Every finding on record at Courtyard Care Center

Based on interview and record review, the facility failed to ensure readily accessible medical record document for resident's clothing and possessions as requested for one of three sampled resident (Resident 1).This failure had the potential to effect on investigation and secure document for personal possessions for Resident 1.Findings:During a telephone interview with Resident 1's significant family member (SFM) on 7/30/2026 at 11:05 a.m., Resident 1's SFM stated facility lost 3 personal photographs of Resident 1 which were not able to reproduce and precious memory of their family's photographs. Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility on 2/8/2024 and readmitted to facility on 12/25/2025. Resident 1 was discharged from facility on 12/27/2025, did not return to facility.Review of Resident 1's FS also indicated SFM was assigned responsible party (RP, a legally assigned person to act on behalf of resident to make day to day decisions) for Resident 1.Review of Resident 1's electronic (E-chart) clinical documentation indicated there was no documented evidence of Resident's Clothing And Possessions, upon admission to facility on 2/8/2025 to identify listed personal belongings for Resident 1.Facility failed to provide a copy of Resident 1's document for Resident's Clothing And Possessions, upon admission on [DATE] as requested on 8/10/2026, 8/12/2026, 8/18/2026 and 8/19/2026.During an interview with facility's medical record director (MRD) on 8/20/2026 at 1:58 p.m., MRD confirmed document for Resident1's clothing and possessions for initial admission on [DATE] was not available. MRD stated all documents for Resident 1 were in outside storage place, unable to bring to facility at this time. During an interview with director of nursing (DON) on 8/20/2206 at 2:10 p.m., DON stated facility not able to retrieve above paper document from outside storage place and this document was not included in electronic documentation system for Resident 1. DON also stated facility should have provided copy of Resident 1's clothing and possessions documented as requested multiple times.During an interview with facility's administration (ADMN) on 8/20/2026 at 2:35 p.m., ADMN stated not able to access Resident 1's documents when went personally to outside storage facility today (8/20/2026) and storage facility did not confirm how long it will take to deliver documents to facility. ADMN also stated facility should have access and provided document as requested for investigation.Review of facility's policy and procedure (P&P) titled, Release of Medical Records, revised 12/19/2022, the P&P indicated, Medical records will be released with a valid request and in accordance with state and federal laws. Long Term Care Surveying/Accrediting Agencies-government agencies involved in long term care may have access to a resident's medical record.

Based on interview and record review, the facility failed to ensure to secure and return personal belongings for one of three sample resident (Resident 1) after discharged from facility. This failure resulted in facility unable to locate and return personal belongings for Resident 1. Findings:During a telephone interview with Resident 1's significant family member (SFM) on 7/30/2026 at 11:05 a.m., Resident 1's SFM stated facility lost 3 family photos for Resident 1. SFM also stated facility provided Resident 1's personal belongings were in a garbage bag and unorganized when SFM went to take personal belongings after Resident 1 was discharged from facility. SFM also stated she end up searched the garbage bag to identify Resident 1's personal belongings since there were other resident's personal belongings in the same garbage bag. SFM further stated facility lost precious memory of their family photos. Review of Resident 1's face sheet (FS, a document that provides resident's information at a quick glance) indicated Resident 1 was admitted to facility on 2/8/2024 and readmitted to facility on 12/25/2025. Resident 1 was discharged from facility on 12/27/2025, did not return to facility.Review of Resident 1's FS also indicated SFM was assigned responsible party (RP, a legally assigned person to act on behalf of resident to make day to day decisions while in facility) for Resident 1.Review of Resident 1's clinical record review indicated no documented evidence of personal possessions been delivered to Resident 1's SFM. Review of Resident 1's document for Resident's Clothing And Possessions, dated 12/25/2025 indicated blank and incomplete for disposition of belongings for RP and nurse's signature indicated for releasing belongings. Facility failed to provide copy of Resident 1's document for resident's clothing and possessions for initial admission on [DATE] to identify list of documented items of Resident 1's personal belongings as requested on 8/10/2026, 8/12/2026, 8/18/2026 and 8/19/2026.Review of facility social service director (SSD) provided electronic mail documentation to Resident 1's SFM, dated 1/8/2026 indicated, The photographs have not been found at the facility.During a telephone interview with licensed vocational nurse A (LVN A) on 8/10/2026 at 2:10 p.m., LVN A confirmed Resident 1 had 3 personal photographs were posted on a wooden board on the wall next to Resident 1's bed when Resident 1 was in facility. LVN A also confirmed those photos were not located and not returned to Resident 1's SFM when she came to take personal belongings for Resident 1 on 12/28/2026. During an interview with facility's SSD on 8/20/2026 at 12:53 p.m., SSD confirmed facility lost photos for Resident 1. SSD also confirmed she communicated with Resident 1's SFM via electronic mail and informed facility was not able locate photos for Resident 1. During an interview with facility's director of nursing (DON) on 8/20/2026 at 2:04 pm., DON stated facility should not have lost photos for Resident 1. DON also stated facility have secured Resident 1's personal belongings and returned to Resident 1's family safely. Review of facility's policy and procedure (P&P) tilted, Resident Personal Belongings, revised 12/19/2022, the P&P indicated, Following the discharge or death of a resident, all personal clothing and items of customized personal nature are to be given to the designated resident representative. The resident's medical record should contain documentation regarding the method of disposition, as well as the shipping and handling receipts.

Based on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans to address a resident to resident altercation, for one of three sampled residents (Resident 3). This failure had the potential to result in the resident not receiving the interventions necessary to maintain their highest level of well-being.Findings:Review of Resident 3's clinical record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage (brain damage caused by lack of oxygen), alcohol dependence, anxiety disorder (a disorder that causes people to feel panicked for long periods of time), and type II diabetes mellitus (a disorder that causes elevated blood sugar levels).Review of Resident 3's minimum data set (MDS, a required assessment for all skilled nursing facility residents to get reimbursed by Medicare) Section C-Cognitive Patterns indicated Resident 3 had a brief interview for mental status (BIMS, a score to evaluate cognitive status of residents) score of four.Review of Resident 3's chart indicated on 8/29/25, Resident 3 was seen in the hallway of the facility yelling and grabbing another resident's arm. Resident 3 and the other resident were separated after the altercation. On 9/4/25, Resident 3 was discharged to another facility.During a concurrent interview and record review with the director of nursing (DON) on 9/12/25 at 12:37 p.m., the DON said the interdisciplinary team, which consists of herself and other department such as social services and rehabilitation, typically updates a resident's care plan after any incident takes place. The DON also confirmed there was no care plan entry for Resident 3.Review of facility policy titled Comprehensive Care Plans, revised 12/19/22, indicated .The comprehensive care plan will describe at a minimum, the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of facility policy titled Care Plan Revisions Upon Status Change, revised 12/19/22, indicated .The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The care plan will be updated with the new or modified interventions

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one out of 3 sampled residents (Resident 1), when there were multiple days for which there was no evidence of documentation of resident behavioral charting after a staff-to-resident incident. This failure had the potential to compromise the resident's health, safety, and overall well-beingFindings:Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (also known as a stroke, an attack in the brain caused by lack of blood flow), mood disorder, and major depressive disorder with psychotic symptoms (a mental disorder that affects mood).Review of Resident 1's clinical record indicated on 8/29/25, Resident 1 had an altercation with a certified nurse assistant (CNA). Resident 1 had called his daughter after a CNA had cared for him, and said the CNA had push him. Resident 1's daughter called adult protective services (APS), and the police were called. Resident 1 told the police that he pushed the CNA first, and the CNA pushed back.During a concurrent observation and interview with Resident 1 on 8/29/25 at 1:54 p.m., Resident 1 was seen in his room, lying in bed, with no visible injuries. Resident 1 said he grabbed the CNA and the CNA pushed him off. Resident 1 also said he had yelled at the CNA.During a concurrent interview and record review with the director of nursing (DON) on 9/12/25 at 12:33 p.m., the DON said the nursing staff should be documenting on residents who have an incident with a staff member or other resident for 72 hours. The DON confirmed that there was only one documented entry for Resident 1 in the 72 hour period after the incident on 8/29/25, on 8/31/25.Review of facility policy titled Abuse, Neglect and Exploitation, revised 12/19/22, indicated .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to.Increased supervision of the alleged victim and residents.

Based on interview and record review, the facility failed to develop care plans for one of four sampled residents (Residents 1) when the facility failed to create a baseline fall care plan (Care plans identify the specific cares and services necessary to meet the residents' needs). Failure to develop care plans had the potential to result in the residents not receiving interventions needed to maintain their health and safety at the highest practicable level. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with a diagnoses including type 2 diabetes mellitus (when blood sugar is too high), end stage renal disease (condition which the kidneys lose the ability to remove waste and balance fluids), muscle weakness, osteoarthritis (when flexible tissue at the ends of the bones wears down). Fall Risk assessment dated [DATE] indicated Resident 1's score was 15, meaning Resident 1 was high risk for fall. A review of Resident 1's care plan did not address his risk for fall. Review of Resident 1's clinical record indicated Resident 1 had several falls in the facility. There was no care plan in Resident 1's record to address the risk for falls. During an interview with the Assistant Director of Nursing (ADON) on 2/21/25 at 11:36 a.m., ADON reviewed Resident 1's record and confirmed there was no care plan to address fall risk. The ADON further stated I don't see it, it should have a separate care plan for fall. Review of the facility's policy, titled Comprehensive Care Plan , revised dated 12/19/22, indicated, the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and [NAME] and psychosocial needs that are identified in the resident's comprehensive assessment. 6.The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs .

