Every finding on record at Connecticut Baptist Homes, Inc

Based on the residents' medical records, facility documentation review, and interviews, it was determined that the facility failed to ensure that residents were free of significant medication errors. Specifically, the facility failed to administer correct medication to Resident #1 which led to harm and resulted in hospitalization with consequences. The findings include:Resident #1's diagnoses included diabetes mellitus, chronic kidney disease, lymphedema, asthma, neuropathy and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented with no memory recall deficits. The Resident Care Plan dated 4/7/26 identified Resident #1 had altered cardiovascular status, impaired circulation and altered respiratory status. Interventions directed to administer medications per the physician's order. A physician's order dated 5/1/26 directed Resident #1 receive the following medications at 8:30 AM everyday: Daily-Vite tablet (a multivitamin) by mouth once a day, Fluticasone Propionate 50 microgram (mcg) spray give two (2) sprays into each nostril once a day (a medication for allergies), and Eliquis 2.5 milligram (mg) tablet by mouth every twelve hours (a medication to keep the blood from clotting). The Reportable Event Form dated 5/27/26 at 10:00 AM identified a licensed nurse who had pre-poured medications for two (2) residents (Resident #1 and Resident #2) and set the medication cups in the top drawer of the medication cart had failed to verify the correct medication cup was obtained to ensure Resident #1 did not receive Resident #2's mediation, resulting in Resident #1 becoming hypotensive (low blood pressure) and dizzy requiring a transfer to the emergency department. The investigation identified Resident #1 was given the following medications Allopurinol 100 mg tablet by mouth (a medication used to treat gout), Aspirin 81 mg tablet by mouth, Metoprolol Succinate Extended Release (ER) 25 mg tablet (a medication used to treat high blood pressure), Olmesartan Medoxomil 40 mg tablet by mouth (a medication used to treat high blood pressure), and Pantoprazole Sodium 20 mg tablet (a medication used to treat gastroesophageal reflux disease). The nurse's note dated 5/27/26 at 2:44 PM identified Resident #1 received the wrong medication in the morning. The note indicated initially Resident #1's vital signs were within normal limits and Resident #1 was at his/her baseline alert and oriented mentation. The note identified after lunch Resident #1 complained of weakness, appeared ashen (pale), blood pressure readings decreased to 81/48 and 110/68 (normal blood pressure is 90-119/60-79) with a pulse rate of 77. The note identified the physician was notified, a new order was obtained to transfer Resident #1 to the Emergency Department (ED for evaluation and Resident was transferred at 1:30 PM. The Prehospital Care Report dated 5/27/26 identified at 1:38 PM Resident #1's blood pressure was 74/40, pulse 57 and respirations 16, a twelve (12) lead electrocardiogram (EKG) was obtained, and Resident #1 was found to be in sinus bradycardia (the heart beats fewer than 60 beats per minute). The hospital documentation identified Resident #1 was hypotensive in the Emergency Department with blood pressures in the 80's, Resident #1 responded well to fluids the blood pressure was stable, blood work was obtained and showed no significant electrolyte abnormalities, EKG interpretation was normal sinus rhythm, there was a discussion with poison control who recommended observation for eight (8) to twelve (12) hours. The note at 10:00 PM identified Resident #1 had remained stable since 5:00 PM and was ready for discharge with close monitoring. The nurse's note dated 5/28/26 at 5:24 AM identified Resident #1 had returned to the facility at 12:10 AM and vital signs were stable. Interview with the 7AM-3PM nursing supervisor, Registered Nurse (RN) #2, on 6/23/26 at 12:22 PM identified on 5/27/26 the 7AM-3PM charge nurse, RN #1, reported that she had given Resident #1 another resident's medications in error. Interview with RN #1 on 6/23/26 at 12:40 PM identified she usually administers the resident medication in the dining room. RN #1 explained on 5/27/26 she prepared Resident #2's medication then realized Resident #2 was not in the dining room, so she labeled the medication cup and put the cup in the top drawer. RN #1 identified Resident #1 rang for his/her medications, so she prepared Resident #1's medication and an emergency came up, so she labeled the cup and put the medication cup in the top drawer of the cart. RN #1 indicated after she returned from the emergency, Resident #1 was still ringing for his/her mediations, she grabbed the wrong cup from the medication cart and gave Resident #1 another resident's medication, Resident #2. Interview with the Director of Nursing (DON) on 6/23/26 at 1:37 PM identified on 5/27/26 RN #1 administered Resident #2's morning medications to Resident #1 who became symptomatic after lunch and required a transfer to the ED for evaluation. The DON identified it is the facility's expectation that once a medication was removed from the blister pack, if it was not administered at that time, the medication should be thrown away and not placed in the medication cart for administration later. The DON identified RN #1 failed to follow the facility policy when she placed the dispensed medications of both Resident #1 and Resident #2 into the top drawer of the medication cart and then administered Resident #2's medications to Resident #1. Review of the facility policy (from Omnicare Pharmacy) titled General Dose Preparation and Medication Administration, last revised 11/15/24, directed, in part, prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The policy further directed, in part, during medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: verify resident identity per facility policy (e.g. picture, armband, name), and verify the medication name and dose are correct.

Based on observations, clinical record review, facility policies, and staff interviews, the facility failed to timely identify and respond to significant weight loss for 2 of 6 residents (Residents #3 and #26). The facility did not complete physician ordered weekly weights, did not obtain required reweights after weight loss of 5 pounds or greater per policy, failed to notify providers and the dietitian of documented significant weight loss, and did not implement or provide ordered nutritional supplements. These failures resulted in delays in assessment and intervention, allowing both residents to experience continued, preventable weight loss over multiple weeks. The findings include: 1.Resident #3's diagnosis included cerebrovascular disease, anxiety, and dementia. A Resident Care Plan dated 10/8/25 identified Resident #3 was at risk for malnutrition with interventions that included to provide gentle encouragement at mealtime, honor food preferences, and diet as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately, cognitively impaired and required set up assistance with oral hygiene, upper/lower body dressing and personal hygiene. Additionally, the MDS identified Resident #3 was independent with eating, was not on a mechanically altered or therapeutic diet, did not have a significant weight loss, and Resident #3 weighed 134 pounds (lbs.). a. A physician order dated 12/4/25 directed weekly weights for 4 weeks and then monthly. Review of the Vital Sign record on 3/26/26 at 11:47 AM with Registered Nurse (RN) #1 failed to identify weekly weights were completed on 12/11/25, 12/19/25 and 12/26/25. Interview with RN #1 on 3/26/26 at 11:47AM identified nurses were responsible for ensuring weights were completed as ordered and she was responsible for oversight. RN #1 further noted all weights were to be documented in the Electronic Medical Record (EMR) once obtained and if the weight loss was greater than 5 pounds (lbs) a reweight should be obtained and the family, physician and dietician were to be notified if the weight loss was greater than 5lbs. b. On 3/26/26 at 11:47 AM, review of the Weight and Vital Summary identified on 12/8/25, Resident #3 weighed 136.2 pounds (lbs.), on 1/1/26 weighed 125 lbs. (a weight loss of 11.2 lbs./8.2% in 24 days), on 1/9/26 weighed 123 lbs. (a 13.2 lb./9.6% loss in 31 days). Additionally, on 2/3/26, Resident #3 weighed 117.8 lbs. (a loss of 19.2 lbs./14% in 57 days).A physician order dated 2/9/26 directed to weigh Resident #3 weekly for 4 weeks related to weight loss (39 days after a 11.2 lb./8.2% weight loss was documented).A physician order dated 2/11/26 directed to provide Med pass 2.0, (a nutritional supplement) 4 ounces by mouth twice a day due to weight loss and suboptimal by mouth intake (41 days after a 11.2 lb./8.2% weight loss was documented).On 2/20/26, Resident #3 weighed 113.6lbs., on 2/24/26 Resident #3 weighed 115.6lbs, and Resident #3 weighed 114.4 on 3/3/26. Physician orders dated 3/16/26 directed to administer Remeron (an appetite Stimulant) 15 milligrams give 1/2 tab to equal 7.6 milligrams by mouth at hours of sleep. On 3/26/26 at 10:05 AM interview with the Dietician identified Resident #3 had lost 11.2 lbs./8.2% pounds from 12/8/25 to 1/8/26. The Dietician noted that on 1/3/26 she sent Registered Nurse (RN) #1 an e-mail requesting weekly weights be completed and to start a nutritional supplement (however she did not identify a specific nutritional supplement). Additionally, the Dietician noted when weekly weights and a nutritional supplement had not been ordered, she sent another e-mail on 2/9/26 to RN#1 requesting weekly weights and a nutritional supplement be ordered. The Dietician further noted that Resident #3 would not have continued to lose as much weight from 1/8/26 to 2/9/26 had a supplement been added when she requested on 1/3/26. An interview on 3/26/26 at 11:47 AM with RN #1 identified she did receive an email from the Dietician on 1/3/26 but failed to act upon the request made by the Dietician identifying it was an oversight on her part. On 3/30/26 at 11:09 AM interview with Advance Practice Registered Nurse (APRN) #1 identified she was notified of Resident #3's weight loss on 2/9/26 (39 days after Resident #3 had a 11.2 lbs/8.2% lb. loss). APRN #1 further noted if she was informed of the weight loss from 1/1/26 she would expect the nursing staff to obtain a reweight on the resident and would have started Resident #3 on Remeron (an appetite stimulant) sooner. Further, identifying the resident should have been reweighed on 1/2/26 because the resident had a weight loss of 5 lbs. or greater per the facility policy and the provider/family should have been notified of the weight loss. (please refer to F 580) 2. Resident #26's diagnoses included Type 2 diabetes mellitus, gastro-esophageal reflux disease and unspecified protein-calorie malnutrition.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact and required partial/moderate assistance with bed mobility and transfers. Additionally, the MDS identified Resident #26 required substantial/maximal assistance with toileting, had significant weight loss, was not on a physician prescribed weight loss regimen and had a diagnosis of malnutrition. The MDS further noted Resident #26 was on a mechanically altered and therapeutic diet. A Nutritional Care Recommendation form completed by Dietician #1 on 11/12/25 identified Resident #26 had a significant weight change of 14 pounds (lbs.) from October 2025 and to weigh the Resident #26 weekly.A physician order dated 11/12/25 directed Resident #26 was to be weighed weekly for 4 weeks.The Resident Weight and Vital Sign summary section located in the electronic health record (EHR) identified on 10/5/25 Resident #26 weighed 140.8 lbs., on 11/7/25 weighed 127.4 lbs. (which was documented by RN #3) (a 13.4 lb./9.5% loss in 33 days). A Nutritional quarterly review note written by Dietician #1 and dated 11/13/25 identified Resident #26 had a 14 lb. weight loss in the past month despite medication changes and interventions and further noted the physician and family would be notified.A physician order dated 11/17/25 directed Resident #26 was to receive a mechanical soft diet with thin liquids, add pudding to lunch and add ice cream to supper.The Resident Care Plan (RCP) dated 11/17/25 identified Resident #26 had impaired cognitive function with cognitive decline, Type 2 diabetes mellitus and was at risk for malnutrition with weight loss over the past 6 months. Interventions included providing diet and supplements as ordered, weigh the resident per the physician's order and to keep the physician and family notified with a dietary consult for a nutritional regimen and ongoing monitoring.The Weights and Vitals summary section located in the electronic health record (EHR) identified that on 12/3/25 weighed 128.2 lbs., on 1/10/26 weighed 116.8 lbs. (which was documented by RN #3) (an 11.4 lb./8.89% loss in 38 days), and on 1/23/26 weighed 116.4 lbs. (a 25.2 lb./17.33% loss in 110 days from 10/5/25 to 1/23/26).A Social Service Note/Care Plan Meeting Note dated 2/10/26 identified Resident #26 attended his/her care plan meeting, and Person #1 was in attendance by phone. The note indicated Resident #26 had lost 11.8 lbs. since December.A Nutritional Care Recommendation form, undated and completed by Dietician #1 directed to add 1 scoop of Prosource to vehicle of choice two times a day for skin healing and to discontinue if refused.A physician's order dated 2/26/26 directed Prosource 1 scoop twice daily in vehicle of choice (drink) at 8:30 AM and 8:30 PM.a. An observation of dining on 3/23/26 at 12:15 PM noted Resident #26 awake, seated in his/her wheelchair, hunched forward over the table in the dining room. A plate of liver and onions of chopped consistency was in front of him/her at the dining room table and Resident #26 was not eating. Resident #26 was not served pudding with his/her lunch (as per physician order dated 11/17/25) and pudding was not indicated on the resident's meal ticket. Resident #26 did not eat the chopped liver and onions that was served, was not prompted/cued or assisted by staff to eat during the meal and was not offered an alternative meal. On 3/26/26 at 12:47 PM, interview and review of Resident #26's lunch meal ticket dated 3/23/26 with the Food Service Director (FSD) identified the meal ticket failed to indicate a pudding was to be served to Resident #26 at lunch. The FSD stated pudding should have been listed on all the resident's meal tickets for lunch and was unsure why it was not on the ticket. The FSD identified he would correct the error and ensure the pudding with lunch and ice cream with dinner was listed on all of the resident's meal tickets. The FSD was unable to indicate if Resident #26 was eating the pudding with lunch and ice cream with dinner as their consumption was not being tracked. Additionally, the FSD identified it was his responsibility to include pudding/ice cream on the meal ticket so that dietary could serve pudding with Resident #26's lunch tray. Additionally, the FSD identified pudding was likely only missed on 3/23/26 but couldn't be sure.A second meal observation on 3/26/26 at 12:05 PM noted Resident #26 seated in his/her wheelchair, hunched forward over the table in the dining room. A plate of chicken pot pie of chopped consistency with a biscuit on top and a plastic handled mug of coffee was in front of Resident #26 at the dining room table. Resident #26 was moving his/her hands but not eating. At 12:09 PM, RN #2 prompted Resident #26 to eat while your food is hot, Resident #26 sat up, began to use the spoon, and take small bites of the biscuit. At 12:11 PM, Resident #26 requested ginger ale which was provided by RN #2. At 12:13 PM dietary staff placed a sealed cup of vanilla pudding in front of Resident #26, but it remained unopened by staff. At 12:15 PM Resident #26 requested cranberry sauce which was provided by the FSD and Resident #26 continued to take small bites of the ground chicken pot pie and biscuit with the cranberry sauce. Resident #26's meal ticket for 3/26/26 indicated a 4 oz. vanilla pudding for dessert. Interview and review of the clinical record with the Dietician on 3/26/26 at 1:45 PM identified she was aware that Resident #26 had a significant weight loss of more than 25 lbs. in the last several months. The Dietician indicated after the resident's weight loss was identified in November 2025, she ordered weekly weights and for the resident to have pudding with lunch and ice cream with dinner (which would have provided an additional 300 calories.b. A physician order dated 11/12/25 directed weekly weights for 1 month.Review of the Treatment Administration Record (TAR) with the Dietician indicated the weekly weights ordered on 11/12/25 had not been documented on the TAR for 11/15/25, 11/22/25 and 11/29/25. The Dietician indicated it would have been the responsibility of the nursing staff to ensure Resident #26's weights were obtained weekly and documented in the TAR.Further review of Resident #26's weight record with the Dietician indicated Resident #26 had an additional 11.4 lb. weight loss from 12/3/25 to 1/10/26 when she was away for a few weeks in January 2026 and was not notified of the weight loss until she returned to the facility on 1/20/26 (10 days later). The Dietician indicated the nursing staff should have notified the Regional Dietician of the resident's weight loss in her absence. The Dietician stated the nursing staff would usually communicate a resident's weight loss in person, via email or put a note in the communication book, however review of her email and the communication book failed to indicate she was notified of Resident #26's continued weight loss. (please refer to F 580).Additionally, the Dietician stated her only intervention on 1/20/26 was for Resident #26 to be re-weighed (which was not obtained until 1/23/26 for a weight of 116.4 lbs.) and she should have ordered the resident to be weighed weekly for 4 weeks but had failed to do so. The Dietician further indicated that although Resident #26 was ordered to have pudding with lunch and ice cream with supper, she was unsure of the resident's intake of the pudding and ice cream because the intake was not being tracked and she had not asked the nursing staff about Resident #26's consumption of pudding/ice cream. Interview and review of the clinical record with RN #3 on 3/26/26 at 3:15 PM identified she obtained and documented Resident #26's weight of 116.8 lbs. on 1/10/26 but failed to notice Resident #26's continued weight loss of 11.4 lbs. from 12/3/25. RN #3 indicated she did not compare the resident's prior weights and assumed RN #1 (who was the nursing supervisor) would have noticed the weight loss trend because RN #1 reviews weights, looks for trends and notifies everyone including the physician, Dietician and responsible party on the morning shift. RN #3 further indicated although Resident #26 was not an ice cream eater and would complain the ice cream was too cold, the resident was still served ice cream with supper but did not eat it. RN #3 identified she had not informed anyone that Resident #26 was not consuming ice cream at supper but should have.Interview and review of the clinical record with the RN Supervisor covering for the Director of Nursing Services (RN #1) on 3/26/26 at 3:45 PM identified she was aware that Resident #26 had a significant weight loss of more than 25 lbs. in the last several months. RN #1 indicated after the resident's weight loss in November 2025 the Dietician ordered weekly weights for 4 weeks and ordered pudding with lunch and ice cream with dinner.Additionally, RN #1 identified weekly weights were documented on the Treatment Administration Record. Review of the Treatment Administration Record (TAR) with RN #1 indicated the weekly weights ordered to be completed in November 2025 had not been documented on the TAR for 11/15/25, 11/22/25 and 11/29/25. RN #1 indicated it would have been the responsibility of the nursing staff to ensure Resident #26's weights were obtained weekly and documented in the TAR. RN #1 further identified Resident #26 should have been re-weighed the following day after the continued weight loss was identified on 1/10/26 (loss of 11.4 lbs.) and indicated a re-weight should be completed with a 5 lb. or more weight loss to confirm the weight loss and then the physician, Dietician and responsible party should have been notified. RN #1 identified it was the responsibility of RN # 3 (who obtained and documented Resident #26's weight on 1/10/26) who should have re-weighed the resident, made the necessary notifications, documented in the nursing progress notes, and passed on the information during shift report. Additionally, RN #1 indicated Resident #26's pudding with lunch and ice cream with dinner was not tracked for consumption so the Dietician would not know if the resident was not consuming it and she was unsure if the nursing staff would notice if Resident #26 had received and eaten the pudding or ice cream during his/her meals. Facility policy related to Weights, dated 11/24, directed each resident will have their weight monitored, which will ensure that each resident maintains an optimum body weight. All residents will be weighed at least monthly unless the physician orders otherwise. If a resident's weight is a gain or loss of 5 pounds or more a reweight will take place the next day. If the resident's repeat weight is a gain or loss of 5 pounds the weight will be reported to the physician and the dietician for appropriate interventions. The responsible party will be notified of the weight change and recommended interventions. Weekly and/or more frequently weights will be done per the physician orders and reported according to the parameters given.Facility policy related to Nutrition, dated 2022, directed the Dietician will develop a plan of nutritional care using clinical observation of nutrition and nutritional intake and the resident's intake and weight will be reviewed. Nursing personnel are to ensure each resident receives the correct diet and significant weight fluctuations are reported to the physician.

