Certified Nursing Assistants (CNAs) should have reported that Resident 1 needed podiatry care since they were not allowed to trim/cut his toenails because he has diabetes (abnormally high blood sugar);- She did not recall receiving a report from the nursing staff that Resident 1 needed a podiatry care consult. The ADON stated Resident 1 needing a podiatry consult should have been reported by the nursing staff.On July 8, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes and contracture (permanent or prolonged shortening of muscles, tendons, ligaments, or skin that causes joints to become stiff or rigid) on left elbow and left knee.The physician's order dated, May 1, 2020, indicated, .CONSULT: May have Podiatry Consult/Care PRN (as needed) for mycotic (fungal infection that causes nails to thicken), Hypertrophic nails (severely thickened, discolored, or claw-like nails) and other conditions that require Podiatry treatment.The care plan dated March 12, 2016, indicated, .Focus.The resident has Diabetes Mellitus (high blood sugar).Goal.The resident will have no complications related to diabetes.Interventions.Refer to podiatrist/foot care nurse to monitor and document foot care needs and to cut long nails.The document titled, (Name of Wound Care Specialist), dated September 5, 2025, indicated, .Chief Complaint.Consult for Podiatry.Dermatologic.Assessment.Onychomycosis (fungal infection).Yellow, Brittle, Crumbly: Right Great Toe; Right 2nd Toe; Right 4th Toe; Right 5th Toe; Left Great Toe; left 2nd toe; Left 4th Toe; Left 5th Toe.Dystrophic nails (abnormally shaped, thickened, or discolored nails): Right Great Toe; Right 2nd Toe; Right 4th Toe; Right 5th Toe; Left Great Toe; left 2nd toe; Left 4th Toe; Left 5th Toe.Paronychia (common bacterial or fungal infection of the skin around fingernails or toenails). Right Great Toe; Right 2nd Toe; Right 4th Toe; Right 5th Toe; Left Great Toe; left 2nd toe; Left 4th Toe; Left 5th Toe.Painful Nail Borders: Right Great Toe; Right 2nd Toe; Right 4th Toe; Right 5th Toe; Left Great Toe; left 2nd toe; Left 4th Toe; Left 5th Toe.Intractable Plantar Keratoma (small, extremely painful deep-seated callus) Callus Formation: right Great Toe.Podiatric Procedure.Debridement of Nails (medical or podiatric procedure in which a professional meticulously thins, trims, and removes diseased, thickened, or fungal nail material) A total of 8 nails were debrided.Paring or cutting of benign hyperkeratotic lesion (podiatrist to carefully shave away the thickened outer layer of dead skin with a sterile scalpel).The Conclusion of the Rendering Provider.The patient's condition has been assessed.will re-evaluate the patient in 60 days on November 4, 2025, to monitor progress and adjust the treatment plan as necessary.There was no documented follow-up communication with the podiatry physician had occurred between September 5, 2025, and July 8, 2026. In addition, there were no records indicating that foot care for Resident 12 was monitored after the podiatrist's assessment and treatment on September 5, 2025.On July 8, 2026, at 11:06 a.m., an interview with a concurrent record review was conducted with the Social Service Director (SSD). The SSD stated the following:- She was the person responsible for coordinating podiatry consults for the residents if needed;- Resident 1 had a current order for podiatry care for consult and as needed;- Resident 1 was last seen by the podiatrist on September 5, 2025, and there had been no follow up with the podiatrist since then. He should have been referred to the podiatrist for a follow up after the September 5, 2025, consult;- There has been a change in the facility's podiatry consulting group and Resident 1's follow-up podiatry appointments during the transition was missed;- Resident 1 was listed for the May 15, 2026, podiatry consultation but was not seen due to insurance issues. The SSD stated there has been no follow up done with the podiatrist or Resident 1's insurance to process the consult;- The nursing staff was responsible for notifying her if a resident required a podiatry consultation, and she has not received any reports indicating that Resident 1 needed such a consult. The nursing staff should have reported Resident 1's need for a podiatry consult; and- Resident 1 has diabetes, and without podiatry care, he could accidentally injure himself, increasing the risk of infection. 2. On July 8, 2026, at 10:58 a.m., an observation was conducted on Resident 2. Resident 2 was lying in bed, alert and declined the interview. Resident 2's bed was located near the bedroom door, and both feet were uncovered and visible from the hallway. Resident 2's toenails on both feet were noted to be uneven and untrimmed, suggesting they had not been cut or trimmed for an extended period.On July 8, 2026, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and mental and behavioral disorder.The physician's order dated November 16, 2021, indicated, May have Podiatry consultation as needed.The podiatry consult notes, dated June 28, 2024, August 30, 2024, and October 30, 2024, indicated Resident 2 refused podiatry care.There was no documentation found indicating that Resident 2 received a podiatry consultation in 2025.The Social Service Director (SSD) progress notes, dated March 18, 2026, indicated Resident 2 refused to see the podiatrist on March 16, 2026. There was no documentation for a follow up consult with the podiatrist after the March 16, 2026, refusal. In addition, there was no care plan initiated or developed to address Resident's multiple podiatry care refusals prior to July 8, 2026.On July 8, 2026, at 11; 06 a.m., an interview with a concurrent record review was conducted with the SSD. The SSD stated the following:- She was the person responsible for coordinating podiatry consults for the residents if needed;- Resident 2 had a behavior of refusal with care including nail cutting or trimming. He refused to see the podiatrist on March 16, 2026, and there has been no follow up after that. - Resident 2 was listed for May 15, 2026, podiatry consultation but was not seen due to insurance issues. The SSD stated there has been no follow up done with the podiatrist or Resident 2's insurance to process the consult.- There has been a change in the facility's podiatry consulting group and Resident 2's follow-up podiatry appointments during the transition were missed. There was no documentation indicating when Resident 2 was last evaluated by a podiatrist in 2025. - The Interdisciplinary Team (IDT) informed Resident 1's responsible party in March 2026 during the IDT meeting of Resident 1's behavior of refusing care, but there was no documentation on how to address the refusal of podiatry care was discussed by the IDT. - Resident 2 refused podiatry care, and there was no care plan created or initiated to address this behavior. The SSD stated it should have been care-planned, however, the care plan was not developed until July 8, 2026.- The nursing staff was responsible for notifying her if a resident required a podiatry consultation, and she has not received any reports indicating that Resident 2 needed such a consult. The nursing staff should have reported Resident 2's need for a podiatry consult.On July 8, 2026, at 11:50 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated:- Included in the nursing staff's responsibilities is to monitor residents' nail and foot care. If a resident required a podiatry consultation for nail care, the nursing staff should inform the licensed nurse, who would then refer the matter to the physician. Afterward, the resident would be observed for any changes in their condition;- The DON stated that she was not informed pr made aware by the nursing staff that Residents 1 and 2 required a podiatry consultation, or referral to the physician. The DON stated the nursing staff should have reported it;- The facility must provide podiatry consultations for residents who need them, even if they lack insurance. All residents should receive podiatrist care regardless of insurance status.The facility's policy and procedure titled, Foot Care, dated October 2022, indicated,.Residents receive appropriate foot care and treatment in order to maintain mobility and foot health.Residents are provided foot care and treatment in accordance with professional standards of practice.Residents are assisted in making appointments and with transportation to and from specialists (Podiatrist.) as needed.Trained staff may provide routine foot care (e.g. toenail clipping) within professional standards of practice for residents without complicating disease process.Residents with foot disorders or medical conditions associated with foot complications are referred to qualified professionals. Foot disorders that require treatment include.nail disorders.The facility's policy and procedure titled, Requesting, Refusing and/or Discontinuing Care or Treatment, dated November 2025, was reviewed. The policy indicated, .If a resident.refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to.Determine why is the resident.refusing.care or treatment.Try to address their concerns and discuss alternative options and discuss the potential outcomes or consequences (positive and negative) of the decision.Detailed information relating to the.refusal, or discontinuation of treatment is documented in the resident's medical record.Documentation pertaining to a resident's request, discontinuation, or refusal of treatment includes at least the following.The date and time the care or treatment was attempted.The type of care or treatment.The resident's response and stated reason(s) for request, discontinuation, or refusal.The name of the person who attempted to Administer care or treatments.That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving medication or treatmentThe date and time the practitioner was notified as well as the practitioner's response.

Based on interview and record review the facility failed for two of two residents reviewed for change in condition (Residents 1 and 2), to consistently monitor and assess residents following a significant change in condition. These failures had the potential for changes in a resident's condition to go unrecognized, which could delay recognition of worsening neurological status, recurrent elopement behaviors, or other complications requiring timely nursing or physician intervention. Findings: 1. A review of Resident 1's record indicated Resident 1 was admitted on [DATE], with diagnoses which included cerebral infarction (brain tissue injury). A review of Resident 1's Change of Condition dated May 25, 2026, indicated, .increased confusion, elopement risk. A review of Resident 1's Progress Notes for 72-hour monitoring was reviewed. The following entries were missing: -May 26, 2026, morning shift -May 27, 2026, night shift -May 28, 2026, morning shift -May 28, 2026, evening shift On June 17, 2026, at 11:20 a.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor 1 (RNS 1). RNS 1 stated licensed nurses were expected to document what was monitored each shift, including the resident's condition and any changes observed. RNS 1 stated the documentation served as evidence that monitoring was performed and allows staff to identify changes in the resident's condition, communicate with the physician when necessary, and ensure appropriate follow-up care. RNS 1 acknowledged there was missing documentation for Resident 1's 72-hour monitoring and stated licensed nurses should have documented the resident's condition and what was monitored each shift. RNS 1 stated the documentation was necessary to determine whether the resident's condition was improving or worsening, communicate changes to the physician or responsible party when needed, and ensure appropriate follow-up care. RNS 1 acknowledged that because documentation was missing, there was no proof the required monitoring had been completed during those shifts. On June 17, 2026, at 11:43 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated 72-hour monitoring should include the resident's behavior, condition, and interventions, and should be documented by the licensed nurse every shift. The ADON stated the documentation was important to identify changes in the resident's condition, determine whether additional interventions were needed, determine how to proceed with the resident's change of condition, evaluate whether monitoring should be extended beyond 72 hours, and determine whether the care plan required re-evaluation based on the effectiveness of the intervention. The ADON acknowledged, Resident 1's 72-hour monitoring had missing entries and without documentation, the facility was unable to determine the resident's condition during the missing shifts or what had been monitored. 2. A review of Resident 2's record indicated Resident 2 was admitted on [DATE], with diagnoses which included metabolic encephalopathy (brain dysfunction causing altered mental status). A review of Resident 2's Change of Condition dated May 31, 2026, indicated, .RESIDENT WAS FOUND IN FRONT PARKING LOT OF FACILITY. A review of Resident 2's Progress Notes for 72-hour monitoring was reviewed. The following entries were missing: -June 1, 2026, morning shift -June 2, 2026, morning shift On June 17, 2026, at 10:10 a.m., a concurrent interview and record review were conducted with the Licensed Vocational Nurse 1 (LVN 1). The LVN 1 stated when a resident experiences a change of condition, the licensed nurse is responsible for assessing the resident, reviewing medications related to the change in condition, notifying the physician and responsible party, updating the care plan, documenting the resident's condition and interventions each shift for 72 hours, and communicating the change of condition to the oncoming nurse. LVN 1 stated the documentation should reflect what was monitored or observed regarding the resident's status, the interventions implemented, and the resident's progress each shift. LVN 1 acknowledged there were missing entries for Resident 2's 72-hour monitoring. LVN 1 stated it was important to document the resident's condition each shift to determine whether the resident was improving, identify any additional issues that needed to be addressed, and evaluate the effectiveness of the interventions implemented. LVN 1 stated the documentation also helped determine whether the resident's needs could continue to be managed by the facility. On June 17, 2026, at 11:43 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated 72-hour monitoring should include the resident's behavior, condition, and interventions, and should be documented by the licensed nurse every shift. The ADON stated the documentation was important to identify changes in the resident's condition, determine whether additional interventions were needed, determine how to proceed with the resident's change of condition, evaluate whether monitoring should be extended beyond 72 hours, and determine whether the care plan required re-evaluation based on the effectiveness of the intervention. The ADON acknowledged, Resident 2's 72-hour monitoring had missing entries and without documentation, the facility was unable to determine the resident's condition during the missing shifts or what had been monitored. A review of the facility form titled, Competency Skills: Change In Condition, undated, indicated, .Complete comprehensive assessment/evaluation and documentation to include responses to nursing care/intervention provided.Resident will be monitored for change of condition with follow up documentation done every shift for 72 hours or as indicated.Best practice: Re-evaluate the resident as a follow-up after initial evaluation/assessment had been done and document in PCC progress notes the outcome of re-evaluation to provide a proof that the resident is followed up and monitored.