Based on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for 82 transfers/discharges. This failure had the potential of not providing 71 residents and/or their responsible party (RP, a person who is accountable for making decisions on behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred. Findings: During a review of Residents 11 and 58's electronic health records regarding their transfers to an acute care hospital, on several occasions, a transfer notification form, that is to be sent to the Ombudsman, was not located. During an interview with the social services director (SSD), on 1/31/25 at 10:22 a.m., the SSD stated the facility do not have any notification forms to the Ombudsman for Residents 11 or 58. The SSD stated the facility did not have an Ombudsman since May of 2024 and did not notify the Ombudsman office of any transfers/discharges, since May of 2024. During a review of a list of residents who were transferred/discharged from May 2024 through January 2025, the list indicated 98 discharge/transfers since May 2024, with only seven notifications to the Ombudsman in January 2025. During an interview with the SSD on 1/31/25 at 12:40 p.m., the SSD stated each resident who was transferred or discharged , from May 2024 through January 2025, was listed; if they went out more than once they were listed each time. Neither the Ombudsman nor the resident or their representative received a notice of transfer/discharge, except the ones in January of this year. During a review of the facility's policy, titled Transfer and Discharge (including AMA), revised 12/19/2022, indicated .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.7. The facility will maintain evidence that the notice was sent to the Ombudsman.12. Emergency Transfer/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1. There were expired food items; 2. Cookware was not properly dried; 3. The temperature log book for the refrigerator used to store food for residents was incomplete. These deficient practices potentially exposed 65 residents, who received food from the kitchen to food-borne illnesses. Findings: 1. During the initial tour of the facility's kitchen on [DATE] at 8:32 a.m., with the dietary aide, (DA), the following were observed: a. Gelatin in refrigerator R3 which had an expiration date of [DATE]. b. Refrigerator R2 had Ground beef which had an expiration date of [DATE]. c. Freezer F1 had a bag of 4 buns with a date of [DATE]. d. One pie crust had dates of [DATE] and use by [DATE]. 2. During an observation and subsequent interview, with the dietary manager (DM), on [DATE] at 10:51 a.m., there were seven large metal sheet pans which were stacked wet on storage rack. During a subsequent interview with the DM, she stated the trays should not be wet. 3. During a record review and subsequent interview, with the director of staff development (DSD), on [DATE] at 3:08 p.m., the refrigerator in the medication room, at station one/two, used for food brought in by visitors, had a temperature log for [DATE] which missing temperatures for [DATE], for a.m. and p.m., on [DATE], for a.m., and p.m., and on [DATE] for a.m. The DSD acknowledged that the temperatures were missing, and should have been there. During a review of the facility's procedure, titled Dish and Utensil Procedure, with an unreadable revision date, indicated .6. Dishes, trays, and utensils shall be air dried before storage. Do not towel dry.

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Staff did not label resident wash basins kept in shared bathrooms with the residents' identifiers; 2. Staff did not wear the proper personal protective equipment (PPE) when entering a room under enhanced droplet precautions; 3. Staff did not label oxygen tubing for one resident (Resident 21); 4. Staff did not ensure the dressing around a gastrostomy tube (GT, a thin, flexible tube inserted through the stomach to deliver nutrients or medications) was intact and correct infection precaution was followed for one resident (Resident 7); and 5. A urinary catheter (a device that drains urine) bag was found touching the floor, for one resident (Resident 38). These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses. Findings: 1. During an observation on 1/27/25 at 8:52 a.m., two unlabeled wash basins were seen in the shared bathroom of resident room AA. During an observation on 1/27/25 at 9:44 a.m., one unlabeled wash basin was seen on top of the paper towel dispenser in the shared bathroom of resident room BB. During an interview with Certified Nursing Assistant G on 1/29/25 at 11:06 a.m., CNA G stated wash basins should be labeled with the resident's name and room number. During an interview with the Interim Director of Nursing (IDON), the IDON stated resident items such as urinals should be labeled with the resident's name and room number. 2. During an observation on 1/29/25 at 8:58 a.m., the IDON and Licensed Vocational Nurse F (LVN F) went into resident room CC wearing a gown, gloves and N-95 mask (a specialized type of face mask that offers more protection than a regular face mask). A sign on the door for resident room CC indicated Enhanced Droplet Precautions, to include a gown, gloves, a N-95 mask and a faceshield. The IDON and LVN F did not don (wear) a faceshield before they entered resident room CC. During an observation on 1/29/25 at 9:45 a.m., the Maintenance Supervisor (MS) went into resident room CC wearing a gown, gloves, and a regular face mask. The MS also did not don a faceshield before entering resident room CC. During an interview with the IDON on 1/29/25 at 9 a.m., the IDON stated enhanced droplet precautions should be gown, gloves and N-95 mask. The IDON stated she did not know about the use of faceshields with enhanced droplet precautions. During an interview with the MS on 1/31/25 at 10:31 a.m., the MS stated that he looks at the sign that was posted on the door to know what PPE to wear in a room. During an interview with the infection preventionist (IP), the IP stated Enhanced Droplet Precautions are all PPE, including gown, gloves, face shield and N-95 mask. The IP also stated that all staff have been given a recent in-service on the correct use of PPE. Review of the facility's policy titled Personal Protective Equipment, dated 12/19/22, indicated All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 3. During an observation on 1/28/25 at 9:06 a.m., Resident 21 was seen lying in bed, wearing a nasal cannula device (a device that goes in the nostrils to deliver oxygen). The tubing did not have a label with a date or initials. During an interview with LVN I on 1/31/25 at 10:39 a.m., LVN I stated oxygen tubing should be labeled with the date when the oxygen tubing was changed. Review of the facility's policy titled Oxygen Administration, last revised 5/20/24, indicated .Change oxygen tubing and mask/cannula weekly and as needed . 49345 4. During an observation on 1/27/25 at 9:08 a.m. with CNA C in Resident 7's bedside, an Enhanced Barrier Protection sign was visible on Resident 7's wall on top of the bed. CNA C was wearing gloves but was not wearing a gown while changing Resident 7's under pad and briefs. Resident 7 had a GT covered in gauze and tape dated 1/25. The GT dressing was loose and tape on the edges were not adhering on the skin. During an interview on 1/27/25 at 9:20 a.m. with CNA C, CNA C stated he did not know if he should wear a gown while doing close contact care for Resident 7. During a concurrent observation and interview on 1/27/25 at 1:19 p.m. with LVN H, LVN H stated, Resident 7's GT dressing was changed every day shift. LVN H verified the date on Resident 7's GT dressing was 1/25. LVN H also stated, CNAs must wear gown when changing Resident 7's briefs. During an interview on 1/30/25 at 1:32 p.m. with the IP, the IP stated that residents who have GT are on Enhanced Barrier Precaution and staff must wear face mask, gown and gloves when doing high-contact procedures or anything procedures that involve touching the resident. The IP also stated that Resident 7's GT dressing must be changed every night shift and as needed. A review of Resident 7's medical records indicated a diagnosis of but is not limited to Dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat) and Gastrostomy Status (a surgical procedure used to insert a tube through the abdomen and into the stomach). A review of resident 7's active physician orders indicated, Enhance Barrier Precaution every shift for Enteral feeding [GT feeding] requirement. PPE [personal protective equipment] : Clean hands before and after leaving room, gown and gloves. It also indicated, GT site: Cleanse with NS [normal saline, sterile solution of water and salt], pat dry, apply dressing every day shift. A review of facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions revised 6/17/2024, the P&P indicated, .3. Implementation of Enhance Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting . A review of facility's policy and procedure (P&P) titled, Personal Protective Equipment revised 12/19/22, the P&P indicated, .1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 5. During an observation on 1/30/25 at 10:39 a.m. with CNA B in Resident 38's bedside, CNA B verified that Resident 38's urine bag was touching the floor. During an interview on 1/30/25 at 1:32 p.m. with the IP, the IP stated that urine bags must not touch the floor. A review of Resident 38's medical records indicated a diagnosis of but is not limited to obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A review of facility's policy and procedure (P&P) titled Appropriate Use of Indwelling Catheters revised 12/19/22, the P&P indicated, .9. Indwelling urinary catheters .will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding .

Based on observation, interview and record review, the facility had a facility medication error rate of 7.7% when four errors out of 52 opportunities during the medication administration for four out of six residents (Residents 12, 224, 55 and 2). This failure resulted in medication not given in accordance with the prescriber's orders which had the potential for residents not receiving the full therapeutic effects of the medications. Findings: 1. During a concurrent medication pass observation and interview on 1/27/25 at 12:31 p.m., with LVN E, LVN E administered three units (standard measurement) of insulin aspart (a type of insulin injection to lower blood sugar level) to Resident 12 with a pen injector (an injector that uses a dial to administer the correct medication dosage). Prior to administering the 3 units, LVN E did not prime (process of filling the tubing) the pen injector needle with two units. LVN E stated I would usually prime the needle with 2 units. Review of UpToDate: Lexidrug (a drug reference for healthcare professionals) indicated for insulin aspart administration .For prefilled pen injectors, prime the needle before each injection with 2 units . 2. During a concurrent medication pass observation and interview on 1/28/25 at 4:41 p.m., with LVN F, LVN F stated she did not have glipizide (medication used to lower blood sugar level) 5 milligram (mg, unit of measurement) on hand to give to Resident 224 along with her other medications at the time. LVN F stated she would need to call the physician to get an order to give the medication at a later time and to call the pharmacy to refill the medication. Review of Resident 224's physician orders, dated 10/29/24, indicated Glipizide Oral Tablet 5 mg Give 1 tablet by mouth two times a day for hyperglycemia related to TYPE 2 DIABETES MELLITUS [high blood sugar level] WITH UNSPECIFIED COMPLICATIONS. Review of the facility's policy titled Provision of Physician Ordered Services, last revised 5/15/23, indicated .Medication administration and therapeutic treatments; Qualified nursing personnel will administer medications as ordered by the physician .Medications will be administered following facility protocols, dosage guidelines, and documentation procedures. 3. During a concurrent medication pass observation and interview on 1/29/25 at 8:53 a.m., with LVN F, LVN F stated she did not have duloxetine (medication used to treat depression [feelings of sadness] and anxiety [feelings of excessive worry and fear]) 30 mg on hand to give to Resident 55 along with his other medications at the time. During a follow up interview on 1/29/25 at 9 a.m.,, LVN F stated she would have to contact the pharmacy to restock the duloxetine, and that It's important to keep the medication cart stocked with their medications. Review of Resident 55's physician orders, dated 6/18/24, indicated Duloxetine HCL Oral Capsule Give 3 capsules by mouth one times a day for m/b feelings of sadness related to SCHIZOAFFECTIVE DISORDER [mental disorder], UNSPECIFIED. Review of the facility's policy titled Medication Administration, dated 12/19/22, indicated Keep medication cart clean, organized, and stocked with adequate supplies. 4. During a concurrent medication pass observation and interview on 1/29/25 at 8:53 a.m., with LVN F, LVN F administered Ketotifen eye drops (a medication that treats dryness in the eyes) in both the right and left eye, for Resident 55. The label on the box the eye drops indicated Instill 1 drop in right eye two times a day for dry eyes. LVN F confirmed what was on the label, and stated It's supposed to be both eyes I think .oh, it's just the right eye. Review of Resident 55's physician order's, dated 101/4/24, indicated Ketotifen Fumarate Opthalmic Solution 0.035% Instill 1 drop in right eye two times a day for dry eyes. Review of the facility's policy titled Administration of Eye Drops or Ointments, dated 12/19/22, indicated .Verify orders and labeling prior to administration .Compare the label with the order to verify correct medication, dose, route and time of administration .Confirm which eye requires treatment .