Based on observation, interviews, and review of facility policy for 2 of 2 medication rooms, the facility failed to ensure expired supplies were discarded and failed to ensure the medication cart was secured when staff were not in attendance. The findings include: 1. Interview and observation of the 2nd floor medication room with the Nursing Supervisor (RN #1) on [DATE] at 8:02 AM identified the following expired supplies a. 14 Covid19 AG Binox now tests ([NAME]), expired [DATE] b. Two (2) 10 milliliter (ml) syringe 22-gauge (g) x one (1) inch (in), expired [DATE] c. Six (6) three (3) ml syringe 23g x 1in, expired 8/20 d. 67 three (3) ml syringe 25g x 5/8 in, expired [DATE] e. 12 Hydrocortisone Acetate suppositories 25mg, expired [DATE]. 2. Interview and observation of the 3rd floor medication room with the Nursing Supervisor (RN #1) on [DATE] at 8:05 AM identified the following: a.One (1) 10 ml syringe 22g x one (1) in, expired [DATE] b. One (1) three (3) ml syringe 23g x 1in, expired [DATE] c. 21 three (3) ml syringe 25g x 5/8 in, expired 2/20 d. 30 Linzess 145 microgram capsules, expired 12/25 e. One (1) filter straw, expired [DATE] - located in emergency medication box f. One (1) filter straw, expired [DATE] - located in emergency medication box g. One (1) filter straw, expired [DATE] - located in emergency medication box h. Two (2) safety glide 25g x one (1) in needles, expired [DATE] - located in emergency medication box i. One (1) Atropine Sulfate one (1) ml vial, expired 2/26 j. Two (2) Clarithromycin 500 milligram tablets, expired 1/26RN #1 identified that the expired items should have been discarded and that it was the responsibility of the nursing staff on the 11:00 PM to 7:00 AM shift to check for expiration dates. RN #1 identified that the 11:00 PM to 7:00 AM checklist was signed off that staff checked for expiration dates.Attempts to contact staff on the 11:00 PM to 7:00 AM shift were unsuccessful.Review of facilities Storage and Expiration Dating of Medications and Biologicals policy, dated [DATE], directed in part that facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals. Facility staff should inspect nursing station storage areas for proper storage compliance on a regular basis. 3. Observation of medication administration on [DATE] at 9:36 AM with Registered Nurse (RN) #2 identified RN #2 prepared medication for Resident #23, turned his back to the medication cart, entered Resident #23's room to administer medication, but left the medication cart unlocked with the top drawer (which contained various bottles of over the counter medications) open in the hallway.Interview with RN #2 on [DATE] at 9:41 AM identified that the policy for medication carts was that it should always be locked when a staff member was not present and that it was his responsibility to ensure that it was. RN #2 indicated that he forgot to lock the medication cart when he left it and that he should have locked it.Interview with the Nursing Supervisor (RN #1) on [DATE] at 10:00 AM identified that medication carts should be locked during medication administration when the assigned nurse was not present and that it was the responsibility of the nurse to ensure that it was secured.Review of facilities Storage and Expiration Dating of Medications and Biologicals policy, dated [DATE], identified that the facility should ensure all medications and biologicals, including treatment options, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on interviews, observations in the Dietary department and facility policy, the facility failed to ensure various food items were labeled with the date opened/expiration date, failed to ensure items were not stacked when wet, failed to identify plates coming from the dishwasher were clean, and failed to take freezer temperatures in 2 of 2 nourishment rooms. The findings include: On 3/23/26 at 10:24 AM, tour of the Dietary department with the Director of Dining identified the following: a. an 18 quart (qt) clear plastic bin (1/16 full) containing loose flour, an 18 qt clear plastic bin (4 qts full) containing loose breadcrumbs, and a 22 qt clear bin (12 qt full) containing loose oatmeal failed to identify the date the items were transferred into the bins from the original packaging and lacked an expiration date. The blue lid to the plastic bins of flour and breadcrumbs had an accumulation of white powdery debris and were dusty. b. a 46-ounce (oz) (almost full) plastic coated box type container of cranberry juice located in the beverage cooler was uncapped (no cap was located in the cooler), exposing the juice to the air. c. Observation of the clean side of the dishwashing room on 3/23/26 at 10:40 AM with the Director of Dining noted Dietary Aide (DA) #1 removed clean dishes and lid covers from the dishwasher and stacked them on a metal cart in the clean side of the dishwashing room. The metal cart contained 28 dome plastic entree lid covers stacked upside down, in 3 piles on top of the metal cart. The inside of the lid covers were wet with water, Additionally, there were stacked plates on the metal cart that clean dishes from the dishwasher were stacked on. The top plate was noted to have yellow, dried on debris and a lid cover was noted to have brown sticky debris along the rim. Interview with DA #1 at that time, identified the plates and lid covers just came out of the dishwasher, were clean and ready to be put into circulation. She identified that she does check the items for cleanliness as they come out of the dishwasher, did not notice the soiled plate and lid cover and must have missed it. Subsequent to surveyor inquiry, the Director of Dining removed the soiled lid cover and plate from the metal cart for re-washing. Interview with the Director of Dining on 3/23/26 at 10:42 AM identified the lid covers were stacked when they came out of the dishwasher because the kitchen does not have drying racks. He further identified that he didn't consider the lid covers to be stacked wet because they were going to be transported to the tray line (which was approximately 12 feet away). Observation of 5 stacked piles of lid covers noted on the tray line (on the counter to the steam table that were going to be used for lunch service/plating) noted the underside of the lid covers were also wet with droplets of water. d. On 3/25/26 at 12:18 PM, observation of the 2nd floor nourishment room (snack room) with the Director of Dining identified a refrigerator temperature of 38 degrees ( ) Fahrenheit (F). The freezer failed to have a thermometer present, but the inside of the refrigerator had 2 metal, round, portable thermometers. The freezer contained 46 (4 ounce) individual containers of majic cup and fat free sherbert, a 28-ounce (oz) tub (1/4 full) of Lactose free ice cream and a full 16-oz container of ice cream. e. On 3/25/26 at 12:20 PM, observation of the 3rd floor nourishment room identified there was no thermometer present for the freezer section, and the refrigerator's temperature was 34 F noted by a metal, round, portable thermometer. The contents of the freezer included 50 (4 oz) individual containers of ice cream and majic cups, a 1 qt tub of Lactose free ice cream (3/4 full) and a 28 oz tub (1/4 full) of Coffee ice cream. The Director of Dietary identified nursing was responsible for checking temperatures of the refrigerator/freezer and therefore did not know where the temperature logs were kept. On 3/25/26 at 12:20 PM, interview with Registered Nurse (RN) #1 identified that Dietary was responsible for checking refrigerator/freezer temperatures and therefore did not know where the temperature logs were kept. On 3/25/26 at 2:00 PM, the Director of Dining provided a temperature log that identified temperatures completed for the 2nd and 3rd floor refrigerators only and noted that temperatures were not taken for the freezer compartments. Additionally, the Director of Dining noted that he originally stated that nursing was responsible for taking temperatures of the refrigerators/freezers in the nourishment room in error. Facility policy for refrigerator temperatures identified temperatures would be monitored with appropriate documentation every 24 hours and a log will be maintained by the department or service manager. The policy failed to identify the frequency of taking freezer temperatures/logging the temperatures from the nourishment room freezers. Facility policy for dating and labeling food identified non-Time/Temperature Control for Safety (TCS) foods that have been removed from their original packaging shall be labeled with the item name, open date, original manufacturer's expiration date, and associate initials.

Based on interviews, review of facility policy and observations of resident bathrooms on 2 of 2 nursing units, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy and in a manner to provide a clean environment. The findings included: Observation on 3/25/26 at 11:33 AM and on 3/25/26 at 1:00 PM observation with Registered Nurse (RN) #1 identified the following: a. room [ROOM NUMBER]'s shared bathroom contained 2 wash basins located on the floor and 1 urinal on the back of the toilet; all items were unlabeled (as to whom they belonged to) and not covered.b. room [ROOM NUMBER]'s shared bathroom contained 1 bedpan located on the handrail near the toilet, uncovered and unlabeled (as to whom it belonged to).c. room [ROOM NUMBER]'s bathroom contained 1 wash basin, which was labeled but located on the floor of the bathroom. c. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin which was uncovered, labeled but stored on the floor and 1 bedpan hanging from the handrail near the toilet which was unlabeled (as to whom it belonged to) /uncovered.d. room [ROOM NUMBER]'s shared bathroom contained 1 unlabeled (as to whom it belonged to) and uncovered wash basin located on the back of the toilet. e. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor which was unlabeled (as to whom it belonged to) and uncovered.f. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor which was unlabeled (as to whom it belonged to) and uncovered.g. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor which was unlabeled (as to whom it belonged to) and uncovered. h. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor, unlabeled (as to whom it belonged to) and uncovered.i. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor and unlabeled (as to whom it belonged to).j. room [ROOM NUMBER]'s shared bathroom contained 1 wash basin located on the floor and unlabeled (as to whom it belonged to).k. room [ROOM NUMBER]'s shared bathroom contained 1 bedpan and 1 wash basin located on the floor; both were unlabeled (as to whom they belonged to).l. Room#314's shared bathroom contained 1 wash basin located on the floor and unlabeled (as to whom it belonged to). Interview with RN #1 on 3/25/26 at 1:20 PM identified resident personal hygiene items such as basins, bedpans, and urinals were to be stored in a cabinet and not on the floor and all items were to be labeled with the resident's name. RN #1 further identified the Nurse Aides were responsible for ensuring items were properly stored, labeled and the nurses were responsible for oversight.Interview with Licensed Practice Nurse (LPN) #1 (who was the Infections Preventionist) on 3/25/26 at 2:24 PM identified she last completed environmental rounds in December 2025 that included observations of rooms/ bathrooms and when she made observations to the resident's room during rounds, she had observed unlabeled and not properly stored personal hygiene items which required her to dispose of the items.Subsequent to surveyor inquiry, all unlabeled personal hygiene items were disposed of by RN#1 on 3/25/26 at 1:30PM.Review of the facility policy, Personal Care Items dated 2024, directed personal care items are handled in a manner to prevent the spread of infection through personal equipment. Personal care items are for single resident use only. To be marked with the Resident's name and discarded after discharge. Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a bag. If a resident uses the bedpan and urinal at will, do not allow placement on the floor or on a bedside table that was used for eating or drinking.