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement appropriate interventions to prevent the elopement of one of three residents reviewed for accidents (Resident 2) after the resident had been identified as being at risk for leaving the facility without notice. This failure resulted in Resident 2 leaving the facility without staff knowledge on June 20, 2026, and had the potential to place Resident 2 at risk for serious harm.Findings: A review of Resident 2's record indicated Resident 2 was admitted on [DATE], with diagnoses which included metabolic encephalopathy (brain dysfunction causing altered mental status). A review of Resident 2's Minimum Data Set (an assessment tool) dated May 25, 2026, indicated a Brief Interview for Mental Status (a cognitive assessment) score of 10 reflecting moderate cognitive impairment. A review of Resident 2's progress notes dated May 28, 2026, indicated .Informed by staff of noting resident exiting front door of facility. Resident stepped outside of front door and staff immediately intervened and were able to redirect resident safely inside of facility .staff notified and aware of resident at risk for elopement .Face sheet left at front desk receptionist to be aware of resident . A review of Resident 2's Leave of Absence Without Notice (LAWN) Evaluation Form dated May 28, 2026, indicated, .IDT (interdisciplinary Team) CONSIDERATIONS .BIMS score .10 .Has diagnosis/es that may impair cognition .Yes .safety awareness a concern .yes .wanders in and out of the facility .Yes .IDT DETERMINATION .IST has determined that the resident is at risk for Leave of Absence Without Notice based on the above consideration . A review of Resident 2's Care Plan dated May 29, 2026, indicated, .Focus.at risk for exit-seeking behavior.found outside facility.Goal.will remain safe within facility grounds.Interventions.Monitor for signs of exit seeking behavior. A review of Resident 2's Change of Condition indicated the following: -Dated May 31, 2026, .RESIDENT WAS FOUND IN THE PARKING LOT OF FACILITY .RESIDENT ATTEMPTED TO LEAVE THE FACILITY .RESIDENT VERBALIZED 'RESIDENT WANTING TO GO OUTSIDE' . -Dated June 20, 2026, indicated, .elopement.Around 2pm CNA (Certified Nursing Assistant) reported that they were unable to find res (resident).Patient was found and brought back to the facility. Further review of Resident 2's record indicated there was no documented monitoring log of Resident 2's whereabouts despite the resident's identified elopement risk. In addition, following Resident 2's prior exit-seeking incidents, the facility did not revise the care plan or implement additional interventions, such as a WanderGuard, before the June 20, 2026, elopement. On June 17, 2026, at 11:20 a.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor 1 (RNS 1). RNS 1 stated residents identified as being at risk for elopement should have frequent documented monitoring of their whereabouts. RNS 1 stated Resident 2 did not have a monitoring log and stated it should have been implemented to track the resident's location and ensure safety. On June 17, 2026, at 11:43 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated staff were expected to perform and document visual checks every 15 minutes to one hour, depending on the resident's condition. The ADON confirmed Resident 2 should have had a documented monitoring log. On June 25, 2026, at 9:25 a.m., an interview was conducted with Resident 2. Resident 2 stated she walked out the front door to take a walk down the street. Resident 2 stated no one was present and the front door alarm did not activate. On June 25, 2026, at 10:30 a.m., an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated she was assigned to Resident 2 on the day of the incident on June 20, 2026. The CNA stated she knew Resident 2 had a history of attempting to leave the facility and routinely checked on her approximately every 20 minutes to one hour and those were not documented. The CNA stated after assisting other residents, she discovered Resident 2 was missing, notified the licensed nurse, and a Code Pink (the facility's missing resident/elopement response) was initiated. On June 25, 2026, at 10:54 a.m., an interview was conducted with the Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated Resident 2 had a history of exit-seeking behaviors. LVN 2 stated interventions before the elopement consisted of visual checks for wandering behaviors. LVN 2 stated there was no documented monitoring and Resident 2 did not have a WanderGuard in place. LVN 2 stated following the elopement, Resident 2 was placed near the nurse's station, a physician was notified, a WanderGuard was applied, hourly monitoring was initiated, and the care plan was updated. On June 25, 2026, at 11:19 a.m., an interview was conducted with Registered Nurse Supervisor 2 (RNS 2). RNS 2 stated staff performed visual checks, and these were not documented. RNS 2 stated the front entrance alarm did not sound because it was daytime and that the receptionist did not observe Resident 2 leave. RNS 2 stated after the incident, a WanderGuard was implemented. On June 25, 2026, at 12:01 p.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she was informed Resident 2 could not be found and Resident 2 was found down the street sitting on the grass at a church. The DSD stated Resident 2 was alert with confusion. On June 25, 2026, at 3:55 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated residents as being at risk for elopement should have their whereabouts monitored by CNAs and licensed nurses. The DON stated after Resident 2's first exit-seeking incident, interventions included monitoring for exit-seeking behaviors and updating the care plan. The DON stated after the second exit seeking incident on May 31, 2026, no additional interventions were implemented. The DON acknowledged a WanderGuard should have been considered after Resident 2's incidents because it alerts staff when a resident attempts to leave the facility. The DON further stated hourly documented monitoring should have been implemented to verify the resident's whereabouts and demonstrate monitoring was performed. A review of the facility policy and procedures titled, Tab Alarms, Bed Alarms, Wanderguard System, dated December 12, 2024, indicated, .Wanderguard would be used for residents at risk for elopement. A review of the facility policy and procedures titled, Wandering and Elopements, dated March 2019, indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, interview, and record review the facility failed to ensure the front door exit alarm was maintained in proper operating condition. This failure had the potential to delay staff awareness of residents exiting the facility and place residents at risk for elopement. Findings: On June 16, 2026, at 3:05 p.m., a concurrent observation and interview were conducted with the Maintenance Supervisor (MS) at the facility's front entrance located in the lobby. The MS activated the front door alarm. When the front door was opened, the alarm did not produce an audible sound. The MS stated the front door alarm should have sounded loudly when the door was opened to alert staff that someone was exiting the building and to help ensure resident safety. The MS stated he did not know the front door alarm was not functioning. The MS further stated the alarm should have been working and acknowledged it was important because it alerts staff when someone attempts to leave the facility. A review of the facility's maintenance report titled Doors Mag Lock, dated May 28, 2026, indicated all door alarms had passes inspection. However, when the front door alarm was tested on [DATE], it failed to produce an audible alarm when tested. In addition, the facility was unable to provide evidence that the malfunctioning front door alarm had been identified and repaired prior to June 16, 2026. On June 17, 2026, at 11:43 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the alarmed door should be working. The ADON stated it was important for the alarmed doors to be working to ensure resident safety and alert staff if someone is accessing the alarmed door. A review of the facility policy and procedure titled, Exit Door Alarm Testing and Inspection, undated, indicated, .Exit door alarm systems shall be maintained in good working order.to ensure the safety and security of residents, staff, and visitors.

Based on interview and record review, the facility failed to ensure that a significant change in condition, an unwitnessed fall with development of a black eye, was immediately reported to the physician and responsible party for one of four residents reviewed for falls (Resident 1). This failure had the potential to place the resident at risk for delayed medical evaluation and treatment of injuries related to the fall.Findings: On February 10, 2026, at 2:40 p.m., an interview with Resident 1's responsible party (RP) was conducted. The RP stated that a family visited Resident 1 on January 24, 2026, at around 3:00 p.m., and noticed that Resident 1 had a black eye and never received a call from the facility regarding an incident. On February 11, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included muscle weakness and dementia (decline in cognitive function). A review of Resident 1's Progress Notes, indicated, .effective date 1/23/2026.LATE ENTRY.situation: The Change in Condition/s reported on this CIC Evaluation are/were: Other change in condition.found resident sitting up position in bathroom floor with both hands holding on to toilet, no apparent injury noted skin intact did no c/o pain on assessment, vital signs wnl (within normal limit), A/O (alert and oriented) at usual baseline .resident stated she slipped and did not hit her head. Further record review of Resident 1's progress note indicated there was no documented evidence that the responsible party was notified immediately following the incident, and the physician was not notified until January 25, 2026, two days after the fall. On February 11, 2026, at 2:41 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated, he was the assigned nurse for Resident 1 on January 24, 2026, the day the RP called the facility to ask about the black eye and had not been informed. LVN 1 stated, he did not observe a black eye and was not aware of a change in condition from the previous shift. On February 11, 2026, at 4:10 p.m., an interview was conducted with Certified Nursing Assistant (CNA 1). CNA 1 stated, she worked the evening when Resident 1 was found on the bathroom floor. CNA 1 stated she was not aware that the incident needed to be documented under a New Alert so it would be visible to other staff. On February 11, 2026, at 4:26 p.m., an interview was conducted with LVN 2. LVN 2 stated she forgot to report the incident that occurred to Resident 1 on the evening of January 23, 2026, to the Registered Nurse, the physician, the family and did not initiate a Change of Condition (COC). LVN 2 further stated reporting and initiating a COC was the expected practice. On February 11, 2026, at 4:47 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, the fall incident involving Resident 1 was a change in condition, and staff were expected to assess, monitor, initiate a care plan, updated the care plan as needed, and notify the physician and responsible party immediately. The DON further stated a COC should be initiated immediately to ensure timely interventions. A review of the facility policy and procedure, titled, Change in condition: Notification of, dated August 25, 2021, indicated, .a facility must immediately inform the resident, consult with the Resident's physician and/or NP, and notify, consistent with his/her authority, Resident Representative where there is: an accident involving the resident.a significant change in Resident's physical, mental or psychosocial status.a need to alter treatment significantly.

Based on interview and record review, the facility failed to ensure timely and ongoing assessment, monitoring, and care-plan revision following a change in condition (unwitnessed fall) for one of four residents reviewed for falls (Resident1). This failure resulted in delayed recognition of injury (black eye) and had the potential to compromise the resident's physical and psychosocial well-being.Findings: On February 11, 2026, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included muscle weakness and dementia (decline in cognitive function). A review of Resident 1's medical records revealed that on January 23, 2026, on the p.m. shift, Resident 1 experienced an unwitnessed fall. A review of Resident 1's Progress Notes, indicated, .effective date 1/23/2026.LATE ENTRY.situation: The Change in Condition/s reported on this CIC Evaluation are/were: Other change in condition.found resident sitting up position in bathroom floor with both hands holding on to toilet, no apparent injury noted skin intact did no c/o (complaint of) pain on assessment, vital signs wnl (within normal limit), A/O (alert and oriented) at usual baseline responsible verbally resident stated she slipped and did not hit her head. Further review of the progress notes indicated there was no documented evidence or staff awareness that an ongoing assessment for delayed injuries and monitoring were conducted on January 23, 2026, and January 24, 2026, following the unwitnessed fall. In addition, there was no documented evidence that the resident's care plan was reviewed or revised to address the fall and to implement interventions to prevent further incidents. On February 11, 2026, at 2:41 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated that he was the assigned nurse for Resident 1 on January 24, 2026, the day the RP called the facility asking why Resident 1 had a black eye and had not been informed. LVN 1 stated, he did not receive any report that Resident 1 had a change of condition (COC) due to a fall. LVN 1 stated once a resident had a COC, the licensed nurse would assess the resident for the next 72 hours. LVN 1 further stated, the COC was not created until January 26, 2026, two days after the fall and Resident 1 did not have ongoing monitoring and assessment until January 25, 2026. On February 11, 2026, at 5:27 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the incident which occurred with Resident 1 was a COC, and when there is a COC, staff are required to assess, monitor, initiate or revise the care plan. The DON stated, since the COC was not done for Resident 1, there was no ongoing assessment and monitoring and no revision of the care plan. The DON further stated a COC should be initiated immediately to ensure timely interventions.