Based on observation, interview and record review, the facility failed to provide appropriate pharmaceutical services when: 1. Two medications, glipizide and duloxetine, were not available for two out of seven residents (Residents 224 and 55) 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 224, 32, 1 and 2) These failures had the potential to affect the health of residents and resulted in the facility not having accurate accountability of controlled medications which had the potential for misuse or diversion. Findings: 1. During a medication pass observation on 1/28/25 at 4:41 p.m., LVN F stated she did not have glipizide (medication that lowers blood sugar) 5 milligram (mg, unit of measurement) in the medication cart for Resident 224, and that she would have to call the pharmacy to get it stocked. A review of Resident 224's physician orders, dated 10/29/24, indicated Resident 224 was to receive glipizide 5 mg tablet two times a day for hyperglycemia [high blood sugar] related to TYPE 2 DIABETES MELLITUS [chronic condition when the body could not produce insulin that could lead to high blood sugar levels]. During a follow up interview with LVN F on 1/28/25 at 4:45 p.m., LVN F stated she would call to get an order for a one-time dose of glipizide at 8 p.m., that day to make up for the dose missed. During a medication pass observation on 1/29/25 at 8:53 a.m., LVN F stated she did not have duloxetine (a medication used to treat depression [feeling of sadness]) 30 mg in the medication cart for Resident 55, and that she would have to call the pharmacy to get it stocked. A review of Resident 55's physician orders, dated 6/18/24, indicated Resident 55 was to receive duloxetine 30 mg Give 3 capsule by mouth one time a day for m/b [manifested by] feelings of sadness related to SCHIZOAFFECTIVE DISORDER [a mental health condition], UNSPECIFIED. Review of the facility's policy titled Organizational Aspects-IA1: Provider Pharmacy Requirements, effective date April 2008, indicated The provider pharmacy agrees to perform the following pharmaceutical services .Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week .Medications which should be promptly available such as anti-infectives, as well as drugs used to treat problems .All other new medication orders are received and available for administration on the day they are ordered . 2. During the survey, four random CDRs for four residents (Residents 224, 32, 1 and 2) were requested for review. On 1/30/25 at 11 a.m., a review of the residents' physician orders, the CDRs and MARs indicated the following: a. Resident 224 had a physician order, dated 10/14/24 for oxycodone (a medication that can treat moderate to severe pain) 5 mg 1 tablet by mouth every 4 hours as needed for moderate to severe pain (7-10). Resident 224 had two instances which were recorded in the CDR but not documented as given in the MAR: on 1/10/25 at 6 p.m. and 1/28/25 at 7:15 p.m. b. Resident 32 had a physician order, dated 10/5/24 for oxycodone 5 mg 1 tablet via G-tube [a thin, flexible tube inserted surgically through the stomach that can be used for delivering nutrition, and medications when a person is unable to eat or drink orally] every 4 hours as needed for pain scale of 7-10 [severe pain]. Resident 32 had seven instances which were recorded in the CDR but not documented as given in the MAR: 1/7/25 at 5 a.m., 1/12/25 at 5 a.m., 1/15/25 at 4 a.m., 1/20/25 at 11:30 a.m., 1/22/25 at 4 a.m., 1/25/25 at 6:06 a.m., 1/26/25 at 11:30 p.m., and 1/27/25 at 10:48 p.m. c. Resident 1 had a physician order, dated 12/31/24, for Roxicodone (Oxycodone HCl) oral tablet 5 mg Give 3 tablet by mouth every 6 hours as needed for Sever pain scale 7-10. Resident 1 had three instances which were recorded in the CDR but not in the MAR: on/1/12/25 at 12:30 p.m., on 1/16/25 at 9 a.m., and on 1/18/25 at 5:02 p.m. d. Resident 2 had a physician order, dated 11/5/23, for oxycodone 5 mg Give 2 tablet by mouth every 4 hours as needed for Pain Management for severe pain 7-10. Resident 2 had six instances which were recorded in the CDR but not documented as given in the MAR: on 1/14/25 at 10:35 p.m., 1/17/25 at 7 a.m., 1/18/25 at 7 a.m., 1/23/25 at 2 p.m., 1/25/25 at 10 p.m., and 1/26/25 at 7 a.m. During a concurrent interview and record review with the interim Director of Nursing (IDON) on 1/30/25 at 2:56 p.m., the IDON reviewed the residents' respective CDRs and MARs: a. For Resident 224, the IDON verified the recorded dates in the CDR and the MAR and confirmed the findings above. b. For Resident 32, the IDON verified the recorded dates in the CDR and the MAR and confirmed all findings except 1/7/25, which she was able to verify as recorded in the MAR and 1/22/25, which was recorded in the CDR as given at 0400, but in the MAR it was recorded as given at 6:28 a.m. The IDON stated that whatever time the medication was taken out and recorded in the CDR should be the time in the MAR as well. c. For Resident 1, the IDON verified the recorded dates in the CDR and the MAR and confirmed all findings except 1/16/25, which was recorded in the CDR at 9 a.m. but recorded in the MAR at 10:42. The IDON stated that this was not okay, that the times should match between the CDR and the MAR. d. For Resident 2, the IDON verified the recorded dates in the CDR and MAR and confirmed the above findings. The IDON further stated that all controlled medications should be recorded in the MAR and the CDR when they were given. Review of the facility's policy titled Controlled Substance Administration & Accountability, last revised 6/5/23, indicated .In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.

Based on interview and record review, the facility failed to ensure residents were informed of risks and benefits of treatment for four (Resident 23, Resident 34, Resident 70, and Resident 174) out of 16 sampled residents when: 1. Resident 23's psychotropic medication (drugs that affect the brain, mood, thoughts, or behavior) informed consent was not completed and verified; 2. Resident 70' psychotropic medication informed consent was not completed and verified; 3. Resident 34's responsible party was not notified in a timely manner about the results of a chest X-ray (digital image of internal composition of the body); and 4. Resident 174's psychotropic medication informed consent was not completed and verified. These failures had the potential to put residents at risk for misidentifying and not reporting possible side effects and adverse reactions that can be detrimental to their health due to lack of knowledge about their psychotropic medications, as well as putting Resident 34 RPs not informed of his current care in a timely manner. Findings: 1. Review of Resident 23's clinical record indicated Resident 23 was admitted on [DATE] with diagnoses of cerebral vascular accident (also known as stroke, a disorder of the brain caused by lack of blood flow), and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 23's clinical record indicated Resident 23 had an order for Risperidone ( medication used to treat symptoms of schizophrenia [mental disorder]) 0.25 milligram (mg, unit of measurement) Give 1 tablet by mouth two times a day for m/b [manifested by] auditory hallucinations related to Schizoaffective disorder. Review of Resident 23's clinical record further indicated an informed consent was signed on 12/13/24 by the resident. The risks, benefits, and side effects of the medication were not listed in the informed consent form. During an interview with the Interim Director of Nursing (IDON) on 1/30/25 at 2:56 p.m, the IDON stated the consent that was in the chart for Resident 23 for Risperidone was the current consent being used. The IDON also stated she would follow up on if the form used for obtaining consent for the use of psychotropics followed facility policy for the use of psychotropics. 2. Review of Resident 70's clinical record indicated Resident 70 was admitted on [DATE] with diagnoses of deconditioning and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 70's clinical record indicated Resident 70 had an order for Olanzapine (medication used to treat schizophrenia) 2.5 mg by mouth daily for schizoaffective disorder. Review of Resident 23's clinical record further indicated an informed consent was signed on 12/29/24 by the responsible party. The risks, benefits, and side effects of the medication were not listed in the informed consent form. During an interview with the IDON on 1/30/25 at 2:56 p.m, the IDON said the consent that was in the chart for Resident 70 for Olanzapine was the current consent being used. 3. Review of Resident 34's clinical record indicated Resident 34 was admitted on [DATE] with a diagnosis including hypoxic brain injury (an injury caused by lack of oxygen). Review of Resident 34's clinical record also indicated he had a chest X-ray ordered and completed on 1/10/25 which indicated the lungs were clear. Review of Resident 34's clinical record further indicated that there was no record of a note stating the responsible party was contacted about the results of the chest X-ray. During an interview with the IDON on 1/30/25 at 4:26 p.m., the IDON stated it was unclear whether the chest X-ray result was communicated to Resident 34's responsible party after the results were received by the facility. Review of facility policy titled Notification of Changes, dated 12/19/22, indicated .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include .Significant change in the resident's physical, mental or psychosocial condition .Circumstances that require a need to alter treatment. This may include .New treatment . 49345 4. A review of Resident 174's medical records indicated diagnoses of but are not limited to, anxiety disorder (mental health conditions that involve excessive fear, worry, or panic), major depressive disorder (persistent feelings of sadness, hopelessness, and lack of interest in activities), and paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). During a concurrent interview and record review of Resident 174's medical records with the IDON on 1/30/25 at 11:20 a.m., the IDON verified that Resident 174 was on Risperidone, Buspirone (anxiolytic, used to treat symptoms of anxiety, such as fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) and Sertraline (antidepressant, used to treat symptoms of depression) medications. The IDON verified and stated that the informed consent they used for psychotropic medication titled, Physician Documentation of Informed Consent. The IDON verified the consent form indicated, PHYSICIAN USE ONLY and there was no space indicated for a signature from a resident or a representative giving the consent. The IDON also verified Resident 174's consent forms for medications Risperidone, Buspirone, and Sertraline dated 8/17/23 did not indicate specific frequency, indications, possible side effects and adverse reactions of each medication, no signature from Resident 174 and no indication if consent was verbal. The IDON verified the facility form titled, Facility Verification of Informed Consent for Resident 174's medications Risperidone, Buspirone, and Sertraline did not indicate a date and signature from Resident 174 or a representative. The IDON also verified Resident 174's consent forms titled, Psychoactive Medication Consent dated 8/20/21 for medications Risperidone, Buspirone and Sertraline indicated the classifications of the medications (anti-psychotic, anti-anxiety, and anti-depressant), the specific frequency and indications of each medications, side effects and adverse reactions, and Resident 174's signature. The IDON verified the form titled, Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or 'Prolonged Use of Active' Device for Resident 174's Risperidone, Buspirone, and Sertraline dated 8/20/21 indicated signature from a facility staff. The IDON stated that the facility changed its consent forms since a new company took over. A review of Resident 174's Physician Orders indicated the following: - Risperidone Oral Tablet Disintegrating 1 mg [milligram, unit of measurement]; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia - Buspirone HCl tablet 10 mg; give 1 tablet by mouth one time a day m/b [manifested by] excessive worrying related to major depressive disorder - Sertraline HCl Oral tablet 50 mg; give 1 tablet by mouth one time a day for m/b expression of sadness over medical condition related to major depressive disorder A review of facility's policy and procedure (P&P) titled, Informed Consent revised 3/25/24, the P&P indicated, Policy Explanation and Compliance Guidelines: 2. Psychotherapeutic Medications: a. The information provided to the resident/health care decision maker regarding a decision concerning the administration of psychotherapeutic medication . i. The reason for the treatment and the name and nature and seriousness of resident's illness. Ii. The nature of the medication to be used including the does, frequency, duration . vi. That the resident has the right to accept or refuse the proposed medications .and if he or she consents, has the right to revoke his or her consent for any reason at any time. b. Prior to initiating the administration of a psychotherapeutic medication .licensed nursing staff shall verify with the resident or surrogate decision maker that he/she has given informed consent for the proposed psychotherapeutic medication .to the prescriber. Psychotherapeutic medications may not be administered until informed consent has been verified. 3. If a form is used to document that informed consent was verified, the licensed nursing staff will complete the Verification of Informed Consent Form and place it under the consent section in the clinical record. 4. The physician may document that he/she obtained informed consent in the clinical record, on progress notes, history and physical or a standard form used by the facility.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for one out of two sampled residents (Resident 23). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes. Findings: Review of Resident 23's admission record indicated Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's POLST form dated 1/20/24 indicated section D for AD was marked for Advance Directive, Healthcare Agent if named in Advance Directive field was empty. Further review of Resident 23's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party (RP, a person who is accountable for making decisions on behalf of the resident). During a concurrent interview and record review on 1/30/25 at 11:09 a.m., with the social services director (SSD), the SSD confirmed that Resident 23's POLST form was marked for Advance Directive but that she would need to follow up to see if there was a copy on file. Review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, dated 12/19/22, indicated .Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on observation, interview, and record review, the facility failed to implement and develop a comprehensive care plan for one of 18 residents (Resident 67), when Resident 67's dementia (a general term for a group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) diagnosis was not addressed. This failure had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care. Findings: During a review of Resident 67's care plans, in his electronic health record, a care plan regarding his dementia was not found. During an interview with the facility's nurse consultant (NC) on 1/29/25 at 8:43 a.m., the NC stated Resident 67 should have a specific cognitive care plan. The NC acknowledged Resident 67 did not have a dementia care plan. During a review of the facility's policy, titled Dementia Care, revised 12/19/2022, the policy indicated .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of ;the expected stable rate of decline associated with dementia and dementia-like illnesses.