Based on clinical record review, interviews, and facility policy for 1 of 3 sampled residents (Resident #9) reviewed for accidents, the facility failed to complete neurological assessments after multiple unwitnessed falls, per facility policy. The findings include: Resident #9 was admitted to the facility in February 2025 with diagnoses that included unspecified dementia, displaced fracture of the left femur and osteoporosis with a current pathological fracture.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was severely cognitively impaired and required supervision or touching assistance for transfers and bed mobility and partial/moderate assistance for toileting.The Resident Care Plan (RCP) dated 11/14/25 identified Resident #9 was at risk for falls due to multiple risk factors with interventions to toilet Resident #9 before and after meals, encourage Resident #9 to wear proper footwear and keep the resident's environment safe.a. A facility Reportable Event (RE) form dated 9/20/25 at 8:00 PM identified Resident #9 had an unwitnessed fall. The RE identified Resident #9 was observed sitting on the floor next to his/her recliner. The resident denied any pain or discomfort and no apparent injury was noted.A nursing note dated 9/20/25 at 11:33 PM identified Resident #9 was sitting on the floor next to his/her recliner and the resident was alert with baseline confusion. No apparent injury was identified. The nursing note failed to indicate neurological assessments were initiated or completed.b. A facility RE form dated 11/10/25 at 6:30 PM identified Resident #9 had an unwitnessed fall. Resident #9 was observed on the floor in front of his/her recliner. Additionally, the RE identified Resident #9 had no complaints of pain or discomfort. A nursing note dated 11/11/25 at 12:00 AM identified Resident #9 was found on the floor in front of his/her recliner. There was no apparent injury noted and the resident had no complaints of pain or discomfort. The nursing note failed to indicate neurological assessments were initiated or completed.c. A facility RE form dated 11/12/25 at 5:10 PM identified Resident #9 had an unwitnessed fall. The RE identified Resident #9 was observed sitting on the floor next to his/her recliner. The resident indicated he/she was going to the bathroom and no apparent injury was noted.A nursing note dated 11/12/25 at 11:54 PM identified Resident #9 was noted sitting on the floor next to his/her recliner. The resident was observed with loose stool on his/her pants and no apparent injuries were identified. The nursing note failed to indicate neurological assessments were initiated or completed.d. A facility RE form dated 11/14/25 at 6:20 PM identified Resident #9 had an unwitnessed fall. The RE identified Resident #9 was sitting on the floor next to his/her recliner. The resident was alert with baseline confusion and had no complaints of pain.A nursing note dated 11/14/25 at 11:03 PM identified Resident #9 was found sitting on the floor next to his/her recline. The resident had no complaints of pain or discomfort and was assisted off the floor. The nursing note failed to indicate neurological assessments were initiated or completed. e. A facility RE form dated 11/27/25 at 10:40 AM identified Resident #9 had an unwitnessed fall. The RE indicated Resident #9 slid out of her recliner chair and onto the floor and had no injuries.A nursing note dated 11/27/25 at 12:54 PM identified Resident #9 slid to the floor from his/her recliner and had a negative head strike. The resident was unable to give a clear answer as to what had occurred due to his/her baseline confusion. The nursing note failed to indicate neurological assessments were initiated or completed. On 3/30/26 at 11:30 AM, interview and review of the clinical record with the RN Supervisor covering for the DNS (RN #1) failed to identify neurological assessments were completed for Resident #9's unwitnessed falls on 9/20/25, 11/10/25, 11/12/25 and 11/14/25. Additionally, although a Neurological Assessment form was initiated for Resident #9 fall on 11/27/25, there was no documentation for 14 out of 22 assessments which should have been completed for the unwitnessed fall on 11/27/25.An interview with the RN Supervisor covering for the DNS (RN #1) on 3/30/26 at 11:30 AM identified neurological assessments should have been completed for Resident #9's unwitnessed falls, especially because the resident was confused and unable to reliably indicate if he/she had a head strike. RN #1 stated it would have been the responsibility of the charge nurse to ensure neurological assessments were initiated, completed and documented on the Neuro Assessment form after the resident's unwitnessed fall.Review of facility policy, Fall Management, dated 10/21, directed neurological assessments will be completed according to policy with all falls unless it is witnessed and the resident did not hit their head and/or the resident is alert, oriented without a diagnosis of dementia/confusion and reports they did not hit their head.

Based on review of the clinical record, facility policy and interviews for 2 of 6 residents (Resident #3 and Resident #26) reviewed for nutrition, the facility failed to ensure timely notification of a significant weight loss to either the physician, Dietician or responsible party. The findings include: 1. Resident #3's diagnosis included cerebrovascular disease, anxiety, and dementia. A Resident Care Plan (RCP) dated 10/8/25 identified Resident #3 was at risk for malnutrition with interventions that included gentle encouragement at mealtimes, honor food preferences, and diet as ordered. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was moderately, cognitively impaired and required set up assistance with oral hygiene, upper/lower body dressing and personal hygiene. Additionally, the MDS identified Resident #3 was independent with eating, was not on a mechanically altered or therapeutic diet and weighed 134 pounds (lbs.). The Weight and Vital Summary located in the electronic health record (EHR) identified Resident #3 weighed 136.2 pounds (lbs.) on 12/8/25, weighed 125 lbs. on 1/1/26 (a weight loss of 11.2 lbs./8.2% in 24 days), weighed 123 lbs. on 1/9/26 (a 13.2 lb./9.6% loss in 31 days). Additionally, on 2/3/26, Resident #3 weighed 117.8 lbs. (a loss of 19.2 lbs./14% in 57 days), on 2/20/26 weighed 113.6 lbs. and weighed 115.6 lbs. on 2/24/26. Interview with Registered Nurse (RN) #1 on 3/26/26 at 11:47AM identified the nurses were responsible for ensuring weights were completed as ordered and she was responsible for oversight. Also, identifying all weights were to be documented to the Electronic Medical Record (EMR) once obtained and if the weight loss was greater than 5 pounds(lbs.) a reweight should have been obtained. Further, identifying the family and physician were to be notified if the weight loss was greater than 5 lbs and the family had not been notified of Resident #3's significant weight loss from 12/8/25 through 1/1/26 until the Resident Care Plan meeting on 1/26/26. 2. Resident #26's diagnoses included Type 2 diabetes mellitus, gastro-esophageal reflux disease and unspecified protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was cognitively intact and required partial/moderate assistance with bed mobility and transfers. The MDS further identified Resident #26 required substantial/maximal assistance with toileting, had weight loss, was not on a physician prescribed weight loss regimen and had a diagnosis of malnutrition. The MDS further noted Resident #26 was on a mechanically altered and therapeutic diet. The Resident Care Plan (RCP) dated 11/17/25 identified Resident #26 had impaired cognitive function with cognitive decline, Type 2 diabetes mellitus and was at risk for malnutrition with weight loss over the past 6 months. Interventions included providing diet and supplements as ordered, weigh the resident per the physician's order and to keep the physician and family notified with a dietary consult for a nutritional regimen and ongoing monitoring. Review of the Weights and Vitals summary located in the electronic health record (HER) identified that on 10/5/25 Resident #26 weighed 140.8 pounds (lbs.), on 11/7/25 weighed 127.4 lbs. (which was documented by RN #3) (a 13.4 lb/9.52% loss in 33 days), on 11/11/25 weighed 125.8 lbs., on 12/3/25 weighed 128.2 lbs., on 1/10/26 weighed 116.8 lbs. (which was documented by RN #3) (an 11.4 lb./8.89% loss in 38 days), and on 1/23/26 weighed 116.4 lbs. (a 25.2 lb./17.33% loss in 110 days from 10/5/25 to 1/23/26). A Social Service Note/Care Plan Meeting Note dated 2/10/26 identified Resident #26 attended his/her care plan meeting, and the residents responsible party (Person #1) was in attendance by phone. The note indicated Resident #26 had lost 11.8 lbs. since December 2025. Interview and review of the clinical record with the Dietician on 3/26/26 at 1:45 PM identified she was aware that Resident #26 had a significant weight loss of more than 25 lbs. in the last several months. Review of the resident's weight record with the Dietician indicated Resident #26 had an additional 11.4 lb. weight loss identified on 1/10/26 (weight of 116.8 lbs.) and she was not notified of the weight loss until she returned to the facility on 1/20/26. The Dietician indicated the nursing staff should have notified the regional dietician of the resident's weight loss in her absence and she was unsure why that was not done on 1/10/26. The Dietician stated the nursing staff would usually tell her in person, email her or put a note in the communication book to notify her of a resident's weight loss, however review of her email and the communication book failed to indicate she was notified of Resident #26's continued weight loss. Additional review of Resident #26's physician/APRN and nursing progress notes with the Dietician noted the physician/APRN and resident representative had not been notified of Resident #26's additional weight loss in 1/10/26 and the nursing staff was responsible to make those notifications. Interview and review of the clinical record with RN #3 on 3/26/26 at 3:15 PM identified she obtained and documented Resident #26's weight on 1/10/26 and failed to notice the residents continued weight loss of 11.4 lbs. (from prior weight on 12/3/25). RN #3 indicated she did not look at the resident's prior weights and assumed RN #1 would have seen the weight loss trend and would have notified the physician, dietician, and responsible party on the morning shift if necessary. RN #3 further identified she always worked the 3:00 PM to 11:00 PM shift, and since Resident #26's weight loss would have triggered in the system, RN #1 should have picked it up the next day. Interview with Person #1 on 3/26/26 at 3:35 PM identified he/she was not notified of Resident #26's weight loss from 12/3/25 to 1/10/26 (loss of 11.4 lb.) until he/she attended the resident's care plan meeting by phone on 2/10/26. Person #1 indicated although he/she had received timely phone calls about the residents falls, she was not notified of the continued weight loss until the care plan meeting and during his/her subsequent visit to the facility to see Resident #26 in February 2026. Interview and review of the clinical record with the RN Supervisor covering for the Director of Nursing Services (RN #1) on 3/26/26 at 3:45 PM identified she was aware that Resident #26 had a significant weight loss of more than 25 lbs. in the last several months. RN #1 indicated after the residents continued weight loss was identified on 1/10/26 (loss of 11.4 lbs.) RN #3 should have notified the physician, dietician, and responsible party on the same day. RN #1 identified it would have been the responsibility of RN # 3 (who obtained and documented Resident #26's weight on 1/10/26) who should have made the necessary notifications and documented in the nursing progress notes and she was unsure why that was not done. RN #1 indicated she was going to need to meet with the nursing staff to provide further education on notifications and documentation. Interview and review of the clinical record with APRN #1 on 3/30/26 at 11:00 AM identified although she was aware of Resident #26's weight loss in November 2025, she was not notified of Resident #26's continued weight loss in January 2026. APRN #1 indicated the nursing staff would have been responsible to notify her in person or by phone of the weight loss and review of APRN #1's communication book and progress notes failed to indicate notification documentation. APRN #1 identified she would have expected to be notified of the residents 11.4 lb. weight loss on the same day (1/10/26) and had she been notified she would have written a progress note, asked for the resident to be re-weighed and requested the dietician to see the resident. Additionally, APRN #1 indicated she would have assessed Resident #26, re-evaluated the resident's supplements and Remeron dosage (a medication used for appetite stimulation), and ordered blood work. APRN #1 stated in addition to herself, the nursing staff should have notified the Dietician, and Resident #26's responsible party of the continued weight loss timely. APRN #1 further indicated that if the regular Dietician was away the nursing staff should have notified the covering/regional dietician of Resident #26's weight loss and not waited for the regular Dietician to return to the facility on 1/20/26. Review of the Weight Policy dated 11/24 directed, in part each resident will have their weight monitored, which will ensure that each resident maintains an optimum body weight. All residents will be weighed at least monthly unless the physician orders otherwise. If a resident's weight is a gain or loss of 5 pounds or more a reweight will take place the next day. If the resident's repeat weight is a gain or loss of 5 pounds the weight will be reported to the physician and the dietician for appropriate interventions. The responsible party will be notified of the weight change and recommended interventions. Weekly and/or more frequently weights will be done per the physician orders and reported according to the parameters given.

Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents observed utilizing an air mattress (Resident #31), the facility failed to ensure the air mattress was set according to physician orders. Additionally, for 1 of 2 sampled residents (Resident #45) reviewed for edema, the facility failed to complete weekly weights after readmission to the facility, per the physician order. The findings include: 1.Resident #31's diagnoses included dementia, chronic respiratory failure, and anxiety. A physician order dated 2/25/25 and currently in effect directed an air mattress for the bed, to set according to the resident's weight, and check for inflation/function every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 was moderately cognitively impaired, dependent on staff for dressing toileting, showering and transfers. The MDS further identified Resident #31 required set up assistance for eating, was at risk for a pressure ulcer, had a pressure reducing device for his/her bed and weighed 152 pounds (lbs.). The Resident Care Plan (RCP) dated 1/7/26 identified Resident #31 had a potential for pressure ulcer development related to impaired mobility and incontinence. Interventions included pressure reducing mattress to bed, keeping skin clean/dry and notifying the charge nurse of any skin issues. Observation on 3/24/26 at 9:45 AM, 3/25/26 at 9:19 AM noted Resident #31 lying in bed on an air mattress that was set at 250 lbs. with a sticker on the setting directing to set according to weight (Resident #31 weighed 152 lbs.). Observation on 3/26/26 at 6:17 AM noted Resident #31 lying in bed on an air mattress that was set at 225 lbs. Interview on 3/26/26 at 6:17 AM with Licensed Practical Nurse (LPN) #2 identified the air mattress was in place to prevent Resident #31 from developing a pressure ulcer and was set incorrectly at 225 lbs. LPN #2 further identified nursing staff were responsible for overseeing that the air mattress was set correctly according to the resident's weight. LPN #2 also indicated Resident #31 had skin issues in the past and was incontinent. Interview on 3/26/26 at 6:28 AM with Registered Nurse (RN) #1 identified the Resident Care Plan directed for the use of an air mattress to be set according to the resident's weight which was 141 lbs. on 3/26/26. RN #1 further noted the air mattress should be set at 150 lbs. Further, identifying all nurses were responsible for ensuring the air mattress was set correctly and nursing was to check every shift that it was set according to the resident's weight per the facility policy. Review of the Use of Support Surfaces Policy dated 2026 directed, in part support surface will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Support surfaces refer to a specialized mattress, mattress overlay, or chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. Support surfaces will be utilized in accordance with the physician orders. 2. Resident #45's diagnoses included metabolic encephalopathy, Type 2 diabetes mellitus, and essential hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #45 had intact cognition, required substantial/moderate assistance for toileting hygiene and showering/bathing self, lying to sitting on side of bed, and sitting to standing. The Resident Care Plan (RCP) dated 10/21/25 identified Resident #45 had impaired circulation related to deep vein thrombosis and lymphedema of the right lower extremity. Interventions included elevating legs when resting and inspecting foot/ankle/calf skin for redness, edema, puffiness, tenderness, and areas with no sensation. Resident #45 was readmitted to the facility on [DATE] from the acute care hospital. A readmission physician's order dated 12/26/25 directed to weigh Resident #45 every week for 4 weeks and then monthly. A Nursing Admission/readmission Assessment on 12/26/25 identified a weight of 185 pounds (lbs.). The Medication Administration Record from 12/26/25 to 1/16/26 identified weights were documented as completed by initials on 1/2/26 and 1/16/26 with no weight number entered. A Weights and Vitals summary located in the electronic health record (EHR) from 12/26/25 to 1/16/26 identified a weight of 180.4 lbs. was documented on 1/2/26, but failed to include weekly weights from 1/9/26, 1/16/26 and 1/23/26. Interview and facility document review with Nurse Aide (NA) #3 on 3/26/26 at 8:47 AM identified that residents were usually weighed monthly on their shower day and that it was the responsibility of the NA to complete them. NA #3 indicated that they know which residents need to be weighed on their shift when given the NA worksheet which was filled out by the unit nurse. Additionally, NA #3 identified that weights were documented on the NA worksheet and given to the unit nurse once all resident weights/vitals were completed for that shift. NA #3 could not identify the reason Resident #45 was not weighed on 1/9/26, 1/16/26 and 1/23/26 although Resident #45 was listed on the NA worksheet to have weights completed weekly. Interview and clinical record review with Registered Nurse (RN) #2 on 3/26/26 at 9:03 AM identified that residents were weighed monthly on their shower day and that it was the responsibility of the NA to complete them. RN #2 indicated that residents were assigned the shower day and it typically stays the same. RN #2 indicated that to see if a resident's orders for weights have changed, they would be informed during report, by the dietician, by the provider, or they would review the resident orders for changes at the beginning of the shift. RN #2 indicated that NAs would document resident weights/vitals on the NA worksheet. After completion the NAs would give the worksheet to the unit nurse to document in the resident's EHR. RN #2 indicated that if weights were not completed, it should be documented by the NA on the NA worksheet and in the EHR by the unit nurse. RN #2 could not identify the reason Resident #45 was not weighed on 1/9/26, 1/16/26 and 1/23/26 and that the NA should have documented why it was not completed. Interview and clinical record review with the Registered Nurse Supervisor (RN #1) on 3/26/26 at 9:08 AM identified that residents were weighed weekly for four (4) weeks upon admission/readmission to the facility and then monthly unless provider orders indicated otherwise. RN #1 indicated it was the responsibility of the NA to complete the weights on the scheduled days, but that it was the overall responsibility of the unit nurse to ensure they were completed and documented in the resident's EHR. RN #1 identified that Resident #45 had physician orders for weekly weights upon readmission into the facility on [DATE]. Review of the facilities weights policy dated 11/24 directed in part that weights will be obtained within 24 hours of admission and then weekly for 1 month. Weights will be recorded in the electronic medical record. Weekly/more frequent weight checks will be done per physician order.