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge for one of three residents reviewed for discharge (Resident) 1 when the resident's identified care needs and required caregiver support were not coordinated through the Interdisciplinary Team (IDT - consists of Director of Nursing, Social Services, and Rehabilitation) prior to discharge to home.The facility discharged the resident without confirming that necessary caregiver support and services were arranged to meet the resident's care needs. This failure resulted in the resident returning to the facility the day following discharge and had the potential to result in unmet needs and harm. Findings:Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness and unsteadiness on feet. Resident 1 was discharged on January 14, 2026, and returned to the facility on January 15, 2026. A review of Resident 1's Discharge Plan Documentation, dated January 12, 2026, indicated the resident required assistance with household tasks (meal preparation, bill paying, and simple cleaning, transfers from bed to chair, and walking. A review of Resident 1's Nurses Progress Notes, indicated the following: -Dated January 14, 2026, .Resident is to DC (discharge) home today. She was accompanied by 2 person transportation and picked up approx (approximately) 1645 (4:45 p.m.). -Dated January 15, 2026, indicated .Resident was discharged home on 1/14/26 with IHSS services. A wellness call was placed today by SSD (Social Service Director) spoke with resident's daughter (name of daughter), who reported that the IHSS hours approved were less than the family anticipated and are not sufficient to meet the residents care needs. (Name of daughter) also reported that she has recently learned of a personal medical condition, which is limiting her ability to assist with her mom's care. A review of Resident 1's Occupational Therapy OT Discharge Summary, dated January 15, 2026, indicated .Feeding.Minimal help required.Personal Hygiene. Minimal help required.Bathing.Minimal help required.Dressing.Minimal help required.Toilet Use.Minimal help required.Transfers.Moderate help required. A review of Resident 1's Physical Therapy PT Discharge Summary, dated January 15, 2026, indicated .D/C Location.Patient discharged to home w/support (with support)/(A) from others.Assistance/Support to be provided = Community Assistance, AM (morning) assistance/caregiver available, PM (afternoon) assistance/caregiver available. On January 16, 2026, at 2 p.m., an interview with the Social Service Director (SSD) was conducted. The SSD stated Resident 1 reported having In House Separated Services (IHSS) in place prior to discharge and the resident's daughter would assist with care at home. The SSD stated she relied on the resident's statement regarding availability of IHSS services and did not contact the resident's daughter to confirm caregiver availability or ability to provide care. On January 16, 2026, at 3:30 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated discharge planning typically reviewed by the IDT. The DON stated, the resident's daughter identified as the resident's caregiver, was not present during the discharge planning discussion. The DON stated, the resident was discharged on January 14, 2026, and returned to the facility on January 15, 2026, the day following discharge. The DON further stated, if the caregiver hours were insufficient, the resident's care needs would not be met in the home setting. The DON stated, Resident 1 was not capable of caring for herself and required a caregiver. On January 20, 2026, at 10:20 a.m., an interview with the Director of Rehabilitation (DOR) was conducted. The DOR stated Resident 1 required minimal to moderate assistance with activities of daily living and required caregiver support at home. The DOR stated that if a family member were to provide care, training would be required prior to discharge. The DOR stated Resident 1's caregiver was not provided caregiver training. The DOR further stated Resident 1 required caregiver support during daytime and nighttime hours and that she was not asked regarding caregiver hours prior to discharge. On March 3, 2026, at 1:37 p.m., an interview with the SSD was conducted. The SSD stated she discussed the discharge plan with the resident but did not include the daughter. The SSD stated Resident 1 told her she will inform her daughter. The SSD stated there was no discussion with the IDT regarding caregiver hours, caregiver training or the level assistance required at home. On March 3, 2026, at 4:26 p.m., an interview with the DON was conducted. The DON stated nursing and rehabilitation should have coordinated discharge needs with Social Services, including caregiver training and required hours, to ensure services were in place prior to discharge. A review of the facility policy and procedure titled Discharge Summary and Plan, dated December 2016, indicated, .When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan the post discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include .the degree of caregiver/support person availability, capacity and capability to perform required care .how those factors will be addressed .

Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was discharge to a safe and appropriate setting. The facility did not verify that the receiving environment could meet the resident's care needs and discharged the resident to an unlicensed room and board (a living accommodation where individuals are offered a place to stay along with meals).These failures resulted in Resident 1 remaining confined to the kitchen area at the room and board, as the resident could not maneuver stairs or access the restroom on his own. Two days later, Resident 1 was transferred to the General Acute Care Hospital (GACH).Findings:On December 30, 2025, at 10:47 a.m., an unannounced visit to the facility to investigate an unsafe discharge issue. A review of Resident 1's admission Record, indicated resident was admitted on [DATE], and discharged on December 17, 2025, with diagnoses including chronic gout (a complex form of arthritis caused by too much uric acid that crystallizes and is deposited in joints), pneumonia (infection in the lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood).A review of Resident 1's History and Physical, dated November 14, 2025, indicated resident had the capacity to understand and make decisions.On December 30, 2025, at 11:18 a.m., an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated that Resident 1 received physical and occupational therapy for strengthening and required a grab bar to transfer from the bed to a wheelchair. However, the DOR stated Resident 1 could propel himself in a wheelchair without assistance.On December 30, 2025, at 12:56 p.m., a telephone interview was conducted with the Room and Board Manager (RABM). The RABM stated Resident 1 was admitted on [DATE], arriving in a wheelchair and remaining in the kitchen area as he could not go up the steps. The RABM stated Resident 1 could not transfer from the wheelchair to the bed or climb stairs independently. The RABM stated due to car trouble, the RABM could not assess him in person and conducted a phone interview, during which Resident 1 claimed he could care for himself. The RABM contacted Adult Protective Services (APS) for placement assistance, and Resident 1 stayed in the kitchen for two days before being transferred to the hospital.On December 31, 2025, at 11:16 a.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated Resident 1 required one- or two-person assistance for transfers, toileting, and bathing and exhibit verbal threats toward staff. On December 31, 2025, at 11:30 a.m., an interview was conducted with the facility's Case Manager (CM). The CM stated Resident 1 was homeless prior to admission and that they applied for recuperative care and Resident 1 had been denied. The CM stated room and board placement requires independence in most activities of daily living (ADL). The CM stated Resident 1 required assistance with ADLs. On December 31, 2025, at 12:02 p.m., an interview was conducted with the SSD. The SSD stated she was working with a third-party placement coordinator for Resident 1's placement. The SSD stated a third-party placement coordinator came and assessed Resident 1 several times prior to Resident 1's discharge on [DATE]. The SSD denied that she had any communication with the RABM prior to Resident 1's discharge. On December 31, 2025, at 1:27 p.m., a telephone interview was conducted with the third-party Business Development Director (BDD). The BDD stated that he was working with the facility for Resident 1's placement. The BDD stated he provided room and board contact information to Resident 1. The BDD stated he met Resident 1 in person and was unaware of the care needs for Resident 1. On December 31, 2025, at 1:52 p.m., a telephone interview was conducted with the Enhanced Case Manager (ECM) with the [name of foundation]. The ECM stated that the foundation assists unhoused people with housing, healthcare, and personalized support. The ECM stated that he was assisting the facility with a safe discharge for Resident 1. The ECM stated that Resident 1 did not meet the criteria for room and board placement because Resident 1 was unable to perform activities of daily living without assistance. The ECM stated that Resident 1 was discharged from the facility on December 17, 2025.On December 31, 2025, at 2:31 p.m., an interview was conducted with the facility's Director of Nursing, (DON). The DON stated the room and board manager should assess the resident in person prior to discharge and social services should arrange the discharge after acceptance. On January 13, 2026, at 2:01 p.m., an interview was conducted with the Administrator (Adm) and the Interdisciplinary Team (DON, SSD, and Physical Therapist). -The Adm stated a resident could be discharged to a room and board if they were high functioning, meaning the resident could perform most activities independently;-The SSD stated she provided the third-party representative with a packet for Resident 1 which included a face sheet, physician order, and the physician's History and Physical. The SSD further stated Resident 1 is wheelchair bound; and-The Adm stated facility staff did not assess the discharge location for Resident 1.A record of Resident 1's Discharge Plan Documentation dated December 17, 2025, indicated .3. Discharge Location.3a. Other destination Room and Board.BB.1. Transportation for Discharge a. W/C [wheelchair] Van.Durable Medical Equipment.15a. wheelchair.D1. Assistance Level 1. Bed Mobility [a person's ability to move and reposition themselves while in bed, including rolling, scooting, sitting up from lying down, and lying down from sitting] .2. Needs Assistance .1b. Toileting.2. Needs Assistance.2. Household tasks (meal prep, bill paying, simple cleaning) .2. Needs Assistance.3. Transfers from bed/chair.2. Needs Assistance .4. Walking .3. Dependent.A review of Resident 1's Progress Notes dated December 16, 2025, at 2:04 p.m., indicated SSD received a call from [name of BDD] who states he was able to find resident room and board placement and has it all arranged for him to discharge tomorrow morning 12/17/25.A review of Resident 1's Order Summary Report dated December 16, 2025, indicated .Resident may DC on 12/17/2025.A review of the packet sent to the third-party representative for the RABM included Resident 1's face sheet, the physician's H&P, and the physician orders. There was no documentation of Resident 1's functional, or ADL status was included in the packet sent to the third-party representative. On January 14, 2026, at 1:43 p.m., an interview was conducted with the SSD, she stated she did not follow-up with the RABM after becoming aware of Resident 1's placement. A review of the facility's policy and procedure titled Discharge Summary and Plan revised December 2016, indicated .10. Residents transferring to another skilled nursing facility, or who are discharged to a home health agency, long-term care hospital, or inpatient rehabilitation facility will be assisted in selecting a post-acute care provider that is relevant and applicable to the resident's goals of care and treatment preferences.

Based on observation, interview and record review, the facility failed to ensure staff provided timely incontinence care consistent with the resident's care needs for one of two sampled residents (Resident B).This failure resulted in Resident B remaining in a soiled brief for approximately an hour, placing the resident at risk for skin breakdown, infection, discomfort, and compromised dignity.Findings:A review of Resident B's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included hereditary spastic paraplegia (weakness with stiffness of legs).A review of Resident B's Minimum Data Set (MDS - an assessment tool), dated October 31, 2025, indicated:- Brief Interview for Mental Status (a standardized cognitive screening tool) score of 15 (cognitively intact).- Functional Abilities-Self Care-Toileting Hygiene-Substantial /Maximal assist [Helper does more than half the effort Bladder-Urinary Continence- Always incontinent.On November 19, 2025, at 4:12 p.m., during an observation in Resident B's room, a strong urine odor was noted. In a concurrent interview with Resident B, Resident B stated she had been changed at approximately 3 p.m., became wet again about 30 minutes later, and remained wet despite notifying staff. On November 19, 2025, during a concurrent observation and interview with CNA 1, the following was observed:-At 4:15 p.m., CNA 1 stated Resident B was wet. CNA 1 was observed to leave Resident B's room without providing incontinence care or explanation to the resident. -At 4:30 p.m., CNA 1 was observed to return to Resident B's room and stated he would change the resident. CNA 1 was observed placing a clean brief on the bedside table and exiting the room again without providing incontinence care. -At 4:33 p.m., CNA 1 returned to Resident B's room and provided incontinence care, approximately one hour after Resident B reported being wet and notifying staff. On November 19, 2025, at 4:40 p.m., an interview with Licensed Vocational Nurse (LVN) was conducted. LVN stated CNAs were required to provide incontinence care every two hours and as needed, and if delayed, staff were expected to communicate this to the resident. On December 2, 2025, at 1:33 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the CNA to provide incontinence care every two hours and as needed, and not doing so placed residents at risk for skin breakdown and infection. A review of the facility policy and procedure titled Dignity, dated February 2021, indicated .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.promptly responding to a resident request for toileting assistance.