Based on observation, interview and record review, the facility failed to ensure needed care and services were provided in accordance with the resident's goals for care for one resident (Resident 38) out of six sampled residents, when Resident 38's physician's order for interaction was not followed. This failure had the potential to put Resident 38 at risk for decline in physical, mental and psychosocial well-being. Findings: During a concurrent observation and interview on 1/27/25 at 8:55 a.m. with Resident 38, Resident 38 was lying in bed, awake, alert and oriented. Resident 38 stated I'm trying to get counseling for emotional situation. I get very irritable at people and I scream. During a concurrent observation and interview on 1/30/25 at 10:55 a.m. with Licensed Vocational Nurse (LVN) A, Resident 38 was lying in his bed. LVN A stated that Resident 38 was not in a wheelchair this morning. LVN A also stated that she never saw Resident 38 in a wheelchair even when Resident 38 was in a different station. During a concurrent observation and interview on 1/31/25 at 9:23 a.m. with Resident 38, Resident 38 was lying in his bed. Resident 38 stated he was not put in a wheelchair this morning. A review of Resident 38's medical records indicated diagnoses of but are not limited to, major depressive disorder (a mental condition that causes a persistent low mood, loss of interest and hopelessness), mood disorder (a mental health condition that causes extreme emotional states, such as depression and mania), and muscle weakness. A review of Resident 38's Physician's Orders indicated, Resident needs to be up in a wheelchair in the morning; one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for interaction. A review of facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services revised 5/15/23, the P&P indicated, .4. Activity restrictions: Nursing and support staff will ensure compliance with activity restrictions prescribed by the physician.

Based on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (removal of waste and excess fluid from the body) treatment received consistent care with professional standards for one out of two sampled residents (Resident 32) when their dialysis communication sheets (DCS) were missing for several treatment days. This failure had the potential for Resident 32's dialysis care not being properly communicated and putting Resident 32 at risk for complications. Findings: Review of Resident 32's clinical record indicated she was admitted on [DATE] with a diagnosis of cerebrovascular accident (CVA, also known as stroke, a brain disorder caused by lack of blood flow to the brain), and end-stage renal disease (when the kidneys no longer function to remove waste from the blood). Review of Resident 32's clinical record further indicated Resident 32 received dialysis on Tuesday, Thursday and Saturday. Review of Resident 32's dialysis record indicated there were missing DCS forms from 1/16/25-1/28/25. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 1/30/25 at 2:56 p.m., the IDON stated the DCS forms should be kept in the resident's chart or in white binder that goes with the resident from the facility to the dialysis center, and then back to the facility. The IDON confirmed there was no DCS forms from 1/16/25-1/28/25 for Resident 32. Review of the facility's policy titled Hemodialysis, last revised 6/5/23, indicated .The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to .Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility .Physician/treatment orders, laboratory values, and vital signs .Dialysis treatment provided .Dialysis adverse reactions/complications .

Based on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two (Resident 25 and Resident 174) out of 23 sampled residents when: 1. Abnormal Involuntary Movement Scale (AIMS, a rating scale that measures the severity of abnormal movements) was not done for Resident 25; and 2. AIMS was not done for Resident 174. This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication). Findings: 1. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness). A review of Resident 25's Physician Order dated 7/4/24 indicated, Seroquel Oral Tablet [antipsychotic medication] 300 mg [milligram, a unit of measurement]; give one tablet by mouth in the morning for m/b [manifested by] visual hallucination related to schizoaffective disorder. A review of Resident 25's Physician Order dated 7/16/23 indicated, Monitor for side effects to use of psychotropic medications. During a concurrent interview and record review of Resident 25's medical records with the CP on 1/31/25 at 9:52 a.m., the CP verified Resident 25 was on antipsychotic medication, Quetiapine (Seroquel). The CP also verified AIMS was not done for Resident 25. The CP stated, the facility should have done it initially and every six months. The CP also stated, since 2022, according to the facility, they do not use AIMS and we did not recommend AIMS since then. The CP also stated, I don't know what they do in replacement of AIMS. A review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b.During the pharmacist's monthly medication regimen review. A review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements dated October 2017, the P&P indicated, .E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: 1 a A residents's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: iii. Without adequate monitoring 2. A review of Resident 174's medical records indicated diagnosis of but is not limited to paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). A review of Resident 174's Physician Orders indicated, Risperidone Oral Tablet Disintegrating 1 mg; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia. During a concurrent interview and record review of Resident 174's medical records with the CP on 1/31/25 at 9:59 a.m., the CP verified Resident 174 was on antipsychotic medication, Risperidone. The CP verified that the AIMS was last done on 9/24/21 for Resident 174. The CP stated AIMS was last recommended to the facility in December 2022 and the facility said they use a different system. The CP also stated, I don't know what they do in replacement of AIMS. A review of facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b. During the pharmacist's monthly medication regimen review . A review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements dated October 2017, the P&P indicated, .E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: 1 a A residents's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: iii. Without adequate monitoring

Based on observation, interview, and record review, the facility failed to ensure four of 18 sampled residents (Residents 23, 25, 70 and 174) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment was not done. The failure resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications. Findings: 1a. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness) A review of Resident 25's Physician Order dated 7/4/24 indicated, Seroquel Oral Tablet [antipsychotic medication] 300 mg [milligram, a unit of measurement]; give one tablet by mouth in the morning for m/b [manifested by] visual hallucination related to schizoaffective disorder A review of Resident 25's Physician Order dated 7/16/23 indicated, Monitor for side effects to use of psychotropic medications. A review Lexicomp indicated, Quetiapine [Seroquel] may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. The EPS include tardive dyskinesia (TD, an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs). During a concurrent interview and record review of Resident 25's medical records with the Consultant Pharmacist (CP) on 1/31/25 at 9:52 a.m., the CP verified Resident 25 was on antipsychotic medication, Quetiapine (Seroquel). The CP also verified Abnormal Involuntary Movement Scale (AIMS) was not done for Resident 25. The CP stated, the facility should have done it initially and every six months. The CP also stated, since 2022, according to the facility, they do not use AIMS and we did not recommend AIMS since then. The CP also stated, I don't know what they do in replacement of AIMS. 1b. A review of Resident 174's medical records indicated diagnosis of but is not limited to paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). A review of Resident 174's Physician Orders indicated, Risperidone Oral Tablet Disintegrating 1 mg [milligram, unit of measurement]; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia During a concurrent interview and record review of Resident 174's medical records with the Consultant Pharmacist (CP) on 1/31/25 at 9:59 a.m., the CP verified Resident 174 was on antipsychotic medication, Risperidone. The CP verified that Abnormal Involuntary Movement Scale (AIMS) was last done on 9/24/21 for Resident 174. The CP stated AIMS was last recommended to the facility in December 2022 and the facility said they use a different system. The CP also stated, I don't know what they do in replacement of AIMS. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 1/31/25 at 11:07 a.m., the IDON stated the facility does not have a specific form to monitor abnormal involuntary movements for residents on psychotropic medications. The IDON also stated, she does not remember the frequency of AIMS. The IDON also verified the facility had no specific form/assessment in replacement of AIMS. A review of facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b.During the pharmacist's monthly medication regimen review . 48935 1c. Review of Resident 23's clinical record indicated Resident 23 was admitted on [DATE] with diagnoses of cerebral vascular accident (also known as stroke, a disorder of the brain caused by lack of blood flow), and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 23's clinical record indicated Resident 23 had an order, dated 10/26/24, for Risperidone 0.25 milligram (mg, unit of measurement) Give 1 tablet by mouth two times a day for m/b auditory hallucinations related to Schizoaffective disorder. Review of Resident 23's medical record indicated there was no AIMS assessment documented anywhere in the electronic chart. During an interview with the Pharmacy Consultant (PC) on 1/31/25 at 10:05 AM, the PC said an AIMS assessment should have been done for Resident 23. 1d. Review of Resident 70's clinical record indicated Resident 70 was admitted on [DATE] with diagnoses of deconditioning and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 70's clinical record indicated Resident 70 had an order for Olazapine 2.5 mg by mouth daily for schizoaffective disorder. Review of Resident 70's medical record indicated there was no AIMS assessment documented anywhere in the electronic chart. During an interview with the Pharmacy Consultant (PC) on 1/31/25 at 10:05 AM, the PC said an AIMS assessment should have been done for Resident 70.