Based on observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #6) reviewed for positioning and mobility, the facility failed to apply a left upper extremity splint per the physician's order for a resident with a hand contracture. The findings include: Resident #6's diagnoses included unspecified dementia with agitation, spondylolysis (stress fracture or crack in bone of vertebrae of spine), and age-related osteoporosis. An Occupational Therapy (OT) evaluation dated 1/29/25 identified Resident #6 had worsening hand tremors, worsening tone and increased left hand tightness. The OT evaluation further noted Resident #6 was at risk for development of a hand contracture and skin breakdown. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #6 was severely cognitively impaired and dependent with toileting, bed mobility and transfers. The MDS indicated Resident #3 had an upper extremity impairment on one side but failed to indicate the use of orthotics. The Resident Care Plan (RCP) dated 1/15/26 identified Resident #6 wore a splint to his/her left hand to inhibit contractures and skin breakdown. Interventions included to check the resident's skin when putting the splint on and off, to put the splint on the left hand when Resident #6 was out of bed and take the splint off when the resident was in bed. Additional interventions included for rehab to check the splint and nursing to monitor skin integrity. A physician's order dated 2/2/26 directed application of a left-hand splint when out of bed and to monitor skin integrity pre and post application of the splint. The Nurse Aide (NA) Assignment Card identified the resident was to have a left-hand splint applied when out of bed and removed when in bed. Observations on 3/23/26 at 12:30 PM and 3/24/26 at 12:28 PM noted Resident #6 out of bed in a customized wheelchair, seated in the dining room without the benefit of a left upper extremity splint.An additional observation on 3/25/26 at 1:17 PM noted Resident #6 out of bed in a customized wheelchair seated in his/her room without the benefit of a left upper extremity splint. Observation and interview on 3/25/26 at 1:33 PM with NA #2 identified Resident #6 was seated in a custom wheelchair in his/her room and without the benefit of a left upper extremity splint on. NA #2 indicated she had been unable to locate Resident #6's splint, but had not informed the charge nurse. NA #2 proceeded to search Resident #6's dresser drawers for the splint but was unable to locate the splint. NA #2 then informed RN #2 that the splint was not available. Observation, interview and review of the clinical record with RN #2 on 3/25/26 at 1:35 PM identified although he had already initialed the Treatment Administration Record indicating Resident #6's left upper extremity splint had been applied, he was unsure why the resident did not have the hand splint applied and he was unaware the splint was unable to be located. RN #2 indicated Resident #6 should have had the left upper extremity splint applied while out of bed and NA #2 should have notified him if she was unable to find the splint. Additionally, RN #2 indicated he would continue to look for the splint and notify the rehab department if he was unable to locate it. Interview with the RN Supervisor covering for the Director of Nursing (RN #1) on 3/25/26 at 2:45 PM identified Resident #6 should have had the left upper extremity splint applied per the physician's order and she was unsure why staff were unable to locate the splint. RN #1 indicated the NA should have notified the charge nurse when she could not find or apply the splint. Subsequent to surveyor inquiry, an observation of Resident #6 on 3/26/26 at 9:48 AM noted Resident #6 out of bed in a customized wheelchair seated in his/her room with a left upper extremity splint applied. An additional interview with RN #2 on 3/26/26 at 10:00 AM indicated Resident #6's left upper extremity splint was located in the afternoon on 3/25/26 at the nurses station. RN #2 indicated he was unsure why the splint was there and not on the resident and he or the NA should have ensured it was applied. Observation, interview and review of the clinical record with the Rehab Director (PT #1) on 3/26/26 at 10:15 AM noted Resident #6 out of bed in a customized wheelchair with the left upper extremity splint applied. PT #1 indicated the splint was to maintain range of motion and to prevent the residents hand contracture from getting worse. PT #1 identified if Resident #6 was not wearing the splint as ordered it could also worsen Resident #6's left upper extremity muscle tone and put the skin integrity of the resident's hand at risk. PT #1 further indicated it would have been the responsibility of the nursing staff to ensure the left upper extremity splint was applied as ordered and if the splint was unable to be located the charge nurse should have notified the rehab department. Review of the facility policy, Splinting Policy, undated, directed nursing staff must apply and remove splints per the ordered schedules, document compliance and observations and report concerns promptly to therapy.