Based on interview and record review, the facility failed to ensure the timely reordering and availability of a prescribed controlled pain medication (oxycodone) for one of three sampled residents (Resident A). This failure resulted in a missed scheduled dose when the medication was not available, placing the resident at risk for unmanaged pain. Findings:On November 17, 2025, at 11 a.m., an unannounced visit to the facility to investigate a quality-of-care issue.A review of Resident A's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included chronic gout (2 or more gout attacks [redness and swelling of affected joint]). A review of Resident A's History and Physical Examination, dated May 31, 2025, indicated Resident A has decision making capacity.A review of Resident A's Physician Order, dated June 24, 2025, indicated .Oxycodone HCl Oral Tablets 5 MG (milligram- unit of measurement) Give 2 tablets by mouth every 4 hours for pain mgmnt (management).On November 17, 2025, at 12:52 p.m., an interview was conducted with Resident A. Resident A stated the scheduled dose of routine Oxycodone (powerful pain killer use for moderate to severe pain) was not administered sometime during the last week of June 2025. A review of Resident A's Medication Administration Record (MAR) from June to July 2025 for oxycodone indicated on June 26, 2025, at 12 p.m., oxycodone was not administered, and a nursing note dated the same day documented that the medication was not given because it was not available. A review of Resident A's Refill Request Form and pharmacy delivery receipt indicated that a refill request for oxycodone 5 mg was submitted on June 19, 2025, and 48 tablets were delivered on June 21, 2025.A review of the physician's order indicated that, based on the prescribed dosing schedule, the 48-tablet supply would have been completed on or about June 25, 2025. Further review of Resident A's record indicated no documentation that the licensed nurse requested a refill for oxycodone on or before June 25, 2025. On November 17, 2025, at 4:10 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the facility practice was to make sure that medications were given as ordered and the licensed nurse were expected to request refill when approximately three doses remain. On November 25, 2025, at 1:21 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she did not administer the oxycodone on June 26, 2025, at noon because the medication was not available. LVN 1 stated when narcotic medication such as oxycodone runs out, she gets it from the emergency kit. LVN 1 further stated there was no oxycodone available in the emergency kit at that time. On November 28, 2025, at 9:22 a.m. a concurrent interview and record review was conducted with LVN 2. LVN 2 stated that 48 tablets of oxycodone 5 mg, delivered on June 21, 2025, would last approximately four days based on the prescribed dose of two tablets every four hours (six doses per day). LVN 2 stated, based on this dosing schedule, the medication supply would have been completed on or about June 25, 2025. LVN 2 stated licensed nurse should request refills when approximately six tablets remain. LVN 2 further stated when refill medications were not available, residents may experience uncontrolled and escalating pain, and that effective pain management was important. On December 2, 2025, at 1:33 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the licensed nurse are expected to request medication refill from the pharmacy when three pills remain in the resident's supply.A review of the facility policy document titled Administering Medications, dated April 2019 indicated, .Medications are administered in accordance with prescriber orders.A review of the facility document titled Refill Request, dated June 19 indicated .Best Practice: Fax refill request 3-5 days prior to supply depletion.

Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to safely and effectively carry out the functions of food and nutrition services when one dietary staff did not perform testing of the sanitizing solution in accordance with the manufacturer instructions.This failure had the potential to result in kitchen equipment used for food preparation and service being maintained outside required chemical parameters, increasing the risk for cross-contamination. Findings:On December 10, 2025, at 8:09 a.m., a concurrent observation and interview were conducted with the Dietary Aide (DA). The DA was asked to demonstrate the sanitation testing process using the Quaternary (sanitation solution) test paper. The DA obtained a test strip from the test paper distribution container, dipped the strip into the sanitizing solution, and counted aloud to 15 seconds, stating we need to count for a total of 15 seconds according to our process. After counting to 15, the DA removed the test strip and compared it to the color chart located on the front of the container. The DA stated the acceptable range should be between 200 and 400 ppm (parts per million - a unit of measure) to ensure effectiveness. A review of the sanitation strip container labeled [brand name] Quat test paper indicated the test strip should be immersed in the sanitizing solution for 10 seconds and immediately compared to the color chart. On December 11, 2025, at 2:45 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the quaternary test paper was used to test the concentration of the quaternary sanitizing solution for dishwashing. The RD stated the test strips should be immersed in the solution for 10 seconds in accordance with manufacturer instructions. The RD stated, they should be following the manufacturers guidelines. A review of the [Brand Name] (QT-40) Quat Test Paper instructions, indicated, .Dip the strip into the sanitizing solution for 10 seconds, then instantly compare the resulting color with the enclosed color chart which matches concentrations of 0-500 ppm (parts per million). A review of the Food Code 2022: section 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness indicated, .with respect to chemical sanitization, section 4-501.114 addresses the proper use conditions for the sanitizing solution.quaternary ammonium compounds.if these parameters are not as specified in the Code or on the EPA registered label, then the provision is violated.in accordance with the EPA-registered label use instructions for food contact surface sanitizers.A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), P.(2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, P and.(3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect for three of three residents reviewed for dignity (Residents 6, 123, and 124) when:1. Resident 123 did not receive her meal at the same time as her roommate. 2. Resident 6's Foley catheter drainage bag was left uncovered and exposed; and3. A staff entered Resident 124's room without knocking. These failures had the potential to negatively affect the resident's dignity, comfort, and psychosocial well-being.Findings: 1. On December 8, 2025, at 12:55 p.m., Resident 123 was observed exiting her room and asking when her lunch would be arriving. Resident 123 stated that her roommate was already eating her lunch and that she was hungry. During a concurrent observation, Resident 123's roommate was observed with her meal tray approximately halfway consumed. On December 8, 2025, at 1:12 p.m., an interview was conducted with Certified Nursing Assistant 2 (CNA 2). CNA 2 stated she had just served Resident 123's meal tray. She further stated Resident 123 should have received the meal at the same time as her roommate. CNA 2 stated it was not right Resident 123 was waiting for her food. On December 8, 2025, at 1:18 p.m., an interview was conducted with the Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated the expectation is to make sure residents in the same room receive and eat their meals at the same time in order to respect resident dignity. On December 11, 2025, at 2:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, the staff are expected to verify meal trays and served them in order so that residents in the same room are served and eating at the same time. The DON stated, it should not occur that one resident is eating while the other resident has not yet received a meal. A review of the facility's policy and procedure titled, Assisting the Resident with In-Room Meals no date, indicated, .the purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms.be sure that everyone is served. 2. On December 9, 2025, at 11:07 a.m., an observation was conducted in Resident 6's room. Resident 6 had a FC bag hanging below the bed, uncovered and exposed to other residents and visitors. On December 9, 2025, at 11:18 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA1). CNA 1 confirmed Resident 6's FC bag was not covered with a dignity bag. She stated the FC bag should be covered for privacy and dignity. On December 11, 2025, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated all FC bags should be covered for dignity with a dignity bag (a cover used to conceal a urinary catheter drainage (Foley) bag from public view). A review of the facility's policy and procedure titled, Quality of Life- Dignity no date, indicated, .each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.residents are treated with dignity and respect at all times.staff are expected to promote dignity and assist residents, for example: .helping the resident to keep urinary catheter bags covered. 3. A review of Resident 124's admission record indicated Resident 124 was admitted to the facility on [DATE], with diagnoses which included altered mental status (confusion). On December 9, 2025, at 8:36 a.m., LVN 1 was observed entering Resident 124's room without knocking prior to entry. During a concurrent interview with LVN 1, LVN 1 stated he did not knock before entering the resident's room. LVN 1 stated he should have knocked prior to entry. LVN 1 further stated that knocking is a courtesy used to announce entry and to respect resident's privacy and dignity. On December 11, 2025, at 9:49 a.m., the DON was interviewed. The DON stated the staff should knock before entering the resident's room to respect their privacy and dignity. A review of facility policy and procedure titled Quality of Life- Dignity, undated, indicated .Residents are treated with dignity and respect at all times. Residents Private spaces and property are respected at all times. Staff are expected to knock and request permission before entering residents' room.

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) to the resident or resident representative (RP) at the time of transfer to an acute care hospital for one of three residents reviewed for closed records (Resident 3). This failure had the potential for residents and/or their RPs not being fully informed of bed-hold rights or the right to return to the facility following hospitalization which could lead to an inappropriate discharge. Findings:A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility July 7, 2022, with diagnoses which included depression (mood disorder).A review of the Nurse Progress Note dated December 6, 2025, at 8:44a.m., indicated, .Resident departed facility at approx (approximately) 0840 (8:40 a.m.) .Resident was sent to (name of hospital) for further evaluation .Resident alert and verbally responsive at time of departure . A review of the facility document titled Bed Hold -Informed Consent-Confirmation of Transfer and Bed hold Provision- Transferred to (blank) Name of Person Notified (blank) .24 Hour Notification (blank). There was no documented evidence the facility provided written notification of bed hold to Resident 3 at the time of transfer on December 6, 2025. On December 10, 2025, at 1:06 p.m., a concurrent interview and record review were conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated she did not notify the resident about the bed-hold policy at the time of transfer. LVN 4 stated she should have completed the bed-hold notification form and should not have been left blank.On December 11, 2025, at 9: 49 a.m., a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated, the licensed nurses are expected to complete the bed-hold notification form at admission and again at the time of transfer to ensure residents bed hold rights are honored and to prevent inappropriate discharge. A review of facility policy and procedure titled Bed-Holds and Returns, undated indicated .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) Residents regardless of payer source, are provided notice about these policies at least twice.1. well in advance of any transfer (admission); and 2. at the time of transfer.