Based on interview and record review, the facility failed to ensure a resident's private medical information was protected against unauthorized disclosure for 1 of 3 residents, when Resident 1 was furnished with medications labeled with medical information relevant to Resident 2 and Resident 3 upon discharge from the facility. This failure resulted in Resident 2 and Resident 3's private information being disclosed to another resident without their permission. Review of Resident 1's clinical record indicated she was admitted on [DATE]. Resident 1had a brief interview for mental status (BIMS) score of 15 (a score of 13 to 15 indicates cognitively intact). Review of Resident 1's social service progress note dated 12/19/23, indicated Resident 1 was accepted at another skilled nursing facility (SNF) and would discharge on 12/20/23. Review of social service progress notes dated, 1/7/24, indicated Resident 1's friend (R1F) came to the facility to return medications given to Resident 1 upon her discharge that did not belong to Resident 1. Per R1F, the medications were not labeled with Resident 1's name and belonged to two residents currently residing at the facility from where Resident 1 had been discharged on [DATE]. During interview on 1/10/24 at 4:15 p.m. with R1F, she stated she accompanied Resident 1 to her home upon discharge from the second SNF. R1F stated Resident 1 noticed, among Resident 1's medication cards, there were 2 medication cards, not labeled with Resident 1's name. R1F stated Resident 1 took pictures of the medication cards and asked R1F if she would return the medications to the facility. During a concurrent record review with R1F, she referred to photos taken by Resident 1, on 1/7/24, which contained pictures of the medications and medication cards of Resident 2 and Resident 3 that Resident 1 had in her possession. Resident 2's medication card contained 42 yellow round pills, and the label of which indicated: [Resident 2's name] . 12/11/23 [facility name SNF], CARBIDOPA-LEVO 25-100MG . GIVE 2 TABLETS BY MOUTH THREE TIMES A DAY FOR PARKINSONS DISEASE. Resident 3's medication card contained 21 white oval pills, and the label of which indicated: [Resident 3's name] . 12/11/23 [facility name SNF], METOPROLOL SUCC ER 25MG . GIVE 1 TABLET BY MOUTH ONE TIME A DAY RELATED TO ESSENTIAL HYPERTENSION . During an interview on 1/11/24 at 10:30 a.m. with the director of nursing (DON), she stated that medications belonging to Resident 2 and Resident 3 were given to resident 1 upon her discharged on [DATE]. The DON confirmed that Resident 2 and Resident 3 were current residents at the facility. The DON stated the facility did not have authorization to disclose Resident 2 and Resident 3's personal health information to Resident 1. The DON further stated Resident 2 and 3's right to have their medical information protected against unauthorized disclosure was violated when the facility discharged Resident 1 and accidentally sent Resident 2 and Resident 3's medications and medication cards labeled with their names, prescriptions, and drug indications. During an interview on 1/11/24 at 1:00 p.m. with Registered Nurse A (RN A), she stated on 12/20/23, she was the assigned pm shift nurse for Resident 1. She stated Resident 1 was being discharged to another SNF and she called the receiving SNF to give report on Resident 1. RN A stated she obtained Resident 1's medications from the medication cart to give to Resident 1 and stated she did not recall giving any other resident's medications to Resident 1 other than those prescribed to Resident 1 upon discharge. Review of the facility's policy Safeguarding of Resident Identifiable Information, dated 12/19/2022, indicated It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentially of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records . 1. A facility may not release information that is resident-identifiable to the public .

Based on observation, interview, and record review, the facility failed to assess bed rails (adjustable metal or rigid plastic bars that attach to the bed) safety for 12 of 17 residents (Residents 6, 11, 12, 21, 26, 28, 36, 43, 46, 52, 54 and 56) periodically, according to their policy. This failure placed the residents at risk for entrapment and injury. Findings: During the initial tour of the facility conducted on 10/2/23, at 9:00 a.m., Residents 12, 52, and 54, all had quarter bed rails elevated. Review for Resident 12's Bed Rails assessments lacked evidence to indicate Resident 12 was assessed for bed rails safety between 1/30/23 and 10/6/23. Review for Resident 52's Bed Rails assessments lacked evidence to indicate Resident 52 was assessed for bed rails safety between 5/30/22 and 10/6/23. Review for Resident 54's Bed Rails assessments lacked evidence to indicate Resident 54 was assessed for bed rails safety between 6/3/22 and 8/24/23. 44577 During an observation 10/2/23 at 8:49 a.m., Residents 36, 43 and 56 were in their beds with quarter side rails up. Review for Resident 36's Bed Rails assessments lacked documented evidence that Resident 36 was assessed for bed rails safety between 4/27/21 and 10/2/23. Review for Resident 43's Bed Rails assessments lacked documented evidence that Resident 43 was assessed for bed rails safety between 4/29/21 and 10/2/23. Review for Resident 56's Bed Rails assessments lacked evidence that Resident 56 was assessed for bed rails safety. 46553 During the initial tour of the facility conducted on 10/2/23, at 9:32 a.m., Residents 6, 11, 21, 26, 28, and 46 all had quarter bed rails elevated. Review for Resident 6's Bed Rails assessments lacked evidence Resident 6 was assessed for bed rails safety between 4/19/22 and 10/6/23. Review for Resident 11's Bed Rails assessments lacked evidence Resident 11 was assessed for bed rails safety between 7/11/22 and 10/6/23. Review for Resident 21's Bed Rails assessments lacked evidence Resident 21 was assessed for bed rails safety between 11/28/22 and 10/6/23. Review for Resident 26's Bed Rails assessments lacked evidence Resident 26 was assessed for bed rails safety between 10/5/22 and 10/6/23. Review for Resident 28's Bed Rails assessments lacked evidence Resident 28 was assessed for bed rails safety between 10/21/22 and 10/6/23. Review for Resident 46's Bed Rails assessments lacked evidence Resident 46 was assessed for bed rails safety between 9/10/22 and 10/6/23. During an interview with the Director of Nursing (DON) on 10/5/23 at 1:15 p.m., she stated bed rails assessments were to be done upon admission and re-evaluated every quarter. Review of the facility's policy and procedure (P&P) titled Proper Use of Bed Rails, reviewed/revised 12/19/2022, indicated, Responsibilities of ongoing monitoring and supervision are specified as follows: b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly upon a significant change in status, or a change in the type of bed/mattress/rail.

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. A dented can of applesauce was stored on a the dry storage shelf. 2. An outdated bag of pinto beans was stored on a dry storage shelf. 3. Outdated onions were stored on a dry storage shelf; and, 4. Outdated ground herbs were stored on top of the kitchen condiment shelf. These failures had the potential to cause foodborne illness for residents who received food from the kitchen. Finding: 1. During a concurrent kitchen observation and interview with the Registered Dietician (RD) on [DATE] at 9:11 a.m., a dented can of unsweetened applesauce was on a shelf in the dry storage area intended for items to be consumed. The RD confirmed this observation and stated dented cans should be stored in an area designated for dented cans. Review of the facility's policy and procedure titled, Food Storage, revised [DATE], indicated, dented or bulging cans should be placed on Damaged Goods Shelf and returned for credits. 2. During a concurrent kitchen observation and interview with the RD on [DATE] at 9:11 a.m., a plastic bag of pinto beans with an open date of [DATE] and use by date of [DATE] written on the bag was on a dry storage shelf. The RD stated the pinto beans should should have been removed. 3. During a concurrent kitchen observation and interview with the RD on [DATE] at 9:11 a.m., a plastic container was filled with red and yellow onions that were soft to the touch. The container had a label that indicated, [DATE] yellow, red onion, UB [use by]: [DATE]. The RD confirmed the onions had passed their use by date. During an interview with the Dietary Manager (DM) on [DATE] at 10:38 a.m., she stated food items should be disposed of by the use by date. 4. During a concurrent kitchen observation and interview with the DM on [DATE] at 2:00 p.m., a bottle of expired Mediterranean-style ground oregano had a label that indicated, opened [DATE] use by [DATE]. The DM stated it should not be there for use. Review of the facility's P&P titled, Food Storage - Dry Storage, revised [DATE], indicated, Any expired or outdated food products should be discarded.