Based on observation, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #6) reviewed for positioning and mobility, the facility failed to complete a mechanical lift transfer with 2 staff members. The findings include: Resident #6's diagnoses included unspecified dementia with agitation, spondylolysis (stress fracture or crack in bone of vertebrae of spine), and age-related osteoporosis.The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #6 was severely cognitively impaired and dependent with toileting, bed mobility and transfers. The MDS indicated Resident #3 had an upper extremity impairment on one side and a lower extremity impairment on both sides. The Resident Care Plan (RCP) dated 1/15/26 identified Resident #6 had impaired mobility, was non- ambulatory and was at risk for falls. Interventions included Resident #6 required total assistance with transfers with a mechanical lift with the assist of 2 staff and had total dependence on staff for repositioning and turning in bed. A physician's order dated 2/2/26 directed transfer Resident #6 with assist of 2 staff using a mechanical lift and the resident was non-ambulatory.The Nurse Aide (NA) Assignment Card identified Resident #6 was non-ambulatory and required assistance of 2 staff for transfers via a mechanical lift. Observation and interview with NA #1 on 3/25/26 at 1:28 PM noted NA #1 was transferring Resident #6 from the wheelchair to the bed with the mechanical lift and without the benefit of another staff person present to assist. NA #1 indicated she was performing the transfer alone in the room with Resident #6 and she should not have been. The resident was observed connected to the mechanical lift and was being moved over the bed while being suspended by the mechanical lift. NA #1 proceeded to lower the mechanical lift and place Resident #6 onto the mattress of the bed. RN #2 then entered the room and indicated NA #1 should have asked for his or the other NA's assistance with the transfer and should not have transferred Resident #6 with the mechanical lift without another staff present and assisting her. RN #2 was unable to identify the reason NA #1 would transfer the resident by herself as he and NA #3 were both on the unit.Interview with the Administrator and the Nursing Supervisor covering for the Director of Nursing Services (RN #1) on 3/25/26 at 1:37 PM identified NA #1 should have had a second staff person in the room when using the mechanical lift to transfer Resident #6 from the wheelchair to the bed. RN #1 indicated all nursing staff were trained on the proper use of the mechanical lift and NA #1 would have been responsible to safely transfer the resident with 2 staff persons.Review of the facility policy, Safe Resident Handling, dated 6/2016, directed to promote a safe, secure, and comfortable experience for residents who require full transfer assistance, staff members are trained on and required to maintain compliance with policies and procedures related to safe resident handling. Failure of staff to maintain compliance would lead to disciplinary action up to and including termination of employment. Safe resident handling and moving required staff use all mechanical handling devices in accordance with policy, instruction, and training.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #42, 9 and 7), reviewed for accidents, for Resident #42 who had severely impaired cognition, a history of falls and was at high risk for elopement, the facility failed to monitor and accurately document the residents location in the facility every 15 minutes according to the plan of care which resulted in the resident being able to exit the facility (elope) unsupervised. These failures to properly monitor and accurately document the resident's location in the facility allowed the resident to elope the facility and resulted in a finding of Immediate Jeopardy. Additionally, for Resident #9, the facility failed to ensure the resident was transferred according to the physician's order resulting in a fall with an injury, and for Resident #7 the facility failed to ensure the staff used a gait belt during a transfer. The findings include: 1. Resident #42 was admitted to the facility with diagnoses that included Alzheimer's disease, anxiety, dementia with behavioral disturbances, violent behaviors, and difficulty walking. The quarterly MDS dated [DATE] identified Resident #42 had severely impaired cognition, rejects care, has behaviors such as pacing 1 - 3 days a week and ambulates with supervision or touching assistance with a walker. The care plan dated 1/12/24 identified Resident #42 wanders, was at risk of elopement and has a history of attempts to leave the facility unattended. Interventions included ensuring a stop sign on the exit door to the stairwell, monitoring the resident's location every 15 minutes and documenting the wandering behavior and attempted diversional interventions on the log. Elopement/wander assessment dated [DATE] identified Resident #42 was at high risk for elopement. The physician's order dated 5/6/24 directed Resident #42 required supervision for transfers and ambulation with a wheeled walker. Review of the every 15 minute check form dated 6/1/24 at 4:00 PM, completed by NA #6, identified Resident #42 was in his/her bed in his/her room. (This is in conflict with the surveillance video that shows that at 3:59 PM Resident #42 was walking in the hallway, rounding the corner toward the residential care unit). Review of the every 15 minute check form dated 6/1/24 at 4:15 PM, completed by NA #6, identified Resident #42 was in a chair in his/her room. (This is in conflict with the surveillance video that shows that at 4:01 PM Resident #42 exited a door to the patio area outside). Review of the every 15 minute check form dated 6/1/24 at 4:30 PM, completed by NA #6, identified Resident #42 fell outside. (This is in conflict with the surveillance video that shows that at 4:34 PM Resident #42 was outside, alone, walking down the driveway that goes up a hill to the residential houses and at 4:35 PM Resident #42 gets down the driveway, passes the trees and went out of camera sight). The nurses note, written by RN #1, dated 6/1/24 at 11:41 PM identified that at approximately 4:30 PM a nurse aide informed this writer that Resident #42 was outside the building and possibly fell . This writer checked on the resident, who was laying on the grass outside. Per the nurse aide, Resident #42 was seen holding a pillow while walking outside the building near the residential living parking lot area. Assessment indicated no abrasions or bruises noted to body. Resident #42 was assisted off the ground with a gait belt, was able to stand and walk without issue, ambulated back to the building, and was placed in a wheelchair. The resident will continue to be closely monitored for safety every 15 minutes. Resident representative updated and verbalized concern with resident's safety. The DNS was made aware of the incident and resident representative's concerns. Interview with the DNS on 6/3/24 at 8:15 AM indicated that she feels the facility has used all interventions related to Resident #42's falls and wandering and that was why Resident #42 was placed on every 15-minute checks for safety. The DNS indicated that Resident #42 doesn't come out of the room during the day but in the evening sometimes will sit in the hallway in a common area. The DNS indicated that the wander guard system is only for residents on the 3rd floor, long term care unit. Interview with NA #6 on 6/3/24 at 9:05 AM indicated that she worked on Saturday 6/1/24 from 3:00 PM until 11:00 PM. NA #6 indicated when she came in at 3:00 PM Resident #42 was wandering in and out of his/her room and wandering back and forth near the nursing station. NA #6 indicated she started rounds and was making the bed in a room at the end of hallway when she saw Resident #42 through the window walking outside in the rear parking lot with his/her pillow. NA #6 got NA #4 and they went down the stairwell outside to find Resident #42 across the parking lot from the facility laying down on the grass under a tree with the pillow completely under his/her back. NA #6 indicated that Resident #42 indicated he/she was sleeping there. NA #6 indicated she ran back to the facility to get the charge nurse. NA #6 indicated they used the gait belt and assisted Resident #42 off the ground and Resident #42 walked back to the building almost to the back door and turned around to go back away from the facility. NA #6 indicated the nurse went into the facility to get a wheelchair for the resident. NA #6 indicated that Resident #42 was all the way on the other side of the back parking lot, over the curb in the grass under the tree near the driveway to the residential houses. NA #6 indicated she did not see when or where Resident #42 had left the facility. Interview with RN #3 on 6/3/24 at 9:50 AM indicated Resident #42 was at high risk for elopement. RN #3 indicated that Resident #42 was at the end of the hallway but wandered up and down the hallway and almost daily would try to go out through the stairwell at the end of hallway by his/her room. Staff put up a stop sign across the stairwell door until the lock with a keypad came in, so Resident #42 couldn't open the door. RN #3 indicated that Resident #42 has attempted to leave the unit before but had not had an elopement and that was why Resident #42 was on every 15-minute checks to monitor his/her location. Interview with the DNS on 6/3/24 at 10:30 AM indicated that Resident #42 did not elope on 6/1/24 because he/she never left the facility property and did not fall because Resident #42 indicated that he/she laid down with the pillow. The DNS indicated that Resident #42 had severe cognitive impairment but to her it was obvious that Resident #42 had taken the pillow to purposefully go outside to lay down in the grass with the pillow. The DNS indicated that Resident #42 was on every 15-minute checks for safety due to wandering. The DNS indicated that she did not know how big the property was other than it had a short and long-term care facility, residential living facility, and up in the back area were residential homes. The DNS indicated that she believes Resident #42 was last seen on 6/1/24 at 4:15 PM and was then seen outside at 4:30 PM. The DNS indicated that she could not say how long Resident #42 was outside before NA #6 saw Resident #42 through the second-floor window. Interview with the DNS on 6/4/24 at 10:28 AM indicated that since admission Resident #42 has been at high risk for elopement and interventions were to try to keep him/her in common areas while awake, have him/her join activities, land redirect if walking around. The DNS noted on 8/21/23 Resident #42 was found outside of facility. The DNS indicated that Resident #42 was placed on every 15-minute checks and a stop sign on the stairwell door until the lock could be installed. The DNS indicated that she had not done an investigation or watched the video surveillance to investigate when Resident #42 had left the facility and when he/she was found. The DNS indicated that the nursing supervisor had called and informed her that Resident #42 had left the facility out the residential living exit doors and a nurse aide had seen Resident #42 in the parking lot outside of the facility walking. When staff arrived outside Resident #42 was found lying on the grass under a tree with a pillow. The DNS assumed it was the tree closest to the exit door approximately 30 feet from exit door. The DNS indicated that the expectation was that the nurse aides would visually check and see Resident #42 every 15 minutes, and then would document the location and what Resident #42 was doing. Observation of the surveillance video for 6/1/24 with the DNS and the Maintenance Director on 6/4/24 at 11:15 AM identified the following: At 3:59 PM Resident #42 was walking in the hallway, rounding the corner toward the residential care unit with a pillow and without a walker. At 4:01 PM Resident #42 exited the right-hand side door to the patio area outside and then was out of camera surveillance site. At 4:28 PM the resident was seen on the camera on the parking lot side looking down to the end of the building where the maintenance garage area is. At 4:29 PM Resident #42 appears and stopped when walking in the parking lot against the stone wall on the opposite side of the facility. At 4:29 and 45 seconds Resident #45 stumbles twice and lays down on the small grassy area in the parking lot away from the facility. At 4:34 PM Resident #42 was back to standing position and started walking down the driveway that goes up a hill to the residential houses towards the other end of the facility. At 4:35 PM Resident gets down driveway, passes the trees and went out of camera sight. At 4:37 PM and 30 seconds a staff member is seen coming from the end of the driveway towards the facility. The DNS indicated that was the nurse aide coming into the facility to get the nurse. At 4:47 PM the nurse exited the facility with the wheelchair, had Resident #42 sit in the wheelchair and was seen pulling Resident #42 backwards in the wheelchair into the facility. The DNS indicated that Resident #42 was to ambulate with supervision using a wheel walker and during video there was no walker or staff assistance. The DNS indicated that Resident #42 does not remember to take the walker that staff must give it to him/her. The DNS indicated that Resident #42 had left the facility at 4:01 PM and was not seen by the staff until at least 4:36 PM. The DNS indicated that no one had witnessed Resident #42 go from a standing position to laying on the ground, but she felt Resident #42 did it on purpose. The DNS indicated that she was not aware prior to watching the video with the surveyor how long Resident #42 had been unattended outside of the facility. Although attempted, an interview with NA #6 was not obtained. Review of the facility Elopement Policy identified the facility strives to promote resident safety and protect the rights and dignity of the residents. Elopement is defined as the ability of a resident who is not capable of protecting him/herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way. Prevention would include frequent monitoring of the resident's whereabouts to assure he/she remains in the facility with every 15-minute checks, cameras are in place that continually monitor all the exits in the building, elevator controls, restricted window openings. When a resident has been found the search Director or DNS will notify all staff that the resident has been found and the charge nurse will examine the resident for injuries. The Physician and resident representative will be notified. The care plan will be updated. Implement every 15-minute checks for safety. Complete a Missing Resident form and required staff present and involved to sign the form. Report the incident to the state authorities as required. 2. Resident #9 was admitted to the facility in November 2019 with diagnoses that included hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, heart failure, and atrial fibrillation. A physician's order dated 1/12/23 directed to provide the assistance of 2 for transfers from bed to/from wheelchair with hemi walker. The care plan dated 3/22/23 identified Resident #9 was at risk for falls related to gait/balance problems and left sided weakness. The April 2023 monthly physician's orders directed to transfer the resident with the assistance of 2 from bed to/from wheelchair with hemi walker, no ambulation. The fall assessment dated [DATE] identified Resident #9 was at high risk for falling. The annual MDS dated [DATE] identified Resident #9 had intact cognition and required extensive 2-person assistance with transfers. The care card, without a revision date, identified to transfer Resident #9 with the assistance of 2 with hemi walker. The May 2023 monthly physician's orders directed to transfer the resident with the assistance of 2 from bed to/from wheelchair with hemi walker, no ambulation. The nurse's note dated 5/11/23 at 11:46 PM identified RN #1 was notified by LPN #1 at 6:30 PM that Resident #9 had fallen. RN #1 observed Resident #9 on the bedroom floor with an L shape laceration on the left mid part of the head that measured 5cm x 0.2cm with moderate amount of bleeding. Resident #9 was alert and verbally responsive complaining of pain to the head and back area with no shortening/lengthening of bilateral legs. A cold compress was applied to the wound area to control the bleeding. Neurological checks and vital signs were initiated and were within normal limits. The physician was notified and ordered Resident #9 to be sent to the hospital for further evaluation. The reportable event form dated 5/11/23 at 6:30 PM identified Resident #9 was being assisted with a transfer of 1 staff and the hemi walker from the wheelchair to the bed and lost his/her balance, struck his/her head on the floor and sustained a laceration on the back of the head. Pressure was applied to the back of the head and Resident #9 was transferred to the hospital for treatment. Review of a statement written by NA #1 dated 5/11/23 identified she was transferring Resident #9 from the wheelchair to the bed. NA #1 indicated she was in front of Resident #9 holding on to his/her clothing. Resident #9 was holding onto the hemi walker and lost his/her balance and fell on his/her back. Review of the hospital inter-agency patient referral report (W-10) dated 5/11/23 identified Resident #9 was seen for a fall and head laceration repair. Resident #9 is to follow up with primary physician regarding wound and staples removal. The revised care plan dated 5/11/23 identified Resident #9 was at risk for falls related to gait/balance problems and left sided weakness. Resident #9 fell on [DATE] and sustained an injury to the head. Interventions included transferring Resident #9 to the hospital for evaluation and treatment. Physical therapy to evaluate and treat as indicated. Review of the education sheet dated 5/12/23 identified the use of gait belt was reviewed with NA #1. All residents that are ambulated and transfer with assist of 1 or 2 must have a gait belt placed around them and used to guide and stabilize the resident. If the nurse aide gait belt is not available there are gait belts at the nursing station for use. NA #1 was given a gait belt. The care plan dated 5/12/23 identified Resident #9 sustained a laceration on the left side of the head that required 10 staples to repair. Interview with MD #1 on 6/3/24 at 10:55 AM identified the nursing staff should have followed the physician's order to provide assistance of 2 when transferring the resident. Interview and review of the clinical record with the Physical Therapy Director on 6/3/24 at 11:00 AM identified Resident #9 was on therapy with activity orders to provide the assistance of 2 for transfers bed to/from wheelchair with hemi walker. Interview with NA #1 on 6/4/24 at 10:40 AM identified she was only employed at the facility for 1 month when Resident #9 fell , and it was her first-time providing care to Resident #9. NA #1 indicated she did not read the care card before transferring Resident #9 and she did not utilize a gait belt during the transfer. NA #1 indicated she did not check the care card and does not know what the care card directs for transfers for Resident #9. NA #1 indicated Resident #9 stood up and let go of the hemi walker and fell backward on the floor. NA #1 indicated Resident #9 was bleeding from his/her head. Interview and review of the clinical record with the DNS on 6/4/24 at 11:43 AM identified while conducting the investigation she called NA #1 who stated she transferred Resident #9 by herself and without a gait belt. The DNS indicated NA #1 should have used a gait belt and had the assistance of 2 persons with the transfer from the wheelchair to bed. The DNS indicated she educated NA #1 regarding the gait belt and reviewing the care card before providing care to a resident. The DNS indicated NA #1 was unable to state the reason why she did not use a gait belt and read Resident #9 care card. Review of the fall management and prevention policy identified to ensure that all residents are assessed for fall risk and that adequate measures are taken to prevent injuries due to falls. Residents will be assessed for fall risk using the Morse fall risk assessment form on admission, quarterly thereafter and with a change of condition. If the resident is at risk for falls, interventions to reduce this risk will be included in the resident's care plan. Review of the facility safe patient/resident handling policy identified to enhance the safety of the work environment for resident care providers and promote a safe, secure and comfortable experience for residents who require partial or full transfer assistance. An interdisciplinary team will evaluate and assess each resident's individual mobility needs. Resident mobility assessments will be performed or reviewed on admission, after a significant change in condition or based on direct care staff recommendations. Safe resident handling and moving requirements: All lifting and transferring of patients/residents will be performed according to their individual plan of care. Gait belts are a tool for gait stabilization - not lifting or moving residents. 3. Resident #7 was admitted to the facility on [DATE] with diagnoses that included stroke, osteoarthritis, hypertension. The care plan dated 12/12/23 identified Resident #7 was at high risk for falls due to deconditioning. Interventions included dycem to wheelchair to prevent sliding and call light in reach. The quarterly MDS dated [DATE] identified Resident #7 had intact cognition, required maximum assistance with personal hygiene, toileting, bathing, and dressing, was totally dependent on staff for transfers and utilized a wheelchair for mobility. Further, Resident #7 had no behaviors and no history of falls in the last 6 months. A physician's order dated 2/14/24 directed to provide the assistance of 1 for transfers from the bed to the wheelchair and to utilize a 1/2 lap tray. A reportable event form dated 3/3/24 at 2:00 PM identified Resident #7 slid and bumped his/her right knee while being transferred. Resident #7 is alert and forgetful, has complaints of pain and swelling to the right knee. Subsequent to physician notification, a new order was obtained to provide the assistance of 2 for transfers. The nurse's note dated 3/3/24 at 3:44 PM identified that Resident #7 is reporting pain in the right knee and the right knee appears swollen. Review of a written statement by NA #7 dated 3/6/24 indicated that on 3/3/24 she was attempting to transfer Resident #7 when she realized she could not transfer the resident without help. NA #7 pressed the call light and asked for the nurse to help her while Resident #7 was sitting on her lap until the nurse came in to assist. Review of a written statement by RN #4 dated 3/6/24 indicated that on 3/3/24 she responded to a call for help at approximately 6:15 AM in Resident #7's room. Upon entering the room, she observed NA #7 sitting on the side of the bed holding the resident on her lap. NA #7 informed RN #4 that she was having difficulty transferring Resident #7 into the wheelchair. RN #4 indicated that she assisted NA #7 to put Resident #7 back into the bed. RN #4 indicated that she straightened out Resident #7's clothes and then assisted transferring Resident #7 from the bed into the wheelchair. A written statement by the DNS on 3/6/24 indicated NA #7 was unable to say how Resident #7's knee was injured or bumped during the transfer. A physician order dated 3/7/24 directed Resident #7 be non-ambulatory with an assist of 2 with a mechanical lift from bed to custom wheelchair. The nurse's note dated 3/7/24 at 11:00 PM identified Resident #7 was seen by physical therapy and having difficulty transferring back to bed. The right knee remains red and swollen. Resident #7 has discomfort when leg is touched. The APRN was notified and ordered a right patella x-ray. Radiology report dated 3/8/24 at 7:29 AM indicated that Resident #7 had a fracture of the distal femoral shaft with malalignment with mild soft tissue swelling. Acute femoral fracture. A reportable event form dated 3/8/24 at 7:30 AM indicated that Resident #7 was complaining of right knee pain and the physician ordered an x-ray. The injury was an acute femoral fracture. Resident #7 was sent to the emergency room . The nurse's note dated 3/9/24 at 2:40 PM identified this nurse received a call from the hospital that indicated the resident's representative declined surgery due to residents advanced age and overall prognosis. Resident #7 arrived at the facility wearing a right knee immobilizer and a new order for narcotics. The hospital discharge summary dated 3/9/24 at 11:43 AM indicated that Resident #7 had a closed bicondylar fracture of the distal right femur. Interview with RN #4 on 6/4/24 at 11:50 AM indicated on 3/3/24 the call light came on from Resident #7's room. RN #4 indicated she got up and went to the room and saw NA #7 sitting on the edge of the bed in the center of the mattress with Resident #7 sitting on her lap with the resident's right shoe partially hanging off. RN #4 indicated NA #7 reported that she thought she could transfer Resident #7 by herself. RN #4 indicated she picked Resident #7's legs up and moved them back into the bed and NA #7 was then able to stand up. RN #4 and NA #7 [NAME] fixed Resident #7's clothes and shoes and transferred resident into the wheelchair. RN #4 indicated that the gait belt was not around Resident #7's waist during the transfer. RN #4 indicated that it was the facility policy that the nurse aide must place a gait belt on the resident for transfers and ambulation. Review of the facility Safe Resident Handling Policy identified to enhance the safety of the work environment for resident care providers and promote a safe, secure, and comfortable experience for resident's who require partial or full transfer assistance. All staff who participate in resident handling activities are required to use a mechanical assistive device for every resident handling activity when residents require partial or full assistance. Gait belts are a tool for gait stabilization and not lifting or moving residents. Definition of a resident that is an assist of 1 with or without a walker the transfer requires physical assistance of 1 staff member. These transfers are always a stand and pivot transfer with the use of a gait belt. 42117

Based on review of facility documentation, facility policy, and interviews the facility failed to ensure that an accurate record of an effective training program for all staff was maintained. The findings include: The Facility assessment dated [DATE] directed that every staff member has knowledge competency in: infection control, bed rails, body mechanics, confidentiality, corporate compliance, harassment, hospitality, lock out tag out, mission and values, hazard communication, abuse, neglect, exploitation and misappropriation; resident rights; identification of condition change; resident preferences and workplace violence. Additional knowledge competencies for all staff include dementia management, infection transmission and prevention, immunization, QAPI, and OSHA hazard communication. Hand hygiene return demonstration competencies and observed knowledge competencies for emergency response are also required. Competencies are based on current standards of practice and may include knowledge and a test, knowledge and return demonstration, knowledge and observed ability, knowledge and observed behavior, and annual performance evaluation. Upon the survey team's request for documentation of the completion of employee's annual in-servicing and competency training, the facility was unable to provide sufficient documentation, including completed and signed Annual Inservice Education Fair 12/11/23 through 12/29/23 packets and competency forms. Interview with the Administrator on 7/8/24 at 11:25 AM identified that the facility was unable to locate staff competency forms and tracking documentation supporting the required annual 12-hour nurse aide training. The Administrator further identified that the documentation had been missing since November of 2023, when the former Staff Development Nurse resigned. The Administrator indicated that starting next week, the facility will begin utilizing online educational modules. Interview with the DNS on 7/8/24 at 12:09 PM indicated that the facility was unable to locate the signed Annual Inservice Education Fair 12/11/23 through 12/29/23 packets and competency forms. The DNS further indicated that the in-service and competency documents had been stored together in a box, and that she had not seen the box since the former Staff Development Nurse had left the position, in November. The DNS identified that the facility had hired a new Infection Control/Staff Development Nurse, and she has been allotted 8 hours per week to oversee the on-going education of the facility staff, including the roll-out and utilization of a new online education program. The Staff Development Nurse was unavailable for an interview. The facility's Annual Education policy directs the facility to develop, implement, and maintain an effective training program for all new and existing staff. The intent is to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. The facility's Competency Evaluation policy directs the facility to evaluate employees to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents. The policy further directs that initial competencies are evaluated during the orientation process and subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations, and checklists are used to document training and competency evaluations.