Based on interview and record review, the facility failed to follow facility's policy and procedures for two of five residents reviewed (Residents 1 and 51) when:1. Staff did not properly identify a resident (Resident 51) and ensure the correct breakfast was served.This failure had the potential to result in adverse reactions due to receiving an incorrect diet and to cause emotional distress. 2. Staff did not change the resident's nasal cannula (a medical device used to deliver supplemental oxygen) on a weekly basis.This failure had the potential to result in cross-contamination and increased risk of infection. 1. On December 10, 2025, at 8:05 a.m. an interview was conducted with Resident 51. Resident 51 stated the breakfast tray that was initially served had another resident's name on the meal ticket and was not intended for him. Resident 51 stated, They didn't even know it was for someone else!A review of Resident 51's admission Record dated December 10, 2025, indicated an admission date of June 11, 2025, with diagnoses including dementia (forgetfulness).A review of Resident 51's History and Physical dated June 12, 2025, indicated resident had the capacity to make decisions.A review of Resident 51's Physician Orders dated July 2, 2025, indicated, .Regular diet Regular texture, Thin consistency.A review of Resident 91's Physician Orders dated October 17, 2025, indicated, .Regular, No Added Salt diet minced & moist texture, Thin consistency, with 1200ml (milliliter - a unit of measure) fluid restriction.On December 10, 2025, at 8:06 a.m., an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated she was a bit distracted and did not correctly identify Resident 51's full name using the meal ticket when serving the breakfast tray. CNA 3 stated she should have identified Resident 51 using his full name, rather than only the first two letters of his first name, to ensure the correct tray was served to the correct resident. CNA 3 stated, proper identification was important to prevent emotional distress, such as refusal of a meal and adverse reactions such as choking. CNA 3 stated the breakfast tray served to Resident 51 was intended for Resident 91, who had a different diet order. On December 10, 2025, at 4:18 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the CNA should have verified the resident's full name against the meal ticket prior to serving the breakfast tray to ensure the correct diet was provided. The ADON stated this was important to prevent adverse effects, such as aspiration related to incorrect food texture or hyperglycemia (high blood sugar) in diabetic residents.On December 11, 2025, at 8:36 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the CNA should have identified the resident using the full name prior to serving the breakfast tray to ensure the correct diet was served to the correct resident. The DSD further stated this was important to prevent any adverse reactions including choking due to incorrect food texture, affecting disease course, and allergic reactions.A review of the facility's policy and procedure titled, Tray Identification, undated, indicated, .before serving the residents .Nursing staff will verify the name of the resident using resident identifier such as door name, wrist band, and or PCC photo .2. On December 9, 2025, at 9:34 a.m., an observation was conducted in Resident 1's room. Resident 1 was observed receiving oxygen via nasal cannula at 2 liters per minute (L/min). The nasal cannula was not labeled with a date, indicating when it was last changed. In a concurrent interview with Resident 1, she stated she uses oxygen continuously. A review of Resident 1's admission Record dated December 10, 2025, indicated the resident was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (lung disease which causes breathing difficulties).A review of Resident 1's Physician Orders dated November 11, 2025, indicated an order for oxygen at 2 L/min continuously via nasal cannula. On December 10, 2025, at 11:25 a.m., a concurrent observation and interview were conducted with LVN 2 in Resident 1's room. LVN 2 stated the nasal cannula tubing was observed with the number 11 written in black permanent marker at the concentrator point. LVN 2 stated the nasal cannula was dated for November and had not been changed weekly in accordance with facility standards of practice. LVN 2 stated oxygen tubing should be changed every seven days and labeled with the date it was changed. LVN 2 further stated not changing the nasal cannula weekly could place the resident at risk for cross-contamination. On December 10, 2025, at 4:08 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated oxygen tubing should be changed weekly on Wednesdays and as needed. The ADON stated the licensed nurse should have changed Resident 1's nasal cannula in accordance with facility practice. The ADON further stated failure to change the nasal cannula weekly could place the resident at risk for cross-contamination. A review of the facility's document titled, Competency Skills Oxygen Administration undated, indicated, .Label Oxygen tubing with date and to be changed every 7 days/PRN (as necessary).

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain cleanliness and proper hygiene when staff failed to clean and trim the resident's fingernails, leaving them long and discolored for one of three residents reviewed (Resident 6).This failure had the potential for Resident 6 at risk for infection and injury due to the unhygienic condition of the resident's fingernails.Findings:A review of Resident 6's medical records indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (decline in mental ability) and diabetes (high blood sugar).On December 9, 2025, at 11:08 a.m., an observation was conducted of Resident 6. Resident 6 was observed sitting on his bed, awake, with fingernails that were long and yellowish in color.On December 9, 2025, at 11:18 a.m., a concurrent observation and interview were conducted with Certified Nursing Assistant (CNA 1) regarding Resident 6's fingernails. CNA 1 stated Resident 6's fingernails were long and yellow and stated the fingernails should have been cleaned and trimmed to prevent the risk for infection. On December 10, 2025, at 3:07 p.m., an interview was conducted with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated that it was the responsibility of the LVN and CNAs to check residents' fingernails and further stated that trimming fingernails was important to prevent residents from scratching themselves, which could result in infection. On December 11, 2025, at 10:07 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated CNAs were expected to check residents' fingernails daily and ensure they were not long or dirty. The DSD stated CNA's or the LVN's should have maintained Resident 6's fingernails by offering to clean or file them to prevent the resident from scratching himself, which could result in injury or infection. The DSD further stated there was no documentation explaining why Resident 6's fingernails were kept long. On December 11, 2025, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated CNAs were responsible for providing daily hygiene care to residents including cleaning fingernails. The DON stated Resident 6 should have been offered nail care daily to prevent scratching, which could result in infection. A review of Resident 6's document titled, Section GG- Functional Activities, dated, November 28, 2025, indicated, .Personal hygiene: The ability to maintain personal hygiene, including comping hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) .score: 01 (Dependent- helper does all the effort. Resident does none of the effort to complete the activity .A review of Resident 6's document titled, Care plan report, dated November 10, 2025, indicated .The resident has an ADL Self Care Performance Deficit r/t Dementia, Limited Mobility, Limited ROM, Musculoskeletal impairment .Interventions .Personal Hygiene/ Oral care: The resident requires (1) staff participation with personal hygiene and oral care.A review of the policy and procedure titled, Fingernails/Toenails, Care of undated, indicated, .the purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections.nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 49) when one medication was documented as administered on December 7, 2025, could not be accounted for as being available for administration as the medication was not received by the facility until December 9, 2025.This deficient practice had the potential for Resident 49's health and well-being to be negatively impacted due to unintended consequences, including decreased medication effectiveness and the potential for adverse reactions (an unwanted effect caused by the administration of a drug). Findings: On December 8, 2025, at 3:38 p.m., Resident 49 stated he had not received his medication Nuedexta (a prescription medication used to to treat pseudobulbar affect [PBA - a condition that causes a person to have sudden, uncontrollable episodes of laughing or crying that do not match how they actually feel]) to help control his cognitive abilities in which he stated they stopped it because they said the insurance didn't cover it and I need it. I don't know if that is true, I have not had it for over one week. I ordered it but they still haven't given it to me and I need it. On December 9, 2025, a review of Resident 49's admission record indicated, the resident was admitted on [DATE], with diagnosis which included, anxiety disorder (persistent excessive worry which is out of proportion to the situation). The Minimum Data Set (MDS - an assessment tool), dated October 1, 2025, indicated a Brief Interview of Mental Status (a screening tool for cognition) score of 13 (cognitively intact). A review of the Order Summary Report, dated December 1, 2025, indicated Resident 49 had a physician's order for Nuedexta Oral Capsule 20-10 mg, to give 1 capsule by mouth two times a day for PBA (pseudobulbar affect - a condition that causes a person to have sudden, uncontrollable episodes of laughing or crying that do not match how they actually feel) emotional outbursts. A review of the Medication Administration Records (MAR) for November and December 2025, indicated Resident 49 did not receive Nuedexta as ordered on: December 4, 5, 6, and 7 (9 a.m. dose)December 8 and 9 (9 a.m. dose). Further review of the MAR for November and December 2025, indicated Neudexta was documented as administered on: December 2 and 3December 7 (9 p.m. dose)December 9 (9 p.m. dose); and December 10 and 11. A review of the Nurse's Progress Notes, dated December 4, 2025, at 9:13 a.m., indicated, .Nuedexta oral tablet.has not arrived from pharmacy. A review of the The Change in Condition dated December 4, 2025, at 9:33 a.m., indicated, .resident missed a scheduled dose of nudexta from the morning medication pass due to it not being delivered from pharmacy. Resident was assessed following the missed dose. No acute distress noted. Vital signs within baseline. Physician has been notified as per facility protocol. A review of Resident 49's Nurse's Progress Notes, indicated: -Dated December 4, 2025, at 8:30 p.m., .Nuedexta Oral Capsule.will give med when available, f/u (follow up) with pharmacist still pending authorization. -Dated December 5, 2025, at 11:05 a.m., .missed dose Nuedexta. Per resident verbatim the other medication won't work if there is no Nuedexta. Nuedexta is pending due to insurance non-coverage-requiring authorization. -Dated December 5, 2025, at 3:21 p.m. indicated, .spoke with (name of pharmacy representative) .Nuedexta order will be processed and sent to facility arriving by December 8, 2025. -Dated December 5, 2025, at 8:49 p.m. indicated, .Nuedexta Oral Capsule.will give med when available. -Dated December 6, 2025, at 8:41 a.m., indicated, .Nuedexta Oral Capsule.awaiting delivery. -Dated December 6, 2025, at 10:13 p.m. indicated, .missed dose of medication Nudexta.continue to monitor needs and safety. -Dated December 7, 2025, at 8:22 a.m. indicated, .Nuedexta Oral Capsule.awaiting delivery from resident pharmacy via mail. -Dated December 8, 2025 at 9:10 a.m., indicated, .Nuedexta Oral Capsule.awaiting delivery. -Dated December 8, 2025, at 8:29 p.m., indicated, .Nuedexta Oral Capsule.medication not available. Resident made aware and verbalized understanding. -Dated December 9, 2025, at 8:56 a.m., indicated, .Nuedexta Oral Capsule.pending pharmacy delivery. Further review of Resident 49's progress notes indicated there was no documentation that the medication was available prior to December 9, 2025. A review of the care plan, Missed dose of medication of Nuedexta, indicated, .interventions.monitor resident for any changes in condition or potential adverse effects.reinforce medication schedule with staff and ensure next scheduled dose is administered as ordered. On December 11, 2025, at 1:42 p.m. a concurrent interview and MAR review was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 stated, the medication was not available from December 5 to 8, 2025. LVN 6 stated if there is a check mark during that time that means it was marked as given. LVN 6 stated she could not locate the medication as being available on the morning of December 8, 2025, and that she did not receive a report from the nurse who had given the medication that it was available. On December 11, 2025, at 1:52 p.m., a concurrent observation, interview, and record review were conducted with LVN 6 and the DON. LVN 6 stated she was able to obtain the tracking verification regarding the delivery of the medication that was received on December 9, 2025, at 1:15 p.m. The DON stated that the process for receiving medications by mail was that the nurse should note the time of delivery, mark the bottle of the medication with the open date and administer the medication on the next scheduled time. The DON stated a dose of Nuedexta was held for the 9 a.m. administration time on December 7, 2025, and that it was given at 9 p.m. by the evening nurse. The DON stated, the medication was held again on December 8, 2025, for the 9 a.m. and 9 p.m. doses. The DON stated it appeared that the medication was given. The DON observed a bottle of Nuedexta with an open date of December 9, 2025. The DON stated the orders from the pharmacy via mail would be processed by the receiving nurse and that a confirmation of the receipt of the medication should be verified. The DON stated the open date should reflect when the medication was first administered. The DON stated the medication appeared to be administered on the evening of December 7, 2025, and was noted to not be available until the afternoon of December 9, 2025. The DON stated they could not identify a bottle or bubble pack with the medication prior to receiving it on December 9, 2025. A review of the facility policy and procedure titled Administering Medications undated, indicated, .Medications are administered in accordance with prescriber orders, including any required time frame.the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations during the monthly Medication Regimen Review (MRR), for one of five residents reviewed for unnecessary medications (Resident 13) when Resident 13's recommended gradual dose reduction of buspirone (antianxiety medication) was not addressed by the physician.This failure had the potential to result in continued unnecessary psychotropic medication use. Findings:A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (forgetfulness) and bipolar disorder (mental illness).A review of Resident 13's History and Physical Examination dated July 31, 2025, indicated the resident had fluctuating decision making capacity.A review of Resident 13's CP recommendation to the attending Physician dated October 2025, indicated Resident 13 was receiving buspirone (anti- anxiety) 20 mg three times daily and included a recommendation to consider, if clinically appropriate, initiating a gradual dose reduction (GDR) with the eventual goal of discontinuation. Further review of Resident 13's record indicated no documentation that the physician reviewed, accepted, or rejected the CP recommendation. On December 11, 2025, at 1:40 p.m., a concurrent interview and record review were conducted with the Director of Nursing (DON) and ADON. The ADON stated the CP recommendation was received via email on November 10, 2025, The DON stated there was no documented evidence the recommendation was communicated to the physician upon receipt. A review of the facility policy and procedure titled Medication Regimen Reviews, undated indicated, .Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated .the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication .the MRR involves a thorough review of the resident's medical record .The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record .