Based on interview and record review, the facility failed to provide services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Complete Resident 1's post fall neurological assessment after unwitnessed fall incidents per facility's protocol 2. Accurately assess Resident 1 upon admission, and develop an individualized resident-centered care plan to address Resident 1's communication concerns. 3. Follow Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Provide Resident 1's pain management as indicated. These failures resulted in inability to timely identify the presence of Resident 1's fracture that contributed to her discomfort, and compromised her health and care because of delayed acute hospital's evaluation, required treatment and surgical intervention. Findings: A review of Resident 1's face sheet indicated admission on 7/1/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her minimum data set (MDS-an assessment tool) dated 7/7/21, indicated short and long term memory problems with severely impaired cognitive skills for daily decision making, and required extensive physical assistance of two staff on bed mobility, transfer, dressing; one person extensive assistance on eating, toilet use and personal hygiene; history of fall with minor injury; 1. A review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation/Request - a form of nurses progress notes to communicate with physician) dated 7/1/21 indicated Resident 1 had an unwitnessed fall when found sitting on the floor in her room and sustained skin tear on her left forearm. Resident had another unwitnessed fall on 7/14/21 when she was found lying on the floor by the lobby. During an interview and concurrent record review with registered nurse A (RN A) on 3/17/22 at 12:40 p.m., RN A upon review of Resident 1's clinical record confirmed the post fall Neurological Flowsheet dated 7/1/21 and 7/14/21 were not completed as per facility's policy and protocol. RN A stated Neuro checks should be completed by licensed nurses for any unwitnessed fall, and fall with possible head injury for 72 hours. A review of the facility's revised 4/2016 policy and procedure, Accidents and Incidents-Investigating and Reporting, indicated the licensed nurses shall conduct neurological assessment of resident/s who had unwitnessed fall, any visual or suspected head injury and document the results on the Neurological Assessment form . A review of the facility's August 2002 revised policy and procedure, Neurological Assessments, indicated neurological assessments are the responsibility of licensed nursing personnel and it should include determination of the state of consciousness, vital signs (temperature, pulse, respirations, blood pressure), pupillary reaction, motor ability. Document the date and time the procedure was performed and all assessment data obtained during the procedure. 2. A review of the IDT (interdisciplinary team-facility staff members from different departments who coordinate care provided to residents) Post Fall Review dated 7/2/21 indicated, Resident 1 was unable to relate what happened due to confusion and language barrier and spoke non-English language only. A review of Resident 1's eINTERACT Change in Condition Evaluation (COC) dated 7/14/21 indicated she had a fall, and the Interdisciplinary Post Fall Review dated 7/15/22 indicated, LN responded to a loud noise and someone saying why from the lobby and noted resident lying on the floor on the left side on 7/14/21 at 22:00, Resident unable to tell what happened due to language barrier .Assisted back to her wheelchair by three (3) staff. During an interview with certified nursing assistant B (CNA B) on 4/13/22 at 10:13 a.m., she stated Resident 1 was confused, spoke her native language and was unable to communicate her needs to staff using the English language. CNA B also stated, can not understand her. During an interview on 4/13/22 at 10:40 a.m., licensed vocational nurse C (LVN C) confirmed Resident 1 did not speak English, could not understand resident's language and did not use any communication board when he communicated with her. During an interview on 4/13/22 at 11:32 a.m., licensed vocational nurse D (LVN D) stated she was unable to communicate with Resident 1 using the English language, and had not used any communication board except to rely on gestures and facial expressions. During an interview on 4/13/22 at 12:10 p.m., RN A confirmed Resident 1 spoke her native language, she was difficult to understand and had to call resident's son for interpretation. During the concurrent record review with RN A and the director of nursing (DON), the DON and RN A reviewed Resident 1's Baseline Care Plan and Summary dated 7/1/21 which assessed Resident's communication ability, and fall risk and they both confirmed the assessment was not accurate. The DON stated the assessment did not accurately reflect Resident 1's inability to understand and communicate easily with staff, and the need for an interpreter. The assessment did not also reflect Resident 1's risk for fall. RN A stated, Resident's son indicated resident had previously fallen at home. Both RN A and the DON concurred staff's admission assessment should be accurate as these were the bases for resident's plan of care. RN A reviewed Resident 1's care plan and also could not find any documented evidence that a care plan to address Resident 1's communication problem was developed. A review of the facility's 11/20/2017 revised policy and procedure, Baseline Care Plan, indicated a baseline care plan provides an effective and person-centered care of the resident that meet professional standards of quality care shall be developed and implemented for each resident by the Interdisciplinary Team (IDT). It is developed within 48 hours post admission. A review of the June 2008 policy and procedure, Residents with Communication Problems, indicated the facility will provide communication aids to all persons with sensory impairments. Staff will assess the resident's ability to communicate at the time of admission and as needed. Staff will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. 3. A review of Resident 1's Nurses Progress Notes dated 7/16/21 indicated, During bedside care, was noted with L LE (left lower extremity) generalized swelling plus guarding, screams in pain with mobility . A review of Resident 1's physician's phone order summary dated 7/17/21 included, X-ray on her L LE STAT (immediately) for Swollen Left Lower extremity. A review of the Radiology Report dated 7/17/21 indicated , TIBIA/FIBULA AP (anterior posterior) and LAT (lateral-side of), LEFT Results: No acute fracture or dislocation is seen. The tibia and fibula are the two long bones located in the lower leg. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. AP and LAT (anterior or front, posterior or back and lateral or side). During a record review and concurrent interview with RN A on 3/17/21 at 1:15 p.m., RN A reviewed Resident 1's X-ray order dated 3/17/21. RN A stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A confirmed the X-ray done did not include the hip. During an interview with the minimum data set coordinator (MDSC) and DON on 3/17/22 at 3:32 p.m., the MDSC stated the licensed nurse who received the physician's phone order for the X-ray did not verify and make certain the correct body part/location to do x-ray of the left lower extremity that included the hip, thigh, knee down to the toes was done as ordered. During a follow up interview with RN A and the DON on 4/13/22 at 12:10 p.m., RN A stated she was focused on the x-ray results that there was no fracture and missed to check the X-ray was done on correct site/location of the body part. RN A also stated, the nurse should have taken another order to check the swollen body part which was the left hip. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should follow the physician orders. 4. A review of Nurses Progress Note dated 7/17/21 indicated Resident 1's son and daughter in law visited resident on 7/17/21, and son expressed concerns over her mother's swelling on left side. A review of the Nurses Progress notes dated 7/17/21 indicated, Received X-ray result for tibia/tibula AP and LAT, Left: No acute fracture or dislocation is seen, MD and RP son notified, on 7/18/21, Resident 1 was still noted with left lower extremity, was screaming and during incontinent (lack of voluntary control over urination or bowel movement) care and she became calm after the incontinent care, and on 7/19/21, Resident 1 was still with episodes of screaming while 2 RCS (resident care specialist) was doing bedside/incontinent care; and stops screaming post care. A review of Resident 1's progress notes, Long Term Care Evaluation dated 7/23/21 indicated, multiple bruising post fall noted on L LE, and the Social Services Notes dated 7/27/21 indicated Resident 1's son inquired about the doctor's visit and about resident's left leg swelling. A review of the Nursing Progress note dated 7/28/21 indicated, Resident new onset of increasing pain as evidence by yelling and guarding pain of the left leg and hip when being given bed care and transfer, communicated to MD with no reply . A review of the Nursing Note dated 7/31/21 indicated, was transferred to bed; noted r/l foot swelling . screaming during bedside care given by 2 RCS then stops post care . A review of the Progress Notes dated 8/2/21, PT (physical therapy) screen completed , unable to tolerate STS (sit to stand) and walking due to LE swelling and guarding with minimal mobility despite pre-pain meds and worsening dementia . During an interview with CNA B on 4/13/21 at 10:10 a.m., CNA B stated she took care of Resident 1 regularly since admission and even after her fall incident. CNA B also stated Resident 1 had a fracture on her left hip because everyone could see the swelling and bulging on the hip few days after resident's fall. CNA B claimed Resident 1 complained of pain when moved every time she would provide care, and had reported always to her charge nurses including the presence of swelling on the left hip. During a record review and concurrent interview with RN A and the DON on 4/13/22 at 12:10 p.m., RN A stated she was focused on the x-ray results that there was no fracture and missed to check site/location of the body part that they did. The DON and RN A both confirmed there were documented evidences that nurses had consistently and repeatedly observed Resident 1 was screaming of pain during resident care since 7/17/21 . RN A stated, LVN C or RN D and herself (RN A) who were aware of the swelling on Resident 1's left hip should have taken another order to check the swollen body [art (left hip).The DON stated most of the staff assigned to Resident 1 were aware of the swelling and discoloration on resident's left hip, leg and foot. During an interview with registered nurse D (RN D) on 4/19/22 at 3:12 p.m., RN D stated she was Resident 1's regular charge nurse for evening shift. Reviewed with RN D her nurses notes from 7/17/21 to 8/6/21 and she confirmed Resident 1 started to have swelling and pain on her left hip since 7/17/21 after her fall on 7/14/21 and it persisted until her hospital transfer. RN D also validated resident had episodes of screaming of pain during ADL (activities of daily living such as personal hygiene, toileting, transfer, etc.) care. RN D also stated certified nursing assistant E (CNA E) and certified nursing assistant F (CNA F) reported to her regarding Resident 1's left hip swelling that they noted during provision of care. RN D concurred that the repositioning and movements during care could have contributed to Resident 1's pain. RN D stated she had informed her former DON about Resident 1's increased and widespread discoloration that extended on her mon pubis (rounded area in front of the pubic bones at the lower part of the belly. RN D concurred if the x-ray was performed on the correct body part and identified there was fracture then Resident 1 would have not suffered this much pain because she could have been sent out to acute and managed promptly. During the concurrent review with RN D, she confirmed Resident 1's Head to Toe Skin Checks done on 7/23/21 indicated she had bruise on left side of head, left lower extremity, left inner and posterior thigh, mon pubis. During an interview with the primary care physician (PCP) on 4/19/22 at 4:15 p.m., he stated that left lower extremity would include all the joints including the hip. The PCP concurred if the nurse followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the activity supervisor (AS) on 4/19/22 at 4:40 p.m., the AS claimed Resident 1 had been attending and actively participating in the daily activities in the activity room prior to her fall on 7/14/21 but she was different after the fall. The AS stated Resident 1 had not attended the activities regularly, and if she attended she could not tolerate being up in her wheelchair log enough to finish any activity, and often exhibited facial grimacing, signs of discomfort. The AS stated having notified the former director of nursing about Resident 1's facial grimacing and changes in her activities. A review of the progress notes dated 8/6/21 indicated Resident 1 was transferred to acute hospital per her son's request. A review of the acute hospital's Emergency Department ED PROVIDER NOTE dated 8/6/21 indicated, presents by ambulance from nursing home to the ED for fall on July 17. She seems to have left hip/thigh pain. Had x-ray done at the nursing home which supposedly showed no fracture. Patient seems to have continued pain in the left leg. Increased swelling . Anytime patient gets moved and palpated around her left hip and thigh, she started screaming She has a bruise over her pubic bone . Also, patient is normally able to walk with a walker and assistance. A review of the acute hospital's Physician Discharge Summary dated 8/18/21 indicated Resident 1 had closed displaced fracture of left femoral neck and had surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's January 2012 revised policy and procedure, Change in Resident's Condition or Status, indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition . The nurse supervisor/charge nurse will notify the resident's attending physician or on call physician when there has been a significant change in resident's physical/emotional/mental condition, a need to transfer the resident to a hospital/treatment center. 5. A review of Resident 1's July 2021 medication administration record (MAR) indicated Observation: Pain- 1-10 level of pain. For 0= no pain, 1-2= Mild Pain, 3-6 Moderate pain, 7-10 = Severe pain. A review of Resident 1's July 2021 MAR and confirmed Resident 1 had 10/10 level of pain (severe pain) on 7/27/21 and 7/28/21 and did not receive any PRN (as needed) pain medication, and no documented evidence that a new PRN order for severe pain was taken. The August 2021 MAR indicated on 8/3/21, Resident 1 had 6/10 level of pain (moderate pain), and on 8/5/21 she had 4/10 level of pain (moderate pain). Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .(milligrams, unit of measurement) 2 tablets by mouth every 6 hours as needed for mild pain (1-3/10 level pf pain). During the record review and concurrent interview, the DON and RN A confirmed licensed nurses did not administer the PRN pain medications and call the doctor to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated nurses should have called the doctor and taken an order to administer for Resident 1's severe pain. Both staff confirmed nurses did not follow the doctor's order when they gave Acetaminophen ordered for mild pain when Resident complained of moderate pain. RN A also stated, Resident 1's severe pain could be related to the presence of fracture on her left hip that was not promptly identified, and could have been aggravated when moved, repositioned and handled during activities of daily living (ADL) care such as diaper change, repositioning, transfer, toileting, etc. A review of the facility's policy and procedure, Pain Management, indicated pain management helps a resident attain and maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. Each shift the licensed nurse will assess the resident for pain and document results on the MAR using the 0-10 pain scale. The pain assessment flow sheet will be initiated for residents who require PRN pain medications. After medications/interventions are implemented, re-evaluate the resident's level of pain within one hour. The licensed nurse administer pharmacological interventions as ordered and document medication administered on the MAR.