Based on review of facility documentation, facility policy, and interviews reviewed for training requirements the facility failed to ensure that an accurate record of continuing nurse aide competence of no less than 12 hours per year, including dementia management training and resident abuse prevention training, was maintained. Upon the survey team's request for documentation of the completion of 12 hours of nurse aide annual in-servicing and competency training, the facility was unable to provide sufficient documentation, including completed and signed Annual Inservice Education Fair 12/11/23 through 12/29/23 packets and competency forms. Interview with the Administrator on 7/8/24 at 11:25 AM identified that the facility was unable to locate staff competency forms and tracking documentation supporting the required annual 12-hour nurse aide training. The Administrator further identified that the documentation had been missing since November of 2023, when the former Staff Development Nurse resigned. The Administrator indicated that starting next week, the facility will begin utilizing online educational modules. Interview with the DNS on 7/8/24 at 12:09 PM indicated that the facility was unable to locate the signed Annual Inservice Education Fair 12/11/23 through 12/29/23 packets, as well as, other in- servicing and competency forms. The DNS further indicated that the in-service and competency documents had been stored together in a box, and that she had not seen the box since the former Staff Development Nurse had left the position, in November. The DNS identified that the facility does complete 12 hours of in-service training, annually, for nurse aides and that there are specific educational requirements that need to be met within a designated timeframe including but not limited to topics like fear of retaliation, abuse, neglect, resident's rights, and dementia care. The DNS further identified that the annual 12 hours of nurse aide training was achieved using poster boards, lectures by department heads and the Staff Development Nurse, demonstrations, and videos. The DNS indicated that the facility had hired a new Infection Control/Staff Development Nurse, and she has been allotted 8 hours per week to oversee the on-going education of the facility staff, including the roll-out and utilization of a new on-line education program. The Staff Development Nurse was unavailable for an interview. The facility's Annual Education policy directs the facility to develop, implement, and maintain an effective training program for all new and existing staff. The intent is to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications. The policy further directs that certified nursing assistants will receive a minimum of 12 hours of education annually. The facility's Competency Evaluation policy directs the facility to evaluate employees to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents. The policy further directs that initial competencies are evaluated during the orientation process and subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations, and checklists are used to document training and competency evaluations.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Residents #20 and 42) reviewed for unnecessary medications, the facility failed to ensure orthostatic blood pressure monitoring was completed per the physician's order for a resident receiving an antipsychotic medication. The findings include: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses that included dementia, panic disorder, and a history of repeated falls. The quarterly MDS assessment dated [DATE] identified Resident #20 had intact cognition, sustained 2 or more falls with no injury and 1 fall with injury since the prior assessment, and received antipsychotic medications on a routine basis. The care plan dated 3/18/24 identified Resident #20 had a behavior problem related to hallucinations, accusatory behavior, and anxiety/panic disorders. Interventions included administering medications as ordered and monitoring for side effects and effectiveness. A physician's order dated 4/16/24 directed to obtain orthostatic blood pressures weekly, times 4 weeks. The April and May 2023 MAR's failed to identify that orthostatic blood pressures were obtained. The nurse's note dated 4/16/24 through 5/11/24 failed to identify that orthostatic blood pressures for the weeks of 4/16/24 and 5/7/24 were obtained or refused. Interview and clinical record review with LPN #4 on 6/4/24 at 9:30 AM failed to identify orthostatic blood pressures were completed on Resident #20 during the weeks of 4/16/24 and 5/7/24. LPN #4 indicated that it is the responsibility of the floor nurse to complete the task. LPN #4 completed the orthostatic blood pressures on 4/23/24 but did not work on the days that the orthostatic blood pressures were not completed. LPN #4 further indicated that Resident #20's blood pressure was documented in the electronic health record on 5/7/24, but only in a laying down position. Interview and clinical record review with the DNS on 6/4/24 at 9:53 AM failed to identify that 4 weekly orthostatic blood pressures were obtained, per the physician's order. The DNS indicated that it is the responsibility of the unit nurse to complete orthostatic blood pressures, and she would educate the nursing staff to complete orthostatic blood pressures, per the physician order. The DNS further indicated that she would ensure the order for orthostatic blood pressures weekly times four, would be completed for Resident #20. The facility's Use of Psychotropic Medication policy directs that residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The facility's Orthostatic Blood Pressure policy directs that orthostatic blood pressures will be taken weekly for one month on all residents receiving new antipsychotic medications, an increase in dosage of an antipsychotic medication, if symptoms of orthostatic hypotension are present, and as ordered by their physician. 2. Resident #42 was admitted to the facility with diagnoses that included Alzheimer's disease, anxiety, dementia with behavioral disturbances, and violent behaviors. The quarterly MDS assessment dated [DATE] identified Resident #42 had severely impaired cognition, rejects care and has behaviors such as pacing 1 - 3 days a week. Resident #42 requires maximum assistance with bathing and putting on footwear, and maximum assistance with toileting and personal hygiene. Resident #42 ambulates with supervision or touching assistance with a walker. Resident #42 is taking high risk drug class of antipsychotic, antianxiety, and antidepressants daily. The care plan dated 1/12/24 identified Resident #42 had impaired cognition with behaviors of wandering and looking for rides home. Interventions included administering medications as ordered and redirecting the resident when wandering in hallway. The psychiatric APRN note dated 3/5/24 indicated a GDR (gradual dose reduction) of the Seroquel was attempted and was unsuccessful, and the dose of Seroquel was increased. A physician order dated 3/5/24 directed to perform orthostatic blood pressures every month. A physician's order dated 3/8/24 directed to administer Seroquel (antipsychotic) 25 mg at 6:30 AM and 1:00 PM, Seroquel 100mg at bedtime, Ativan (antianxiety) 0.5mg twice a day, and Lexapro (antidepressant) 20 mg daily. A physician order dated 3/9/24 directed to increase Seroquel to 50 mg at 6:00 AM and 1:00 PM. A physician order dated 3/19/24 directed to discontinue Lexapro 20mg related to falls and increased cardiac concerns when used with high doses of Seroquel. Start Lexapro 15 mg daily for anxiety. Review of the electronic medical record from 4/1/24 - 4/30/24 identified no documentation of orthostatic blood pressures. Review of April 2024 TAR failed to reflect documentation of the orthostatic blood pressure. A physician order dated 4/11/24 directed to add Seroquel 50 mg at 5:00 PM daily. Review of the electronic medical record from 5/1/24 - 5/31/24 identified no documentation of orthostatic blood pressures. Review of April 2024 TAR failed to reflect documentation of the orthostatic blood pressure. Interview with APRN #1 on 6/3/24 at 1:22 PM indicated that on 3/5/24 she had put in the order for orthostatic blood pressures weekly times 4 weeks, because anytime there is a change with an antipsychotic medication, she was trained to order the weekly orthostatic blood pressures. APRN #1 indicated that Seroquel can lower the blood pressure and that's why they do the orthostatic blood pressures. APRN #1 indicated that if the nursing facility as a nursing measure or physicians order wants to continue orthostatic blood pressures monthly for the antipsychotics they can. Interview with the DNS on 6/4/24 at 10:50 AM indicated that any antipsychotic medications are followed by the psychiatric APRN. The DNS indicated the expectation was the nurses would follow the physician's orders for the weekly times 4 weeks orthostatic blood pressures, then monthly orthostatic blood pressures for residents that were on antipsychotic medications. The DNS indicated that if Resident #42 had refused, her expectation was the nurse would write refused on the Kardex and then put in a progress note as to why the resident had refused. After clinical record review, the DNS indicated that there was a physician's order for monthly orthostatic blood pressures due to Resident #42 being on antipsychotic medications, and they were not done for April and May 2024. Review of the facility Use of Psychotropic Medication Policy identified residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. A psychotropic drug affects the brain activity associated with mental processes and behaviors. Psychotropic drugs include but are not limited to antipsychotics, antidepressants, anti-anxiety, and hypnotics. The facility's Orthostatic Blood Pressure policy directs that orthostatic blood pressures will be taken weekly for one month on all residents receiving new antipsychotic medications, an increase in dosage of an antipsychotic medication, if symptoms of orthostatic hypotension are present, and as ordered by their physician. 47457

Based on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #10) reviewed for accidents, the facility failed to complete neurological vital signs after an unwitnessed fall, and for the only sampled (Resident #54) reviewed for a non-pressure skin condition, the facility failed to ensure weekly skin audits were completed, per the physician's order. The findings include: 1. Resident #10 was admitted to the facility with diagnoses that included dementia, osteoarthritis, hard of hearing, and diabetes. The care plan dated 1/2/24 identified Resident #10 was at risk for falls. Interventions included close supervisor while awake and encourage common areas when in wheelchair for close supervision. The fall risk assessment dated [DATE] identified Resident #10 was at high risk for falls. The quarterly MDS dated [DATE] identified Resident #10 had moderately impaired cognition, had no behaviors and required maximum assistance with toileting, bathing, and dressing. A reportable event form dated 3/31/24 at 3:50 PM identified Resident #10 was awake and alert with confusion, had an unwitnessed fall in his/her bedroom and indicated that he/she slid out of wheelchair attempting to take his/her off shoes. Resident #10 required the assistance of 1 for transfers. A nurses note dated 3/31/24 at 4:25 PM identified Resident #10 was found sitting on the floor in his/her room in front of the wheelchair at 3:50 PM. Resident #10 indicated that he/she was trying to take off his/her shoes and slid off wheelchair. The care plan dated 3/31/24 identified the resident had a fall from wheelchair. Interventions included that if staff see the resident removing shoes while in the wheelchair, attempt to provide assistance or redirect the resident. Interview with the DNS on 6/2/24 at 12:28 PM indicated that with all witnessed and unwitnessed falls, the nurses must follow the neurological assessment policy for vital signs and neurological assessments. The DNS indicated that if a resident has intact cognition with no diagnosis of dementia and can state they did not hit their head during a fall, then the nurses do not have to do the neurological assessments per the policy. The DNS indicated the completed neurological assessment sheets after a fall after are placed in the resident's medical record. Interview with the DNS on 6/2/24 at 12:55 PM, after review of the clinical record, identified the neurological assessments after the unwitnessed fall on 3/31/24 were not done. Review of the post fall neurological assessment policy identified the post-fall assessment is critical for identifying injuries and guiding appropriate treatment, emphasizing safety and optimal care. If a fall is witnessed and the head was not involved, or a resident is cognitively intact and denies hitting their head then neurological assessments do not need to be done. Neurological checks will be conducted and documented on the Neurological Assessment Sheet until completed. The Neurological Assessment Sheet included the date and time of the fall, the level of consciousness, pupils, hand grasps, blood pressure, pulse, respirations, temperature, oxygen saturation level, and signs or symptoms of headaches, nausea, or vomiting every 15 mins for 1 hour, every 30 minutes for 2 hours, every 2 hours for 8 hours, every 4 hours for 24 hours, and every 8 hours for 2 days. 2. Resident #54 was admitted to the facility on [DATE] with diagnoses that included dementia, sepsis, and difficulty in walking. A physician's order dated 10/27/23 directed to conduct a skin assessment every week, on shower day. The annual MDS assessment dated [DATE] identified Resident #54 had severely impaired cognition, was always incontinent of bladder, and was dependent for toileting hygiene. The care plan dated 1/28/24 identified Resident #54 was at risk for pressure ulcer development and skin impairment related to impaired mobility and incontinence. Interventions included weekly skin assessment on shower days and notifying the charge nurse of any skin issue. Review of Resident #54's weekly skin evaluations dated 2/1/24 through 3/31/24 failed to identify that a skin assessment was completed by the nurse (5 out of 10 weeks) on the following shower days: 2/19/24 2/26/24 3/11/24 3/18/24 3/25/24 The reportable event form dated 3/31/24 identified Resident #54 was observed with a bruise to the right forearm measuring 2.8cm x 3.0cm during bedtime care. The physician and family were notified, and his/her name bracelet was removed. Interview with RN #4 on 6/4/24 at 9:50 AM identified that it is the responsibility of the charge nurse to complete weekly skin assessments on the scheduled shower days. RN #4 further identified Resident #54's scheduled shower day was Monday during the day shift, and even if a resident refuses the shower, a skin assessment should still be completed. Interview with the DNS on 6/4/24 at 10:00 AM identified that the nurses on the units are responsible for completing weekly skin assessments on the resident's shower days. The DNS further identified that she would expect to see weekly skin audits completed per the facility policy and that she plans to re-educate nursing staff to complete the skin assessments weekly. The facility's Skin Assessment policy directs that residents are assessed on admission using the Braden Scale, and they are reassessed by a licensed nurse using this tool quarterly and with a significant change in their status. The skin is also assessed weekly with their shower and documented on the weekly shower assessment sheet.