Based on observation, interview, and record review the facility failed to follow their policy for smoking for 13 of 14 residents who smoke. This failure resulted in Residents 1 & 2 receiving cigarette burns resulting in treatment and had the potential to jeopardize the health and safety of the facility's 14 vulnerable smokers resulting in an immediate jeopardy situation. On December 19, 2022, at 6:20 p.m., an Immediate Jeopardy (IJ-a crisis in which the health and safety of individuals are at risk) was identified and called in the presence of the Administrator (ADM) due to lack of supervision and safety measures per the facility's policy to ensure the safety of the facility's smokers. On December 20, 2022, 8:09 a.m., the facility submitted an acceptable removal plan which indicated: The facility failed to provide an environment free from accident hazards F689 Accidents The following plan of action outlines immediate interventions employed by the facility to abate any further concerns surrounding the above issue: 1. Resident #1 and #2 have been reassessed for smoking safety and adaptive smoking equipment. The care plans for each resident have been reviewed, revised, and updated to reflect their level of supervision and assistive equipment. 2. The facility has identified residents that currently smoke. Each resident is currently being reassessed to ensure that a current smoking assessment and care plan reflects their current status, level of supervision, and need for adaptive equipment i.e. cigarette extenders assist with lighting/holding cigarettes safely) 3. The facility has initiated staff education for all departments. The education includes the facility's policy related to smoking, smoking times, designated smoking areas, smoking assessments, care planning, smoking safety, supervision, designated smoking areas, smoking assistive equipment, and the reporting of adverse smoking events. Staff education/in-servicing began during the evening shift of 12/19/2022. Inservice education for all departments continues today, 12/20/2022, to include all scheduled staff as well as conducting phone calls to those staff not scheduled. Phone calls with be made to those staff members to ensure they receive the updated education on 12/20/2022. (Any staff member out on vacation, out ill, or out on extended leave will receive the in-service education upon returning to the active schedule). 4. The facility will conduct a smoking meeting on 12/20/2022 with residents who currently smoke to ensure that the smoking policy and expectations are communicated and clarified to ensure resident safety and supervision accordingly. 5. The activities department will bear primary responsibility for the smoking program. Additional departments may participate in the smoking program as required. Please accept this letter as our credible allegation of compliance for the Notice of Determination of Immediate Jeopardy verbally issued on December 19, 2022. Observation, interviews, and record reviews were conducted to ensure the removal plan was implemented. On December 20, 2022, at 3:45 p.m., the immediate jeopardy was removed in the presence of the Director of Operations (DoO), Director of Nursing (DON), and the ADM. Findings: A review of the facility's list of residents who smoke indicated the facility had 17 residents (3 discharged ) who smoke. 1. On December 16, 2022, at 2:15 p.m., during a concurrent observation and interview with Resident 1, Resident 1 was observed smoking on the facility's patio in her wheelchair. No facility staff member was noted to be providing supervision on the patio. Resident 1 stated she smokes when she wants and not according to a schedule. No smoking apron noted on the resident. She further stated smoking is not supervised. No smoking aprons, fire extinguisher, nor smoking blankets were noted on the patio. On December 19, 2022, at 2:46 p.m., during an interview with Resident 1, she stated she burned herself while smoking alone at the facility. She further stated it required treatment from the facility's staff. A review of Resident 1's records indicated the resident was admitted to the facility on [DATE], with diagnoses which included neuropathy (damage to nerves outside of brain & spinal cord), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and absence of legs (bilateral) above the knee. A review of Resident 1's Brief Interview for Mental Status (BIMS), dated November 28, 2022, indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1's Change in Condition Evaluation (CoC), dated May 25, 2022, indicated, Resident requested treatment nurse for skin assessment to left upper extremity .(resident) stated her cigarette .fell on her arm and caused a small burn to her arm .Treatment orders received and carried out. The CoC further indicated the resident sustained a burn on her right lateral elbow under the section titled Skin Status Evaluation . A review of Resident 1's care plan titled Resident is identified as a SMOKER, dated May 26, 2022, (after Resident 1's burn) indicated interventions including provide constant and/or frequent supervision when resident is smoking. A review of Resident 1's May 2022 physician orders indicated an order for Burn: right elbow: cleanse with NS (normal saline), pat dry, cover with DD (dry dressing) x 14 days . every day shift dated May 26, 2022. A review of Resident 1's care plan entry titled The resident has .impairment to skin integrity at right elbow r/t (related to) burn ,dated May 26, 2022, including interventions which included follow facility protocols for treatment of injury . A review of Resident 1's Treatment Administration Record (TAR) for May 2022 indicated the resident received wound treatment for Burn; right elbow . from May 26, 2022 to May 31, 2022. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only .Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 2. On December 19, 2022, at 1:40 p.m., during a concurrent observation and interview with Resident 2, the resident was noted to be sitting up in bed. The resident appeared alert and oriented. The resident stated she does smoke. She stated she smokes whenever she wants to smoke. She stated she calls staff for assistance to smoke. She stated she is supervised when she smokes. The resident stated she has burned herself smoking while in the facility. A review of Resident 2's records indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypertension (high blood pressure) and kidney failure. A review of Resident 2's Brief Interview for Mental Brief Status (BIMS), dated December 5, 2022, indicated the resident had a score of 3 (severe cognitive impairment). A review of Resident 2's Functional Status Assessment, dated December 5, 2022, indicated the resident had bilateral impairment to both upper extremities (arms). A review of Resident 2's care plan entry titled The resident is a smoker , revised September 17, 2019, indicated interventions including, staff will provide smoke breaks, smoking apron .instruct resident about the facility's policy on smoking: locations, times .the resident requires supervision while smoking A review of Resident 2's Change of Condition (CoC), dated October 19, 2022, indicated the resident sustained a burn to her right index finger while smoking. The CoC further indicated, Another resident gave her a cigarette and the resident burned herself. The resident is a supervised smoker and should not be smoking alone. Explained to other resident to not give resident anything to smoke if nobody is out there to watch her. A review of Resident 2's smoking assessment, dated April 22, 2022, indicated the resident is a supervised smoker who needs assistance while smoking to assure safe smoking. A review of Resident 2's November 2022 Treatment Administration Record (TAR) indicated the resident began to receive treatment .to R (right) 2nd digit topically every day shift for burn . beginning November 30, 2022. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. The ADM stated he was aware of Resident 2's burn from smoking. He stated Resident 2 should have been supervised while smoking. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only .Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 3. On December 19, 2022, at 1:30 p.m., during a concurrent observation and interview with Resident 3, the resident was observed smoking on the facility patio unsupervised. He stated he smokes whenever he wants to smoke. He stated he has not been assessed to determine if it is safe for him to smoke independently. A review of Resident 3's records indicated the resident was admitted to the facility on [DATE], with diagnoses which included asthma, dementia (impaired ability to remember, think, or make decisions), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). A review of Resident 3's Brief Interview for Mental Status (BIMS), dated September 11, 2022, indicated the resident had a score of 6 (moderate cognitive impairment). A review of Resident 3's smoking assessment, dated October 21, 2022, indicated, .Resident needs assist while smoking to ensure safety smoking policies. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 4. On December 16, 2022, at 2:15 p.m., during a concurrent observation and interview with Resident 4, Resident 4 was observed smoking on the facility's patio. No facility staff member was noted on the patio. Resident 4 stated he smokes when he wants and not according to a schedule. He stated smoking is not supervised. A review of Resident 4's records indicated the resident was admitted to the facility May 22, 2019 and readmitted on [DATE] with diagnoses which included congestive heart disease (a weakness of the heart that leads to a buildup of fluid) and diabetes mellitus (body's inability to regulate blood sugar). A review of Resident 4's Brief Interview for Mental Status (BIMS), dated October 19, 2022, indicated the resident had a score of 12 (mild cognitive impairment). On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 5. On December 27, 2022, at 1:35 p.m., during an interview with Resident 5, he stated he did smoke whenever he wanted to smoke. He stated he is an independent smoker. He stated he is supervised now. He stated he did not require supervision. A review of Resident 5's records indicated the resident was admitted to the facility on [DATE] with diagnoses which included right sided hemiplegia (weakness) and heart failure. A review of Resident 5's Brief Interview for Mental Status (BIMS), dated October 26, 2022, indicated the resident scored 15 (no cognitive impairment). A review of Resident 5's smoking assessment, dated October 21, 2022, indicated, .Resident is able to smoke independently. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 6. A review of Resident 6's record indicated the resident was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (a condition marked by impaired muscle coordination) and leukemia (cancer that starts in blood-forming tissue). A review of Resident 6's Brief Interview for Mental Status (BIMS), dated November 16, 2022 ,indicated the resident scored 9 (moderate cognitive impairment). A review of Resident 6's smoking assessment, dated October 21, 2022, indicated, .Resident is able to smoke by self . On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 7. On December 27, 2022, at 3:00 p.m., during an interview with Resident 7, she stated she smokes whenever she wants. She stated she is an independent smoker, has smoked for years, and does not need supervision. She stated she smokes alone. She further stated she likes to smoke at night because she worked nightshift for years. She will read a book and smoke outside. A review of Resident 7's record indicated the resident was admitted to the facility on [DATE] with diagnoses which included heart failure and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 7's Brief Interview for Mental Status (BIMS), dated November 19, 2022, indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 7's smoking assessment, dated October 21, 2022, indicated, .Resident is safe to smoke independently . On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 8. On December 27, 2022, at 2:35 p.m., during an interview with Resident 8, the resident stated he smokes. The resident then did not or could not answer any further questions. A review of Resident 8's record indicated the resident was admitted to the facility on [DATE] with diagnoses which included malnutrition (lack of proper nutrition) and kidney failure. A review of Resident 8's Brief Interview for Mental Status (BIMS), dated November 2, 2022, indicated the resident had a score of 7 (moderate cognitive impairment). A review of Resident 8's smoking assessment, dated October 21, 2022, indicated, .resident can light cigarette by self, but may need help at time example, like if he just got out of dialysis. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could supervise the residents. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN1), he stated during his new employee orientation he was instructed that staff are to supervise smokers. On December 19, 2022, at 4:00 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she is unaware of the facility's smoking practice. She further stated smoking residents should be supervised by staff. She stated if she observes a resident going to smoke, she attempts to get a CNA to go supervise the resident. She stated she is unaware if there are designated smoking times for the facility. On December 19, 2022, at 4:18 p.m., during a concurrent interview and review of the facility's smoking policy with the Administrator (ADM), he stated residents who smoke get smoking assessments upon admission to the facility. He stated the activities department are aware of the facility's smokers. He stated smokers requiring supervision are to be supervised by a CNA or other staff. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays. He stated residents assessed as independent smokers can smoke without a staff member present. The ADM reviewed the facility's smoking policy indicating all smoking is to be supervised and stated the facility was not following the policy. A review of the facility's policy and procedure titled Smoking Policy revised October 24, 2017 indicated, Resident smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the residents .All smoking sessions will be supervised by Facility Staff members only . Residents who smoke shall wear a ' smoking apron' .if they are found not to be safe .Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area. 9. On December 27, 2022, at 2:20 p.m., during an interview with Resident 9, she stated she has not smoked since November 11, 2022. She stated staff will take her out to smoke when she can get one to do so. She stated the staff do not stay while she smokes. A review of Resident 9's record indicated the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and diabetes mellitus (body's inability to regulate blood sugar). A review of Resident 9's Brief Interview for Mental Status (BIMS), dated October 4, 2022, indicated the resident had a score of 11 (mild cognitive impairment). A review of Resident 9's smoking assessment, dated October 21, 2022, indicated, .Resident need assist while smoking to assure safe smoking. On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA1), she stated the facility previously permitted smoking during designated times, but the facility now allows any resident who smokes to go outside independently to smoke when they wish. She further stated in the past the facility observed designated times so a staff member could superv [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for one of 19 residents (Resident 1) reviewed for accident hazards, when the staff transferred Resident 1 using a torn sling (a tightly woven fabric that is placed under and around the resident) with the mechanical lift (a battery powered lift that utilizes a sling with loops that attach to the lift to transfer the resident). This failure resulted in Resident 1 falling from the lift and sustaining a femoral (thigh bone) fracture (broken bone) which required Resident 1 to be transferred to the acute hospital for medical treatment. Findings: Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (memory loss), contracture (tightening or shortening of muscles and joint stiffness) right elbow, contracture right hand, contracture left hand, and contracture unspecific ankle. The History and Physical, dated November 22, 2019, was reviewed. The History and Physical, indicated Resident 1 did not have the capacity to understand and make decisions. The Care Plan, dated November 20, 2019, was reviewed. The Care Plan, indicated, The resident is Moderate risk of falls/injuries r/t (related to): decreased mobility, medication regimen, contractures, [CONDITION(S)] (uncontrollable shaking of the body), history of fall(s), history of fracture .Interventions: Use of mechanical lift for transfer . The MDS (Minimum Data Set - an assessment tool) dated August 31, 2020, was reviewed. The MDS indicated Resident 1's functional status for bed mobility and transfer were total dependence with two persons assist. The BIMS (Brief Interview for Mental Status - an assessment for cognitive status) dated August 31, 2020, was reviewed. The BIMS indicated Resident 1 had a score of three (severely impaired). The Progress Notes, dated November 4, 2020, at 10:38 p.m., were reviewed. The Progress Notes, indicated, .During transfer of resident from shower chair to her bed by physical therapist along with 3 other nursing staff and DON (Director of Nursing) assisted with transferring resident with the use of Hoyer lift (a type of mechanical lift), one of the sloops of the sling (a loop of the sling that attaches to the mechanical lift) was noted to be torn, attending [sic] to hold up the upper end of the right side where the sling is torn. During the transfer due to shift to resident weight to the side in which the sling strap was torn, resident began to quickly slide to the right side, staff lowered resident to the floor .MD (Medical Doctor) made aware, resident was sent to (abbreviated name of hospital) ER (emergency room ) . On November 19, 2020, at 4:05 p.m., an interview was conducted with the Administrator (ADM). The ADM stated during transfer the sling for the mechanical lift ripped. The staff continued to transfer Resident 1 with the mechanical lift by holding the straps of the sling. During transfer the strap of the sling tore and Resident 1 fell . During an interview with the Director of Physical Therapy (DPT) on July 20, 2021, at 10:05 a.m., the DPT stated he recalled the incident on November 4, 2020, regarding Resident 1. The DPT stated Licensed Vocational Nurse (LVN) 1, LVN 2, Certified Nursing Assistant (CNA) 1, the DON, and himself continued to use the torn sling for the mechanical lift to transfer Resident 1. The DPT stated that they should not have continued to transfer Resident 1 using a torn sling. On July 20, 2021, at 10:50 a.m., an interview was conducted with LVN 1. LVN 1 stated during the transfer of Resident 1 on November 4, 2020, the mechanical lift sling tore, and Resident 1 fell . On July 20, 2021, at 12:40 p.m., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed, awake and able to respond to simple questions. Resident 1 was unable to recall the fall incident on November 4, 2020. On July 20, 2021, at 7:10 p.m., a telephone interview was conducted with CNA 1. CNA 1 stated the sling tore three times while Resident 1 was being transferred with the mechanical lift. CNA 1 stated she suggested to the other nurses not to continue to transfer Resident 1 with the torn sling but LVN 1, LVN 2, the DPT, and the DON, wanted to continue to transfer Resident 1 using the torn sling and the mechanical lift. During the transfer the sling broke and Resident 1 fell on top of the legs of the lift. The acute hospital record dated November 4, 2020, was reviewed. The acute hospital record indicated, Right hip .acute (severe and sudden onset) .fracture of the right .femoral shaft (thigh bone) . A review of the INVACARE (Battery Powered Patient Lift ) User's Manual, dated October 1, 2018, was conducted. The manual indicated, .Using the Sling .Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately .Transferring the Patient .DO NOT move the patient if the sling is not properly connected to the hooks of the hanger bar .If any attachments are NOT properly in place, lower the patient onto the stationary surface and correct this problem otherwise, injury or damage may occur . The tag attached on the sling titled, Patient Lift Slings was observed. The Patient Lift Sling tag indicated, .If signs of tearing, fraying or wear are found discard the sling immediately; worn out slings are not safe for use and may result in injury or death . The facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE, dated November 2012, was reviewed. The policy indicated, It is the policy (name of company) to utilize portable lifting equipment to transfer residents in safe and comfortable manner and based on individual resident's needs or plan of care .Facility staff are to follow the manufacturer's instructions for the use of each specific type of lifting machine .

Based on interview and record review, the facility failed to ensure one of three residents (Resident A) change of condition was immediately reported to the resident's physician when the resident had a change in his mental status after a fall from his bed and was found face down on the floor; and Resident A's physician was not notified after the resident's enteral feeding pump ( a mechanical pump used to give liquid feedings at a specific rate through a tube that has been placed into the resident's stomach) was found laying on his chest for an unknown period of time. These failures caused delays in the medical care and treatment for [REDACTED]. Findings: On (MONTH) 29, (YEAR), at 12:55 p.m., the complainant, a family member (FM) 1 of Resident A was interviewed by telephone. FM 1 stated Resident A had a history of [REDACTED]. FM 1 stated Resident A was sent to the facility for rehabilitation, with a plan for Resident A to return home. The family member stated the family requested side rails for Resident A's bed but was told no. FM 1 stated she received a call from a facility nurse on (MONTH) 23, (YEAR), about 10 p.m., who said Resident A fell out of bed face first, and that he was okay. FM 1 was told his vital signs (temperature, heart rate, blood pressure, and respiratory rate) were fine. FM 1 stated she asked the nurse if the facility called 911 to have Resident A sent to the hospital for further evaluation and was told no. FM 1 stated she went to see Resident A at the facility the next day and found him more confused and not responding. FM 1 stated Resident A's doctor came to the facility, told the family he was not aware of Resident A's fall, and ordered the nurse to call 911. FM 1 further stated Resident A was treated at ( name of HOSP (Hospital) 2) for injuries related to the fall and later returned to the facility. FM 1 stated several days later Resident A was sent to (name of HOSP 3) and passed away on (MONTH) 7, (YEAR). On (MONTH) 30, (YEAR), at 9 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding Resident A. On (MONTH) 30, (YEAR), at 9:55 a.m., Resident A's facility medical record was reviewed, and indicated Resident A was admitted to the facility on (MONTH) 19, (YEAR), from (name of HOSP 1) with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Physical Therapy Plan of Care, dated (MONTH) 19, (YEAR), untimed, indicated Resident A was .Unable to maintain balance without mod/max (moderate/maximum) support .dependent for all functional mobility . The Occupational Therapy Plan of Care, dated (MONTH) 20, (YEAR), untimed, indicated, .left sided weakness, left hand splint, + foley (sic) catheter, fall risk .Bed mobility .dependent 100% assist . Resident A's medical record from HOSP 1 was then reviewed. The record from HOSP 1 indicated Resident A was admitted to HOSP 1 (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. The record indicated Resident A's [MEDICAL CONDITION] site was surgically revised and the cannula (tube) was removed before Resident A was discharged . The Physician's discharge summary indicated Resident A was alert and oriented x 3 (normal is person, place, time, situation), could verbalize his needs, and had left side paralysis when he was discharged from HOSP 1. Resident A's record from the SNF (skilled nursing facility) was further reviewed. The SBAR Note (communication form used to document physician notification of changes in condition) indicated, .unwitnessed fall .11/23/2017 . Doctor was notified we started neurochecks . There was no documented indication the RN or LVN immediately assessed and evaluated Resident A's level of alertness, oxygen level, heart and lung sounds, range of motion, speech, status of his [MEDICAL CONDITION] site, PEG tube, or Foley catheter for changes or injuries. There was no documented indication what information was given to Resident A's Physician, the Physician's response, or if any new orders were given. The document, titled Neuro Check Flow Sheet, dated (MONTH) 23, (YEAR) to (MONTH) 25, (YEAR) was reviewed. The Flow Sheet indicated neuro checks (neurological assessment rating scale used to check for changes in mental status/signs of head injury scored 3 lowest to 15 highest) were not initiated until 11:50 p.m. (1 hour and 50 minutes after Resident A was found face down on the floor at around 10 p.m.). The Flow Sheet further indicated Resident A's neuro check scores were abnormal with a score of 11 (opened his eyes to command, was confused, and moved to withdraw from pain) at that time. There was no documented indication nursing staff called to notify Resident A's Physician of the abnormal neuro signs or at what time they were initiated. The medical record notes titled, Functional Rehab Documentation . dated (MONTH) 22 and 23, (YEAR), completed by the RNs, indicated, Resident alert, awake, verbally responsive and able to make needs known . The Functional Rehab Documentation . form, dated (MONTH) 24, (YEAR), at 1515 (17 hours and 15 minutes after Resident A was found on the floor) indicated, Resident is awake, on bed, non-verbal, total care rendered . The Nurse's Notes for (MONTH) 19, (YEAR) to (MONTH) 24, (YEAR), were reviewed. There was no documented evidence in the notes of Resident A's fall on (MONTH) 23, (YEAR), notification of Resident A's Physician or if any orders were given to address Resident A's fall. There was no documented indication in the Nurse's Notes to indicate when Resident A was last provided care prior to the fall or assessments or interventions done for Resident A after he fell . There was no documented indication that nursing staff initiated 72 hour monitoring to assess Resident A for further changes in condition. There was no documented indication of Resident A's transfer to HOSP 2 on (MONTH) 24, (YEAR), the time, or his condition at the time he was transferred. On (MONTH) 30 , (YEAR), at 9:30 a.m., the Director of Nursing (DON) was interviewed. The DON stated when a resident had an unwitnessed fall, the Physician and family should be immediately notified, and neuro checks should be done for 72 hours. During a concurrent record review, the DON acknowledged Resident A's first neuro check was not done until 1 hour and 50 minutes after he was found on the floor. On (MONTH) 30, (YEAR), at 11 a.m., the DON was further interviewed. She stated neuro checks should be started as soon as the resident was found after a fall. She was unable to find documented indication in the Nurse's Notes to show Resident A's condition during his stay at the facility after an initial assessment on (MONTH) 19, (YEAR) at 6:14 p.m. The DON stated RNs are responsible for the Functional Rehab Documentation completed once daily for residents. She further stated the LVNs are responsible for checking resident's [MEDICAL CONDITION] sites, G tubes, and administering medications, and documenting this information in the record each shift. LVN 1 was interviewed on (MONTH) 30, (YEAR), at 11:50 a.m., . LVN 1 stated she did not remember Resident A but recognized her signature on Resident A's Neuro Check Flow Sheet. and stated LVNs are supposed to document any changes of condition including 72 hour monitoring after a change of condition on all residents. During a concurrent record review, LVN 1 stated Resident A should have had neuro checks started ASAP (as soon as possible). LVN 1 stated Resident A did hit his head