Based on observation, interview and record review, the facility failed to follow its own policy and procedure to evaluate residents' fall risk, to investigate the fall, to implement resident centered care plan, to revise the fall care plan and/or place the effective interventions to prevent four of 17 sampled residents (Residents 1, 24, 37 and 38) from multiple falls recurring when: 1. For Resident 1, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 1 had eight (8) unwitnessed falls from 5/21/2020 to 1/25/2022. 2. For Resident 24, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 24 had four (4) unwitnessed falls from 9/11/2021 to 1/8/2022. 3. For Resident 37, staff failed implement the fall care plan intervention to provide dycem (non-slip mat) on his wheelchair, which had resulted in Resident 37 sliding on his wheelchair and falling on the floor on 8/17/21. Resident 37 sustained an abrasion on his chin. Resident 37 had eight (8) falls from 8/16/21 to 1/23/22. 4. For Resident 38, staff failed to provide frequent checks on Resident 38, which had resulted in Resident 38's fall onto the floor lying on her back and sustaining a hematoma (a bad bruise, it happens when an injury causes blood to collect and pull under the skin) on her right scalp on 6/17/21. Resident 38 had nine (9) falls from 5/20/21 to 12/31/21. These failures resulted in the residents' continued falls and resulted in fall injuries. Resident 1 had a left humerus fracture (upper arm break) from the 6th fall on 6/21/2, a head contusion (a bruise) from the seventh fall on 11/19/21 and head laceration from the eighth fall on 1/25/22. Resident 24 had a fourth fall on 1/8/22 with a closed fracture of second thoracic vertebra (middle part of back that connects to ribs). Resident 37 had a sustained abrasion on the chin from the fall on 8/17/21. Resident 38 had a sustained hematoma on the right scalp from the fall on 6/17/21. Findings: 1. During a review of Resident 1's clinical record it indicated she was admitted with multiple diagnoses including hypertension (high blood pressure), dementia with behavior disturbance (decline in mental capacity affecting daily function and impairs reasoning), unspecified [CONDITION(S)] (a mental disorder characterized by a disconnection from reality). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/2/21, it indicated Resident 1's mental status evaluation revealed moderate impairment. During a review of Resident 1's clinical record it indicated Resident 1 had falls on the following dates: 5/21/20, 9/4/20, 10/29/20, 1/22/21, 3/12/21, 6/21/21, 11/19/21 and 1/25/22. During a review of Residents 1's clinical record, the fall risk assessments dated 4/9/20, 7/17/20, 5/21/20, 9/5/20, 10/17/20, 10/29/20, 3/12/21, 4/17/21, 6/21/2, 11/19/21, and 1/30/22 indicated Resident 1 was a high risk for falls. Resident 1's 1/22/21 fall risk assessment indicated low risk for falls. Review of Resident 1's Minimum Data Set (MDS) dated [DATE], the annual review indicated Resident 1 was able to perform Activities of Daily Living (ADLs) with supervision and set-up to one person assist. Following the fall on 6/21/21 the MDS dated [DATE] indicated the performance of ADLs was with extensive assistance and two person assist with total dependence. During a review of Resident 1's fall risk care plan dated 4/9/20 indicated Resident 1 is high risk for falls, interventions included; 1. Anticipate resident's needs. 2. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. 3. Educate resident the use of call button for assistance and not to get up from bed or wheelchair unassisted 4. Refer to rehab. 5. Ensure nonskid socks when ambulating or mobilizing in wheelchair. 6. The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. 7. The resident's bed will keep in the lowest position. a. During a review of Resident 1's Interdisciplinary Team (IDT a group of health care professionals from diverse fields who work toward a common goal for residents) note dated 5/22/20 at 1:00 p.m., indicated Resident 1 had an unwitnessed fall on 5/21/20 at 5:10 p.m. [Resident 1] was found sitting on the floor of her room. Resident stated, I was getting my rosary under my bed, but I slid on the floor. No injuries. Predisposing diseases indicated Dementia /Alzheimer's disease and other: difficulty in walking, muscle weakness. Conditions that contributed to the fall were listed as: unsteady gait. IDT recommendations indicated Resident is alert and wishes to be independent. She has weakness on her bilateral lower extremities and is at high risk for fall. Resident is educated on the use of call light and not to get up unassisted. Care plan revision and referral to physical therapy. Other intervention recommendations: PT (physical therapy) evaluation with focus on safety, recommended and given a reacher (tool for reaching), educated how to use. Frequent reminders to call for assistance when she drops something on the floor, not to attempt to pick it up. During a review of Resident 1's clinical record, the Fall Risk assessment dated [DATE] at 10:45 p.m. indicated Resident 1's level of consciousness (awareness)/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Resident 1's fall risk care plan dated 5/21/20 and 5/22/20 indicated Resident 1 was found on the floor, beside her bed, interventions included 1. Frequent reminders to call for assistance if she drops something on the floor and not to attempt to reach down for it. 2. Keep personal items within easy reach. 3. Assess neurological (brain) status and vital signs, notify MD for any significant abnormal changes. 4. Assess resident's immediate needs for toileting, need for food, thirst or in pain, reaching for something, educate resident the use of call light for assistance and not to get up unassisted 5. Provide resident with a reacher and educate her on how to use it. 6. PT eval with focus on safety. b. During a review of Residents 1's IDT note dated 9/9/20 at 1:00 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on at 9/4/20 at 4:00 p.m., Resident 1 .had fallen in her room at the bedside sometime early evening of 9/4/20.landed on knees and had to turn to a sitting position for her to get back to bed. No injury. Predisposing diseases indicated Dementia/Alzheimer's disease and other: [CONDITION(S)], difficulty walking, muscle weakness. Conditions that may contributed to the fall were listed as: history of falls, cognitive deficits (an inclusive term used to describe an impairment of how individual's mentally processes information), and recurrent dizziness with episodes of double vision. IDT recommendations indicated resident has recurrent complaint of dizziness and double vision. Also having episode of auditory and visual hallucinations (perception of something not present). Ambulatory with forward wheel walker. Care plan revision and referrals to occupational therapy. Other intervention recommendations included: occupational therapy evaluation and treat with focus on safety. Assess resident for dizziness and double vision and instruct resident to stay in bed if symptoms persist. Review of Resident 1's Fall Risk assessment dated [DATE] at 10:19 a.m., the fall risk assessment indicated Resident 1's level of consciousness/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Resident 1's fall risk care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated Resident 1 claimed fall in her room, interventions included; 1. Assess the resident and instruct her to stay in bed if dizziness and double vision present. 2. Guarantee appropriate room lighting especially during the night. 3. Move items used by resident within easy reach, such as call light . 4. Notify MD (medical doctor) and RP (responsible party). 5. OT (occupational therapy) evaluation and treat if indicated. 5. Respond to call light as soon as possible. 6. Teach client how to safely ambulate (walk), including using safety measures such as handrails in bathroom. During a review of Resident 1's fall care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated no evidence that the facility addressed cognitive deficits that may have contributed to the fall as indicated in IDT note dated 9/9/20 at 1:00 p.m. c. During review of Resident 1's IDT note dated 10/29/20 at 3:53 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on 10/29/2020 at 4:00 a.m. Staff responded to a loud noise coming from the residence room and noted the resident lying on the floor in supine position between the bed and over bed table . According to the resident she was trying to sit at the edge of her bed . slid down to the floor. she complained of pain at the back of the left ear 3/10, no injury. Conditions that contributed to the fall were listed as: history of falls, cognitive deficits, and episodes of confusion (decreased alertness), dizziness, and double vision. IDT recommendations indicated: Resident has episodes of dizziness and double vision but denies having them prior to this event. Was wearing nonskid socks, floor dry, room well light and height of bed in lowest position. Care plan revision and referrals to physical therapy and occupational therapy. other intervention recommendations physical therapy and occupational therapy referral with focus on safety. During review of Resident 1's Fall Risk assessment dated [DATE] at 4:33 a.m., the fall risk assessment indicated Resident 1's level of consciousness /mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's fall risk care plan dated 10/29/20, the care plan indicated Resident 1 had an actual fall interventions included 1. Encourage resident to ask for assistance. 2. Neuro checks (assessment of the brain) for three days. 3. Observe/document/report PRN (as needed) for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture (position in which someone holds their body when standing or sitting), agitation (state of anxiety or nervous excitement). 4. Place frequently used items in reach. 5. Refer to rehab PT/ OT with focus on safety. During a review of Resident 1's fall care plan dated 10/29/20, the care plan indicated no evidence that the facility addressed cognitive deficits and episodes of confusion that were indicated in the IDT note dated 10/29/20 at 3:53 p.m. as conditions that may have contributed to Residents 1's fall risk or the intermittent confusion indicated on the Fall Risk assessment dated [DATE] at 4:33 p.m. that increased Resident 1's risks for fall. During a review of Resident 1's fall care plan, dated, 10/29/20, the care plan indicated no evidence of new interventions were created in order to prevent future falls. d. During a review of Resident 1's IDT note dated 1/22/21 at 1:50 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on 1/22/21 at 1:50 p.m. resident had fallen on the floor. Resident stated she wants to use the commode and cannot get anyone to help her, and she then got up from her bed unassisted and fell . No injury noted. Conditions that may have contributed to the fall were listed as: unsteady gait and history of falls. IDT recommendations indicated, resident has generalized weakness on bilateral lower extremities. At times she wishes to be independent, impulsive and does not want to call for assistance. Care plan revision and referral to physical therapy. Other intervention recommendations encourage resident not to get up unassisted and use call bell for assistance. Anticipate residents' basic needs. During review of Resident 1's SBAR communication form dated 1/22/21 at 2:01 p.m., the SBAR indicated things that make the condition worse are resident at risk of not using her call button or ask for help due to diagnosis of dementia. During review of Resident 1's Fall Risk assessment dated [DATE] at 4:14 p.m. indicated Resident 1's level of consciousness/mental state was alert, had no falls in past three months and was a low risk for falls. During review of Resident 1's fall risk care plan dated 1/22/21, the care plan indicated Resident 1 had an unwitnessed fall. Interventions included 1. Notify MD and RP. 2. Assess for injury. 