Based on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to the report an allegation of potential mistreatment to the state agency timely. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition and required limited assistance of 1 person with transfer, ambulation, dressing and toileting. The Resident Care Plan (RCP) updated on 1/27/22 identified Resident #1 had a deficit in self-care performance related to impaired balance and high fall risk. Interventions included: directing staff to praise all effort by the resident during self-care, staff to continue to encourage the resident to participate as able with the washing, dressing, hygiene, toileting, and shower. Staff to document and notify the nurse if the resident experienced a significant decline or improvement. Review the Grievance Form dated 3/23/22 identified Resident #1 expressed a concern regarding the care s/he received from Nurse Aide (NA #1) who had a very bad attitude. Resident #1 indicated that NA #1 during a shower threw a washcloth at him/her. Resident #1 complained of having pain in his/her leg and made a remark that NA #1 was not sympathetic. Resident #1 also asked for an extra blanket as he/she was cold at night instead NA #1 removed the blanket from his/her bed and placed it in the laundry. NA #2 overheard Resident #1 complain and provided the blanket to Resident #1. Resident #1 also stated that NA #1 was mean and rushed her/him with care. Resident #1 did not want NA #1 to care for him/her. The Grievance Form further identified the Resident # 1's grievance was resolved on 3/23/22. The corrective action plan was NA #1 would no longer provide care to Resident #1 but would only check Resident #1's condition to make sure he/she was not in distress and alert another nurse aide to care for the resident. The social worker note dated 3/24/22 identified that she met with Resident #1 regarding an incident that happened the previous evening shift and Resident #1 requested to no longer have NA #1 provide care to her/him. An attempt to interview the social worker during the survey was unsuccessful. Interviewed with Director of Nursing Services (DNS) on 8/11/22 at 1:00 PM identified she could not provide evidence that the state agency was notified immediately and no later than 2 hours after the allegation of abuse and mistreatment. A follow up interview with the DNS on 8/12/22 at 10:30 AM identified that she asked NA #2 who overheard Resident #1 complaint about the incident, but she did not obtain a written statement from NA #2. She recalls that NA # 2 took over care for Resident #1 for the rest of the 3 :00PM-11:00PM shift. The facility failed to report an allegation of mistreatment to the state agency timely within accordance to facility policy. A review of the facility's Abuse Neglect, Mistreatment, and Misappropriation of Resident Property 2017 notes mistreatment means inappropriate treatment or exploitation of a resident. For reporting notes the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately to the state agency via telephone and written report to follow within 72 hours.

Based on review of the clinical record, facility policy and interviews for one resident (Resident #52) reviewed for wandering, the facility failed to develop a comprehensive care plan to address the resident's wandering behavior. These findings include: Resident #52 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] identified Resident #52 was severely cognitively impaired, the resident required supervision with 1 staff for transfer, walking in the room and locomotion on the unit and to ambulates with a walker. The quarterly assessment also noted no documentation of wandering behavior. A review of Resident # 52's March 2022 behavior monitoring sheet for wandering identified the resident demonstrated wandering behaviors 18 times on the evening shift and indicated the resident responded to redirection and return to room. An elopement risk assessment completed on 4/8/22 identified that Resident #52 scored a 11 which indicated that a score of 10 or higher the resident is at risk and should have interventions implemented to minimize the risk of elopement. A review April 2022 behavior monitoring sheet for wandering identified Resident #52 demonstrated wandering behaviors 15 times on evening shift but responded to redirection and/or return to room. A care plan reviewed on 4/19/22 lacked documentation that Resident #52 had wandering behaviors and lacked interventions for at risk for elopement. A nursing progress note dated 6/4/22 at 6:04 AM identified Resident #52 was very confused going into other residents' rooms trying to leave the building, However, the resident was easily redirected and placed on every 15-minute check. A nursing progress note dated 6/4/22 at 3:36 PM identified Resident #52 had increased confusion and could not be redirected despite many attempts. Resident #52 became verbally inappropriate, family member and the Medical Doctor (MD) was updated, the resident received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident continued on every 15-minute checks. A nursing progress note dated 6/5/22 through 6/13/22 identified Resident #52 continued to wander up and down the hallway, required redirection constantly and noted every 15-minute checks maintained. A nursing progress note dated 6/14/22 at 6:30 AM identified Resident #52 no longer exhibited wandering behavior; every 15-minute checks maintained. A psychiatric Advanced Practice Registered Nurse (APRN) note dated 6/23/22 identified that she was asked to evaluate Resident #52 due to recent increase in pacing and agitation with recommendations to increase antipsychotic medication. A nursing progress note dated 6/26/22 at 11:00 PM identified Resident #52 continued every 15-minute checks and there was a need for frequent redirection back to the room. Resident # 52 stated s/he wanted to go home to eat, and s/he didn't want to stay at the facility anymore. A review of July 2022 behavior monitoring sheet for wandering identified Resident #52 demonstrated wandering behaviors 17 times on the evening shift, the resident responded to redirection and/or return to room. A psychiatric APRN note dated 7/6/22 identified Resident #52 had increased agitation after family member left and the resident was medicated with good effects. A quarterly MDS assessment dated [DATE] identified Resident #52 was severely cognitively impaired, the resident required limited assistance with 1 staff for transfers, walking in the room and locomotion on the unit and to ambulate with a walker. The quarterly assessment further identified Resident #52 experienced delusions and wandering behaviors 4 to 6 days during the assessment period. An elopement risk assessment completed on 7/7/22 identified that Resident #52 scored 11 which directed that a score of 10 or higher the resident was at risk for elopement and should have interventions implemented to minimize the risk. A care plan reviewed on 7/22/22 lacked documentation Resident #52 had exhibited frequent wandering behaviors and lacked the appropriate interventions to address the resident's elopement risk. Interview with Registered Nurse (RN #1) on 8/11/22 at 10:30 AM identified Resident #52 wandered frequently although improved over the past few weeks. Resident # 52's wandering behaviors mostly occurred on the evening shift, but the resident was able to be redirected. RN #1 further indicated he was aware that the Resident #52 seemed to become agitated after family visits and would require when needed medications at times but could also be redirected. Interview and review of Resident #52s care plan with RN # 4 (MDS Coordinator) on 8/11/22 at 1:00 PM identified Resident #52's demonstrated wandering behaviors and agitation after his family member visited. The staff would routinely place Resident #52 on every 15-minute checks until Resident #52 became calm. RN #4 identified Resident #52's care plan failed to identify the resident's wandering behavior and did not include specific interventions to address the behavior or note any elopement risk. RN # 4 indicated it was her responsibility to ensure the care plan was comprehensive and indicated she could not explain why she did not update the resident's care plan after the April 2022 elopement risk assessment. Interview with the DNS on 8/11/22 at 1:45 PM identified that she was aware Resident #52 had wandering behaviors but was easily redirected. She also indicated Resident # 52 had not had an elopement event. The DNS further indicated if a resident is at risk for elopement the staff will implement every 15-minute checks if they feel a resident is unsafe. She also indicated she was aware the staff had implemented every 15-minute checks for Resident #52 when s/he became agitated and exhibiting pacing. She was surprised that the behavior was not identified in Resident #52's plan of care as she would have expected the wandering behaviors to be on the care plan. Although requested the facility was unable to provide behavior monitoring sheets for May 2022 and June 2022. Attempts to contact RN #5, evening nurse, were unsuccessful. The facility policy, Dementia Care dated 1/22 directs in part that care plan interventions will be related to each resident's individual symptomatology and that the care plan goals and interventions will be monitored on an ongoing basis and the care plan will be revised as needed. The facility policy Comprehensive Care Plan dated 2/4/21 in part directs staff to develop and implement a comprehensive patient centered care plan for each resident that addresses the resident's identified needs.

Based on clinical record review and interviews for 1 of 6 sampled residents (Resident #50) reviewed for unnecessary [CONDITION(S)] medication use, the facility failed to monitor the resident's targeted behavior specific to the anti-psychotic medication use and the facility failed to monitor orthostatic blood pressure in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1 a. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was cognitively intact, and the resident required extensive assist of 1 person with transfers, ambulation, toileting, dressing and hygiene. The nurse's note dated 8/1/22 identified Resident #50 showing the staff the tips of his/her finger and stated that there was an egg coming out from his/her finger. The Advance Practitioner Registered Nurse (APRN) was notified of the hallucination. A urine specimen was ordered and collected. The resident was started on Urinary Tract Infection ([CONDITION(S)]) protocol. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 8/4/22 identified Resident #50 was on [MEDICATION(S)] (anti-psychotic medication) related to behavior management, hallucination/[CONDITION(S)]. Intervention included: to administered medication as ordered, to monitor or document any side effects and the effectiveness of the medication, consultation with the pharmacy or MD to consider dosage reduction when clinically indicated, to monitor for adverse reaction of psychoactive medication such as: unsteady gait, tardive dyskinesia, frequent fall and to monitor orthostatic blood pressure twice a day for 3 days. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The behavior monitoring flow sheet from August 5 through 10, 2022 failed to identified staff monitoring the resident's behaviors which included hallucination or [CONDITION(S)]. Interview with RN #1 on 8/10/22 at 11:40 AM, identified that he would monitor and document the resident behavior every shift in the behavior monitoring flow sheet when a resident was started on a new anti-psychotic medication for hallucinations and [CONDITION(S)]. RN #1 further indicated that Resident #50 should have a targeted behavior monitoring flow sheet for the resident's hallucination/[CONDITION(S)] for the utilization of [MEDICATION(S)]. Interview with Director of Nursing Service (DNS) on 8/10/22 at 2:45 PM identified the nurse should start a behavior monitoring flow sheet when a resident is started on an anti-psychotic medication. b. Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was cognitively intact, and the resident required extensive assist of 1 person with personal hygiene. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Director of Nursing Service (DNS) on 8/10/22 at 2:45PM identified staff should document the resident's targeted behavior related to the use of anti-psychotic medication and monitor closely for adverse reaction.

Based on clinical record reviews, review of facility policy and interviews for 2 residents (Residents #16 and #17) reviewed for pressure wound for Resident #16, the facility failed to ensure consistent monitoring of the resident's pressure relief mattress and for Resident # 17, facility failed to ensure the dietician addressed the resident's new pressure area and. The findings included: 1.Resident # 16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 16 was severely cognitive impaired, required extensive assistance of two persons for bed mobility, transfer, and toileting, required totally dependent on the assistance 2 persons for bathing and limited assistance of one person for eating. The MDS assessment also indicated Resident #16 had a stage 2 pressure ulcer present on admission. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 7/6/2022 for a stage 2 pressure ulcer on coccyx area related to impaired mobility and incontinence. Interventions directed to follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound physician noted dated 8/3/2022, directed reevaluation of support surfaces and to set to appropriate weight. Most recent documented weight was 88 pounds on 8/4/2022. An observation made on 8/09/22 10:15 AM identified the pressure relieving air mattress on while Resident #16 was lying in bed was set at 240 pounds. A wound physician note dated 8/10/2022 directed to re-evaluate support surfaces and to ensure air mattress was set for appropriate weight. Observation on 8/10/2022 9:00 AM identified that the pressure relieving air mattress on while Resident #16 was lying in bed was set at 240 pounds. Observation 8/11/2022 10:05 AM noted the air mattress setting was set at 240 pounds while Resident #16 was lying in bed. An interview and clinical record review with RN#2 on 8/11/2022 at 10:10 AM failed to identify a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 identified that Resident #16 should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN#2 further indicated that though the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent to inquiry, RN#2 obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Use of Air Support Mattress policy dated 11/24/2021 noted in part a support mattress will be utilized with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2 Resident #17 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change in condition assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive 2 persons physical assistance for bed mobility, transfers, toileting, personal hygiene and indicated no pressure ulcer. A care plan reviewed on 3/15/22 identified Resident #17 was at risk for weight loss and to encourage intake. The care plan further identified that Resident #17 was at risk for skin impairment with intervention to complete weekly skin assessments. A dietician quarterly assessment dated [DATE] identified Resident #17 was on a carbohydrate-controlled diet, small portions, bread with each meal and fortified potatoes daily, Resource Breeze- 120 ml twice a day, Power breakfast, Med Plus 2.0- 120 ml daily as supplements. The dietician quarterly assessment on 5/22/22 further identified Resident #17's weight had dropped over the past 3 months and Body Mass Index (BMI) was within normal limits. Med Plus recently added to other supplements/fortified foods. Additionally, noted the resident's skin was intact, the resident's intake varied and indicated the dietician would follow up. A quarterly MDS assessment dated [DATE] identified Resident #17 was mildly cognitively impaired, the resident required extensive assistance of 1 staff member for bed mobility, personal hygiene, and noted at risk for development of pressure wounds. A Nursing progress note dated 5/30/2022 at 8:50 PM identified that a NA noted redness on Resident #17's right hip area which measured approximately 5 Centimeter (CM) x 4 CM, no bruises or open area noted. The resident expressed no complaints of pain or discomfort when touched even with slight pressure during palpation. The resident's family member, the DNS and APRN were made aware of the area. The MD will be update in the A.M. The at risk for skin impairment care plan dated 5/30/22 identified Resident #17 had stage 1 pressure wound on the right hip on 5/30/22. Intervention includes the application of an air mattress on the bed. A Nursing Skin/Wound progress note dated 5/31/2022 at 2:33 PM identified Resident #17 had R hip 5 CM x 4 CM red non blanchable area. The right hip stage 1 open area was tender and warm to touch. The progress notes also identified the resident frequently stays on right side in bed. An air mattress was requested. Education was provided to the staff on frequent repositioning. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing skin/wound progress note dated 6/10/22 at 10:20 AM identified Resident #17 has a pressure ulcer on the right hip, measuring 3 CM x 3 CM with a thin moist scab in center that measured 1.3 CM x 0.4 CM with 0 depth and 1 CM border around scab of granulation tissue. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Santyl Ointment to the wound bed followed by foam adhesive daily for 7 days and to obtain a wound consult if no improvement. A Nursing skin/wound progress note dated 6/15/2022 at 11:08 AM identified that Resident #17's Pressure Ulcer R hip was improving with current treatment which measured 1.1 cm x 0.4 CM and no depth. The area was noted with a thin yellow slough to center. 0.25 CM of granulation tissue. No warmth noted, scant serosanguinous drainage. Superficial scratch below wound, no signs and symptoms of infection and directed to continue current treatment. A wound consulting physician note dated 6/22/22 identified Resident #17 had an unstageable pressure wound to the right hip, full thickness, measuring 1.7 CM x 1.0 CM x 0.1 CM with thick 70% adherent devitalized tissue. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing skin/wound progress note dated 6/23/22 at 6:54 AM identified Resident #17's R hip pressure wound is unstageable due to necrosis. Measurements status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Peri wound indurated with [CONDITION(S)]. No warmth or tenderness, Light serous drainage and 70% necrotic with 30% viable. Treatment plan directed sitting for 60 minutes, repositioning per facility protocol and to turn side to side and front to back every 1-2 hours if possible. A Nursing skin/wound progress note dated 6/29/22 at 10:30 AM identified Resident #17's R hip pressure ulcer: 1.2 CM x 0.7 CM with no depth. Wound bed 60% slough. 40% pink/red. Peri wound indurated 1.2 CM with non-blanchable [CONDITION(S)]. No warmth or tenderness noted, scant serous drainage. [MEDICATION(S)] and border gauze applied per orders. A dietician progress note dated 6/30/22 at 7:43 PM identified Resident #17's most recent weight was 111.6 pounds on 6/24/22 with weight decrease of 11% times 6 months. Resident # 17 had been declining in his/her weight since February 2022. Now noted with right hip pressure area status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted with increased confusion and agitation noted. Interview with RN #1 on 8/11/22 at 10 :00 AM identified that when a resident has a change that require a dietician to evaluate, a note would be added to the Dietician Communication Log. If the change was significant such as a weight loss or new pressure area, he would notify the supervisor to come and evaluate. RN #1 indicated he would not contact the dietician directly. Interview with RN #2 (nursing supervisor) on 8/11/22 at 10:10 AM identified that once s/he is notified by staff there is a change or concern about a resident, she would come and evaluate the resident. The APRN and family would be notified. She was unsure if a new pressure wound was identified, how the dietician was notified by indicating that the APRN would communicate the notification to the dietician. She also indicates when there is a change it is a multidisciplinary process. Interview with the Dietician on 8/11/22 at 11:30 AM identified that she is on site at the facility once a week and that staff can communicate directly with her when onsite. There a communication book on each unit that the staff can document who they want her to see and why. She continued by stating that she has remote access to the residents via electronic record (PCC) and can check on weights remotely. Dietician further indicated if there are urgent issue, the Director of Nursing Services or supervisor could reach her by phone. Interview and review of Resident #17's medical record on 8/11/22 at 11:38 AM identified that she saw Resident #17 for a quarterly nutrition review on 5/22/22 and her next progress note dated 6/30/22, based on her documentation was the next time she evaluated Resident #17 and at that time, Resident #17 had a pressure wound. She continued by stating she was not aware the resident had developed a wound on 5/31/22 and was not aware the wound had worsened 6/10/22. She stated that she would have likely seen the resident on 5/31/22 and/or on 6/10/22 based on the medical record documentation and stated she must not have been informed. The Dietician further indicated Resident #17 was on supplements already and when she did evaluate Resident #17 on 6/30/22 and had no additional dietary recommendations. Interview with RN #3 (Infection Preventionist) on 8/11/22 at 12:15 PM identified that she rounds with the wound physician and documents the wound physician's assessment and plan in the nurse's notes. She also makes sure the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietician would need to be involved with the treatment team if a new pressure was identified. She was not responsible for contacting the dietician it would be the nurse's responsibility. She also indicated the MDS Coordinator, or the Director of Nursing Services (DNS) would likely contact the dietician. Interview with RN #4 (MDS Coordinator) on 8/11/22 at 1:00 PM identified that if a resident experiences a significant change she would communicate the change to the interdisciplinary team which would include the dietician, infection preventionist and therapy depending on the resident's needs. She is notified of changes by the nurse on the unit or the supervisor. Interview with the DNS on 8/11/22 at 1:45 PM identified that she would expect the dietician to evaluate a resident with a new pressure area within the week, when onsite at the facility on Wednesdays. She continued by stating that the infection preventionist or the MDS Coordinator would reach out and that the nurses have a communication book on each unit to document concerns. The DNS could not explain why the dietician did not evaluate Resident #17 timely after the identification of the pressure wound except the dietician may have been off. The Dietician Communication Log on 8/11/22 lacked documentation of Resident #17's pressure wound. The facility policy Nutrition Assessment and monitoring dated 1/1/21 directs in part that in addition to quarterly nutritional assessment, an interval evaluation will be completed as soon as possible for a resident with a new pressure injury but no longer than 5 days. Resident #17 developed a new pressure area on 5/31/22 and the dietician assessment was not completed until 6/30/22.