because he was found face down. Resident A's record from HOSP 2 was reviewed. The record indicated Resident A was brought to HOSP 2 by ambulance on (MONTH) 24, (YEAR), at 9:19 p.m. ( 23 hours and 19 minutes after he fell ). The History and Physical, dated (MONTH) 24, (YEAR), at 11:18 p.m., indicated, .was found on floor, fell off bed at (name of SNF) .family came and noted he was more confused with expressive dysphasia (difficulty understanding and speaking words) . The record indicated Resident A became lethargic and non-responsive on (MONTH) 25, (YEAR). The Physician's Progress Note, dated (MONTH) 25, (YEAR), at 5:49 a.m., indicated, .acute traumatic SAH (subarachnoid hemorrhage-bleeding into space between brain and tissue that covers brain) .acute [MEDICAL CONDITIONS] . Resident A's SNF record was further reviewed. The record indicated Resident A was readmitted to the facility from HOSP 2 on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].at 85 ml/hr (milliliters per hour a unit of measure) to provide 1020 ml .via enteral pump for tube feeding ON:1800 (6 p.m.) OFF: 0600 (6 a.m.) The physician's orders [REDACTED]. The Nurse's Admission Assessment, dated (MONTH) 30, (YEAR), at 2100 (9 p.m.) indicated Resident A was .Confused .oriented to person (normal is oriented to person, place, time, situation) .weakness .Paralysis Left side . The SBAR form, dated (MONTH) 01, (YEAR), at 4 a.m., indicated, .CNA (Certified Nursing Assistant) informed CN (charge nurse) pt (Resident A) was found with [DEVICE] pole/machine on his chest as it appeared pt pulled it down on himself. CNA stated she picked it up and put it back where it was pt still connected, machine still on. When pt was asked what happened, pt did not wake enough to disclose, pt's roommate (sic) stated he heard a loud crash and pt (name of Resident A) say oh oh .no signs of bruises, abrasions, or bumps .pt's family and Dr will be notified .To be notified by AM shift . The area of the SBAR form to document Resident A's mental status was marked NA. There was no documented indication the nurse (LVN 3) evaluated Resident A's level of alertness, oxygen level, pain level, heart and lung sounds, range of motion, PEG tube or [MEDICAL CONDITION] sites. There was no documented indication LVN 3 asked the RN on duty to assess Resident A for injuries or changes in his condition. The Nurse's Notes, dated (MONTH) 30, (YEAR) through (MONTH) 7, (YEAR), were reviewed. There was no documented indication LVN 3 notified Resident A's Physician that Resident A was found with the pump on his chest for an unknown period of time, or requested any additional tests to check for potential injuries. There was no documented indication of Resident A's condition, assessments, or interventions done on (MONTH) 1, (YEAR), when Resident A was found. There was no documented indication Resident A's family was notified of the incident. The handwritten Provider's Progress Note, dated (MONTH) 1, (YEAR), untimed, found in Resident A's record indicated, .staff indicates pt pulls lines & PEG .secure PEG . and had no Resident's name, room number, or medical record number on the Note. There was no documented indication in the Note to indicate the Provider was aware that Resident A was found with the pump on his chest for an unknown period of time. The Nurse's Notes, dated (MONTH) 7, (YEAR), at 12:32 p.m., indicated Resident A was found having labored breathing, clammy and sweaty, at 9:30 a.m., and had an oxygen saturation level of 78% (normal is 92-100%). The record indicated Resident A was sent to HOSP 3 by ambulance at 10 a.m. On (MONTH) 6, (YEAR), at 2:10 p.m., Resident A's record from HOSP 3 was reviewed. The record indicated Resident A was brought in by ambulance on (MONTH) 7, (YEAR), at 10:12 a.m., with complaint of shortness of breath for 30 minutes. The record indicated Resident A was in severe distress, diaphoretic, and unresponsive. The record indicated Resident A had two code blue (life saving measures given) events and passed away at 11:17 a.m. On (MONTH) 30, (YEAR), at 2:45 p.m., the Director of Nursing (DON) was interviewed. During a concurrent facility medical record review, the DON verified there was no documented indication Resident A's Physician was immediately notified when Resident A was found with the enteral feeding pump on his chest. The DON was unable to state how the facility's nurses decide when to notify the Physician immediately and when it may be okay to endorse to the next shift. The DON stated the nurses may have had difficulty reaching the Physician, but she could not find any documentation in the record to support that statement. The DON acknowledged the potential for Resident A to have unseen injuries from the pump laying on his chest. On (MONTH) 6, (YEAR), at 11:25 a.m., the Director of Staff Development (DSD) was interviewed by telephone. The DSD stated the facility's process for falls or changes in condition was: whoever found the resident should stand by and call for help, the nurses should do a head-to-toe assessment, try to wake the resident, notify the Physician, and get whatever x-ray or lab tests the Physician orders [REDACTED]. The DSD further stated when the nurses reported the incident to the Physician, the nurse should include all of the information from the assessments, and document the date, time, who was notified, and the Physician's response/orders verbatim in the record. The facility policy and procedure, titled, Condition Change of Resident last revised (MONTH) (YEAR), was reviewed and indicated, .It is the policy of this facility to observe, record, and report changes in condition to the attending physician .If unable to reach the attending physician or the physician on call, call the facility medical director or 911 .Notify resident's representative after the resident is stable .Monitor resident's condition as often as the condition warrants .in accordance with recognizable standards of care .Document per facility policy . The facility policy and procedure, titled, Falls/Accident Mitigation and Intervention, last revised (MONTH) (YEAR), was reviewed and indicated, .After a fall or other similar accident .the resident shall have a physical assessment documented in the nursing notes .The attending physician and legal representative .shall be notified .The facility shall begin 72 hour charting .and continue to assess for latent injuries or changes in condition . The facility policy and procedure, titled, Neurological Assessment ( Neuro Checks), last revised (MONTH) (YEAR), was reviewed and indicated, It is the policy of this facility to provide neurological assessments as indicated for the resident involved in an incident .may include .resident found on floor .Neurological checks are completed within the time frames noted on the Neuro Check Flow Sheet or as ordered by the physician .

Based on observation, interview and record review, the facility failed to ensure Patient A received adequate supervision and assistance with mobility while in bed to prevent a fall that resulted in a femur (thigh bone) fracture. Findings: On December 6, 2012, an unannounced visit was conducted at the facility to investigate a complaint that Patient A had fallen off her bed and sustained a femur fracture. A record review of Patient A was conducted on December 6, 2012. Patient A was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician documented on October 13, 2012, that the patient "has capacity to understand and make decisions." A review of the MDS (Minimum Data Set, an assessment tool) dated October 18, 2012, indicated Patient A was able to make herself understood and was able to understand others. The MDS further indicated that the patient was totally dependant for bed mobility with a two plus person assist. The Physical Therapist documented on October 22, 2012, "assist with two CNAs (Certified Nursing Assistant) for positioning...in bed." A care plan developed on October 23, 2012, for risk for fall or injury documented the environment would be free of fall hazards and patient would be assisted with mobility per ADL (activities of daily living) care plan. The ADL care plan documented the resident required total, extensive assistance with bed mobility and toileting, and was dependant with transfers. There was no documentation indicating side rails were to be used as an enabler for mobility transfers or repositioning. Record review of nursing documentation dated October 22, 2012, November 3, 15, 16, 21, and 22, 2012, indicated Patient A needed two CNA's for repositioning. On November 23, 2012, at 6:00 p.m., documentation indicated that Patient A called the RNA (Restorative Nursing Assistant) to help reposition her on the left side. Patient A "slid on the bed and fell on floor." Nurses heard a loud noise and found Patient A on the floor." Patient A stated, "I slid on the bed and I rushed to the floor, the RNA left the room 10 to 15 minutes ago." An interview conducted on December 6, 2012, at 11:20 a.m., with the RN (Registered Nurse) supervisor, revealed the RNA answered Patient A's call light at approximately 6:00 p.m. The RNA turned the patient on her left side and exited Patient A's room. The patient turned her call light on. The RNA or CNA did not immediately answer the call light. The patients foot fell off the bed, then her body fell and she landed on the floor. Some nurses heard a loud noise and found the patient on the floor. The patient stated, "I tried to call, I repositioned myself and I fell . I slid from the mattress and fell on the floor." An X-ray performed on November 23, 2012, revealed Patient A sustained a right femur (thigh bone) fracture. The supervisor stated, "I presumed her foot fell first. Her bed was a big boy bed (large bed frame used for obese patients), she used side rails for positioning. The patient's body had scooted down to the lower part of the bed. I'm not sure if the side rails were up or down." Observation on December 6, 2012, at 11:30 a.m., of the "big boy bed" revealed the bed had a large frame with two half side rails that were removed and lying on top of the bed frame. An interview was conducted on December 6, 2012, with the RNA at 12:10 p.m. The RNA stated as she was leaving the building at 6:30 p.m., she heard Patient A calling for help. She (RNA) answered the patient's call light. The patient requested to be repositioned . The RNA stated she independently repositioned the patient using the overhead trapeze bar and the side rail, then left for the evening. The RNA stated, "I would reposition her by myself because I knew how to do it without any help." An interview was conducted on December 6, 2012, at 3:00 p.m., with the LVN (Licensed Vocational Nurse). She stated, "I heard a loud noise. Me and another LVN saw (Patient's name omitted) on the floor on her back. The patient requested not to move her leg. Her bed was a big boy bed. It had half side rails on both sides. She used the side rails to move. You need two people to turn her. The patient stated she was reaching for the call light and became impatient and fell out of the bed." An interview was conducted with Patient A on December 11, 2012, at 8:40 a.m. The patient stated, "I was sliding my feet off the bed, I turned the light on and called for help and no one came in. I used the side rails to turn. Sometimes my feet would slide off the bed but a nurse would move me back to the center of the bed. Sometimes I had one or two CNA's to help me move." The CNA assigned to Patient A was interviewed on December 11, 2012, at 4:40 p.m. She stated, "It was dinner time and I was with another resident when (Patient A's name omitted) wanted to be repositioned. Sometimes the resident would help me by grabbing the rail or trapeze bar. I would change her by myself. If she wasn't feeling good or was in a lot of pain I would get another CNA. If (Patient's name omitted) was lying on her side, the side rails would go up only half the height of the patient's body while in the upright position. The side rails wouldn't fit her completely. If she leaned into the rail she could fall over because it only came up mid chest or a little past, but not to the shoulders." During an interview with the supplier of the low air loss mattress on December 13, 2012, at 9:40 a.m., he indicated the company had rented the mattress only to the facility. An interview was conducted with the facility Administrator on February 19, 2013, at 9:55 a.m. He stated the facility ordered the bed frame and mattress at the same time. The low air loss mattress was ordered after the IDT (Interdisciplinary Team) felt the patient had issues with skin breakdown. The bed frame and side rails were set up by same company that provided the low air loss mattress. A request was made to review the receipt of rental for the big boy frame, mattress and side rails. However, none was provided. A review of the IDT notes dated November 9, 2012, revealed no evidence of documentation regarding the need for the low air loss mattress. A review of the hospital notes dated 11/26/12, revealed Patient A was evaluated by an Orthopaedic physician and transferred back the the facility with a knee immobilizer. Patient A developed "intractable right femur pain" and was transferred to the emergency room for supracondylar (rounded projection on a bone) fracture of the femur and knee joint effusion (escape of fluid into tissue). An ultrasound of the lower limb was performed to rule out DVT (deep vein thrombosis). There was no evidence of a DVT. The hospital orthopedic physician documented on 11/26/12, "female with a history of morbid obesity, weighing approximately 400 pounds...while moving in bed, she rolled out of bed, landing on her right side with pain to the right leg...she has not ambulated in approximately 8 years...over the last 2 years to have lost motion and movement of her right foot and toes with noted severe contracture to the right foot and toe...Based on her significant history, her nonambulatory status for 8 years, significant contracture to her lower extremities...operative intervention maybe significantly complicated by her medical conditions and based on her low functional activity level, the risks and complications outweigh the benefits of operative intervention...Recommend pain control. Will place her in a knee immobilizer."