Based on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to the implement the facility's policies and procedure for investigating an allegation of mistreatment. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition and required limited assistance of 1 person with transfer, ambulation, dressing and toileting. The Resident Care Plan (RCP) updated on 1/27/22 identified Resident #1 had a deficit in self-care performance related to impaired balance and high fall risk. Interventions included: directing staff to praise all effort by the resident during self-care, staff to continue to encourage the resident to participate as able with the washing, dressing, hygiene, toileting, and shower. Staff to document and notify the nurse if the resident experienced a significant decline or improvement. Review the Grievance Form dated 3/23/22 identified Resident #1 expressed a concern regarding the care s/he received from Nurse Aide (NA #1) who had a very bad attitude. Resident #1 indicated that NA #1 during a shower threw a washcloth at him/her. Resident #1 complained of having pain in his/her leg and made a remark that NA #1 was not sympathetic. Resident #1 also asked for an extra blanket as he/she was cold at night instead NA #1 removed the blanket from his/her bed and placed it in the laundry. NA #2 overheard Resident #1 complain and provided the blanket to Resident #1. Resident #1 also stated that NA #1 was mean and rushed her/him with care. Resident #1 did not want NA #1 to care for him/her. The Grievance Form further identified the Resident # 1's grievance was resolved on 3/23/22. The corrective action plan was NA #1 would no longer provide care to Resident #1 but would only check Resident #1's condition to make sure he/she was not in distress and alert another nurse aide to care for the resident. The social worker note dated 3/24/22 identified that she met with Resident #1 regarding an incident on 3/23/22 the previous evening shift and Resident #1 requested to no longer have NA #1 provide care to her/him. A review of facility documentation dated 3/23/22 through 8/11/22 failed to reflect that the facility investigated Resident # 1's allegation of mistreatment within accordance to the facility policy for Abuse Prohibition. An attempt to interview the social worker during the survey was unsuccessful. Interviewed with Director of Nursing Services (DNS) on 8/11/22 at 1:00 PM identified that she reviewed Resident # 1' grievance with the Inter-Disciplinary team to find a resolution for the grievance. The DNS also indicated if a grievance elevates to an allegation of abuse, she would then follow the Abuse Prohibition Policy. Resident #1's grievance dated 3/23/22 did identified the resident complained about the care he/she received from NA #1. The DNS further indicated that she did not investigate the grievance as a mistreatment because when she interviewed Resident #1, he/she did not repeat to her that NA #1 threw a towel at him/her. Resident #1 indicated to her NA #1 had a bad attitude and rushed her/him during care. She also indicated she interviewed Resident #1 to obtain a statement to determine whether there was any allegation of abuse. A follow up interview with the DNS on 8/12/22 at 10:30 AM identified that she asked NA #2 who overheard Resident #1 complaint about the care, but she did not obtain a written statement from NA #2. She recalls that NA # 2 took over care for Resident #1 for the rest of 3 :00PM-11:00PM shift. The facility failed to identify an allegation of abuse and follow the facility's written policy and procedures for investigating an allegation of potential mistreatment. A review of the facility's Abuse Neglect, Mistreatment, and Misappropriation of Resident Property 2017 for Investigation notes it is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. For Procedure notes the investigation is the process to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed, as indicated. The information gathered is given to administration. A review of facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property - in part notes mistreatment means inappropriate treatment or exploitation of a resident. The abuse policy requirements also identified that all staff would monitor resident and would know on how to identify potential signs and symptoms of abuse.

Based on a review of clinical records, review of facility documentation, and interviews for one of three sampled residents reviewed for accidents with injury (Resident #1), the facility failed to follow the plan of care resulting in an accident with injury and/or that Resident #2 was transferred in a safe manner and in accordance with the physician's orders [REDACTED]. a. Resident #1's [DIAGNOSES REDACTED].#1 had a Brief Interview for Mental Status (BIMS) score of seven out of fifteen, indicative of severe cognitive impairment and required extensive assistance of two with transfers. Review of the June 2017 physician's orders [REDACTED]. Review of the reportable event and facility investigation dated 6/15/17 identified R #1 moved his/her leg during transfer striking it against the hanger bracket where the foot rest gets attached to the wheel chair. The resident sustained [REDACTED]. Further review of the facility documentation and R #1's clinical record identified that NA #3 assisted the resident to the wheel chair without the benefit of a second staff member in accordance with the physician's orders [REDACTED].>Facility documentation identified NA #3 was suspended on 6/15/17 for the rest of the day for failure to comply with facility policies and NA #3 terminated employment on 8/3/17. Clinical record review and interview with LPN #1 on 8/24/17 at 1:03 PM stated he/she was the charge nurse on 6/15/17 when R #1 sustained the laceration. It was identified that the Resident was an assist of two for the transfer activity and that NA #3 transferred the Resident without assistance. Attempts to interview NA #3 on 8/24 and 8/25/17 were unsuccessful. b. Resident #2's [DIAGNOSES REDACTED].#2 had severe cognitive impairment and required extensive of two for transfers. The monthly Physician's activity order dated 8/7/17 directed stand pivot transfer with assist of two. Review of the clinical record and NA care card (directs care in accordance with the care plan) identified the resident was non-ambulatory and transfers were with an assistance of two using the stand pivot method. Resident transfer observation on 8/24/17 at 12:30 PM identified R #2 was lifted from his/her wheel chair with an assist of two by his/her arms and legs. NA #1 was positioned on the Resident's left side, placed his/her left arm under R #2's left axilla (armpit) and grasped the Resident's left leg under the knee. NA #4 was positioned on the Resident's right side and placed his/her right arm under R #2's right axilla and grasped the right leg behind the knee. The Resident was lifted up and away from the wheel chair, suspended between the two NA's, carried approximately 3-4 steps and then the Resident was placed in a seated position on the edge of his/her bed. The height of the bed was not adjusted prior to the transfer and was observed in its lowest position. Interview with NA #1 and NA #4 on 8/24/17 at 2:10 PM indicated that the resident was identified as non-ambulatory and that the charge nurse had instructed them to transfer R #2 by scooping the Resident up holding under the arms and legs. Review of therapy documentation and interview with PT #1 on 8/24/17 at 3:30 PM indicated R #2's clinical record lacked any documented rehab services since his/her date of admission on 9/28/16. The Resident had record of only one therapy screen dated 10/24/16 related to a bruise to the lower leg (calf) of unknown etiology. Furthermore when a Resident was unable to bear weight the technique of lifting under the arm in the axilla had the potential for causing shoulder injuries such as shoulder dislocations and placed pressure on the brachial plexus nerves with the potential to cause nerve damage. PT #1 further stated that lifting a Resident by the legs have the potential for hip and knee injuries. Interview with LPN #1 on 8/25/17 at 10:23 AM indicated that on 8/24/17 it was brought to his/her attention that R #2 was non-weight bearing and this was considered a change in the Residents mobility status. The LPN stated that the facility policy was to contact therapy when a change in transfer status was identified, however, the transfer technique of scooping R #2 up by the under arm and leg technique was indicated per rehab. Furthermore he/she did not fully understand what PT #1 had recommended and did not communicate this new transfer technique clearly to the NA's. LPN #1 was unable to provide documentation that the resident was assessed when informed the resident was unable to weight bear. Subsequent interview with PT #1 on 8/25/17 at 2:20 PM indicated he/she had just completed R #2's mobility screen and identified the Resident was at baseline with the ability to weight bear and transfer using the stand pivot method. Review of the facility's Safe Resident Handling policy indicated the interdisciplinary team would evaluate and assess Resident mobility needs based on direct care staff recommendations. Use of a mechanical lifting device was recommended when total body movement of a non-ambulatory resident was required. When a change in a Resident's mobility was identified a representative of the interdisciplinary team would perform a mobility assessment. In accordance with the facility policy, if a new and/or improved handling technique was indicated in-service staff training would be provided. The transfer of R #2 on 8/24/17 failed to comply with the RCP and/or facility policies.

Based on clinical record review, review of facility documentation and interviews for one of three residents (Resident #1) who was at risk for falls, the facility failed to provide supervision while the resident was in the bathroom resulting in a fall. The findings include: Resident #1's [DIAGNOSES REDACTED]. The 60-day Medicare assessment dated [DATE] identified that Resident #1 had severe cognitive impairments, required two plus persons physical assist with transfers and personal hygiene, balance during transitions from seated to standing position, walking, turning around and moving on and off the toilet was not steady and the resident was only able to stabilize with human assistance, the resident had functional limitation with one side of the lower extremities, and no falls since admission (12/22/10). The fall risk assessment dated [DATE] identified a score of 16 which indicated that Resident #1 was a high risk for falls. The resident care plan dated 12/30/10 identified the resident was at risk for falls related to the left hip fracture, a history of falls, a lack of ability to ambulate without assistance and a visual/perceptual impairment. Interventions directed tabs alarm at all times, transfer assist of one with walker, ambulate with wheeled walker and gait belt and do not leave alone on the toilet. The 11PM-7AM shift nurse's note dated 3/18/11 identified that at 6:45 AM Resident #1 fell out of the out the wheelchair during morning care in the bathroom. The range of motion assessment identified that Resident #1 did not sustain an injury and an x-ray of the left hip obtained on 3/19/11 indicated no fractures were noted. Review of the nurse aide assignment, updated 3/2/11, directed to utilize a tab alarm at all times and a notation directed that any resident that requires an alarm out of bed cannot be left alone in the bathroom. The reportable event form dated 3/19/11 identified that at 6:45 AM Resident #1 fell out of the wheelchair. Interview with Registered Nurse (RN) #1 on 3/28/11 at 2:50 PM identified that at the beginning of the 11PM-7AM shift, Nurse Aide (NA) #1 was instructed that any resident who required an alarm was not to be left alone in the bathroom. RN #1 indicated that NA #1 came out of a resident room and requested a bottle of mouth wash, NA #1 returned to the room and then immediately called RN #1 into the room. RN #1 was unaware at the time that Resident #1 had been left alone in the bathroom and the tab alarm though present on the wheelchair was not clipped to the resident. Interview with NA #1 on 3/30/11 at 1:45 PM identified that RN #1 had instructed her not to leave Resident #1 alone in the bathroom. NA #1 stated that while Resident #1 was getting washed, she (NA #1) stepped out of the room to get mouthwash and when she went back into the bathroom Resident #1 was on the floor. In addition, NA #1 indicated that she did not attach the clip of the tab alarm to the resident.

Based on clinical record review, review of facility documentation and interviews for one of four residents reviewed for accidents (R # 34), the facility failed to provide supervision while in the bathroom to a resident at risk for falls resulting in a fall with injury. The findings include: Resident # 34's [DIAGNOSES REDACTED]. The quarterly assessment dated [DATE] identified the resident had impaired short term memory, was totally dependent on staff for all mobility and ADL's, had limited range of motion on one side, and had falls in the previous 30 days and 31-180 days. The fall risk assessments dated 7/6/09 and 10/1/09 identified the resident was at a high risk for falls. The care plan originally dated 2/12/09 identified a risk for falls. Interventions included to monitor safety awareness and keep call light within reach. Physician orders [REDACTED]. The nurse's note dated 1/19/10 on the 3-11 PM shift identified the nurse was notified that the resident had fallen to the floor while seated on the toilet and had sustained a small laceration to the left side of the forehead and left eye. Pressure was applied to the area, the physician was notified and directed to transfer the resident to the emergency room for treatment. The resident was transferred to the hospital at 8:15pm. The hospital interagency report dated 1/19/10 noted a sutured laceration. A statement from Nurse Aide #1 dated 1/20/10 noted the resident was transferred to the toilet with assistance and left unattended for a minute when the resident attempted to get up independently and fell . Attempts to contact NA # 1 were unsuccessful. Interview with the DNS on 1/31/10 at 2:15pm noted the resident should not have been left unattended.