3. Assessed for pain and medicate. 4. Encourage the use of call button and not to get up unassisted. 5. Anticipate and assist basic needs: toileting, food, thirst, medicate for pain, reaching out down. During review of Resident 1's clinical record no evidence was provided on how the facility anticipated Resident 1's needs for toileting, food, thirst, medicate for pain, reaching out down, an intervention indicated on care plan dated 1/22/21. During a review of Resident 1's fall care plan, dated 1/22/21, the care plan indicated no evidence of new interventions were created in order to prevent future falls. During review of Resident 1's fall care plan, dated 1/22/21, the care plan indicated no evidence the facility addressed resident at risk of not using her call button or asking for help due to diagnosis of dementia as indicated on Resident 1's SBAR dated 1/22/21 at 2:01 p.m. that contributed to the fall. e. During review of Resident 1's IDT note dated 3/15/21 at 11:56 a.m., the IDT note indicated Resident 1 had an unwitnessed fall on 3/12/21 at 3:48 p.m.resident with sitting on the floor at the bedside. According to resident she was about to sit at the edge of her bed, but she was already sliding and could not control it, so she slowly eased herself down to the floor. No injury noted, complaint of pain 4/10 on right hip. Predisposing diseases indicated Dementia /Alzheimer's disease and other: [CONDITION(S)], difficulty walking, weakness. Conditions that contributed to the fall: history of falls, cognitive deficits. IDT recommendations indicated resident is ambulatory with forward wheeled walker (FWW). Has muscle weakness and difficulty walking. Has impaired safety judgment and is impulsive. Care plan revision. Referrals to physical therapy and occupational therapy. Other intervention recommendations refer to physical therapy and occupational therapy with focus on safety. Remind resident to slow down and maintain balance prior to standing or sitting activity. During review of Resident 1's Fall Risk dated 3/12/21 at 4:08 p.m., the fall risk indicated Resident 1's level of consciousness/mental state was intermittent confusion, had three or more falls in past three months and was a high risk for falls. During review of Resident 1's fall risk care plan dated 3/12/21 and 3/15/21, the care plan indicated Resident 1 slid on the floor in her room related to impulsiveness, unable to slow down, muscle weakness pain and impaired safety judgment interventions included 1. Neuro check per facility protocol 2. Note for any pain and discomfort, offer pain medications as needed. 3. Notify MD. 4. Placed belongings and call light within reach. 5. Refer to therapy with focus on safety. 6. Remind resident to slow down, control her balance prior to standing or sitting. During review of Resident 1's fall care plan dated 3/15/21, the care plan indicated no evidence the facility addressed Resident 1's cognitive deficits, impaired safety judgment and impulsiveness as indicated in the IDT note dated 3/15/21 at 11:56 a.m. and level of consciousness/mental state of intermittent confusion indicated Fall Risk dated 3/12/21 at 4:08 p.m. that increased Resident 1's risk for falls. f. During review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation, an assessment tool used to facilitate prompt and appropriate communication of a problem) Communication form dated 6/21/21 at 10 p.m. indicates Resident 1 had an unattended fall on 6/21/21 (time not indicated), with complaints of pain on left shoulder. SBAR also indicated things that make the condition worse are resident does not use call light for assistance, not using FWW when ambulating. During review of Resident 1's SBAR Follow-up dated 6/22/21 at 12:49 a.m. indicated at 8:15 p.m. loud bang in the hallway and resident (Resident 1) yelling help, help .resident laying on her left side on the floor in the hallway by the residence room facing the nursing station. Complain of pain on arm pointing to left mid upper arm she was standing by her door looking for nurse, turned around to go back to her room, her legs felt shaky and fell landing on her left arm. During review of Resident 1's Fall Risk dated 6/21/21 at 10:40 p.m. it indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's Nursing progress notes dated 6/22/21 at 8:17 a.m. indicated resident was complaining of severe pain of the left shoulder .there was obvious swollen as well as bruising. Xray results: Comminuted minimally displaced left humeral neck and head fracture (broken upper arm bone). Resident 1 left the facility at 5 a.m. to the Emergency Department. During review of Resident 1's Emergency Department visit summary dated 6/22/21 at 1:42 p.m. indicated Resident 1's diagnosis was: Closed displaced fracture of surgical neck of left humerus .Acute [MEDICATION(S)] (inflammation of the urinary bladder) .Resident was given a sling [a device to limit movement of the shoulder or elbow while it heals] . During review of Resident 1's Nursing progress notes dated 6/22/21 at 9:52 p.m. indicated Resident 1 arrived at 7:00 p.m.with complaint of pain of the left shoulder and arm due to fracture of left humerus due to fall left shoulder warm to touch and appear swelling with no redness .resident with new diagnosis of [CONDITION(S)] [urinary tract infection] During review of Resident 1's fall risk care plan dated 6/22/21and 6/23/21, indicated Resident 1 had an actual fall. Interventions included 1. Assess severity of pain and offer medication as ordered. 2 Follow-up with orthopedics in a week. 3. Keep left upper extremity in sling provided by the ER 4. Maintain left upper extremity in proper alignment. 5. Monitor swelling and bruising of left upper extremity and notify MD if significantly worse or if there is skin opening. 6. PT/OT evaluation and treat with focus on safety. 7. Administer pain medication as ordered, notify MD of unrelieved pain. 8. Encourage and reorient to the use of call light when help is needed. 9. Notify RP and MD. 10. Remind resident to always use forward wheeled walker when ambulating. 11. Send resident to acute hospital per MD order. 12. Start left shoulder X ray due to pain. 13. Transfer to hospital ER via ambulance for further evaluation on fall. During review of Resident 1's fall care plan dated 6/22/21 and 6/23/21, the care plan indicated no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 6/21/21 at 10:40 p.m. that increased Resident 1's risk for falls. During review of Resident 1's care plan dated 6/22/21 indicated to remind the resident to use the walker, following the fall on 6/22/21 resident had pain in the left arm, was diagnosed with a broken bone and according to nurses notes the resident was using a sling. During review of Resident 1's IDT weekly At Risk meeting note dated 6/24/21 at 2:17 p.m. indicated resident had a fall 6/21/21, while she was turning in the hallway, claimed her leg became shaky while turning back towards her room, causing her to fall on her left side, complain of pain 6/10, had swollen and bruising on the area, X ray revealed comminuted mildly displaced fracture left humeral neck and head, she was sent to the ER for further evaluation and follow up. Sling was applied to the left upper extremity. Offered medication for pain. Continue with auditory hallucination .Resident has intermittent confusion usually ambulate with forward wheel walker (FWW) but did not use during the fall, reminded to use the forward wheel walker. Physical therapy and occupational therapy evaluation and treatment. Started on antibiotic for [CONDITION(S)] till 6/29/21. Care plan reviewed and updated. During review of Resident 1's IDT risk review note dated 7/26/21 at 5:18 p.m. indicated, . decline in late loss ADL, falls with major injury and range of motion (ROM) limitations receiving services. Residents' prior function was independent to supervision. She previously [was] able to ambulate around with FWW. Recently she had a fall while trying to turn back to her room and her legs weakened and fell on the floor on her left side to staining fracture of her left humeral neck and head. Left upper extremity is immobilized with a splint. She had a decline in function since requiring extensive assistance with bed mobility, transfer, bathing and dressing due to pain and ROM limitations of the upper extremity . g. During review of Resident 1's change in condition notes dated 11/19/21 at 10:00 a.m. indicated Resident 1 had a fall on 11/19/21 with injury: bump to back of lower head. During review of Resident 1's nursing notes dated 11/19/21 at 11:15 indicated at around 9:45 a.m., Resident 1 was noted sitting on the floor, facing her bed, walker on her side .noted bump on back of head approximately 2.5x 2.5 centimeters (cm., unit of measurement), skin intact, no bruising noted. At around 10:34 a.m. resident complained three out of 10 pain on bump site, medicated for pain. Per resident she was standing up and fixing her personal belongings on her table when she got out of balance and fell . Nursing notes dated 11/19/21 at 10:53 indicated, .nurse and received an order to send the resident to the hospital for further evaluation. During review of Resident 1's Emergency Department note: Discharge summary dated 11/25/21 at 11:52 indicated Resident 1 presented with fall. Patient reports that she was trying to get up from bed and her legs gave out, she fell on the side hitting her head on the side table. Denies any LOC . Complaining of pain in her back, left sided chest wall, left shoulder (acute on chronic). 8 to 10 hours into emergency visit, patient went into a period of A Fib with RVR (abnormal heartbeat) heart rate in the 140s. Patient otherwise asymptomatic .heart rate controlled . discharged Condition stable. Discharge diagnosis: principal problem: fall During review of Resident 1's clinical record there was no evidence the facility completed an IDT note following Resident 1's fall on 11/19/21. During review of Resident 1's Fall Risk assessment dated [DATE] at 11:34 a.m. it indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1 to 2 falls in the past three months and was a high risk for falls. Review of Resident 1's fall risk care plan dated 11/19/21 indicated Resident 1 had an actual fall related to poor balance. Interventions included 1. Provide activities that promote exercise and strength building where possible provide one to one activities if bedbound. 2. PT (physical therapy) consult for strength and mobility. 3. Continue interventions on the at-risk plan. 4. Monitor/ document /report PRN (as needed) times 72 hours to MD (medical doctor) for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. 5. Neuro checks. Review of Resident 1's fall care plan dated 11/19/21 indicated there was no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 11/19/21 at 11:34 a.m. that increased Resident 1's risk for falls. h. Review of Resident 1's IDT Fall Review dated 1/26/22 at 9:32 p.m. indicated the resident had an unwitnessed fall on 1/25/22 on the evening shift. Resident 1 was asked what happened and she said she tried to sit on her walker after she finished brushing her teeth in the bathroom in her room, but the walker was not locked, causing her to fall. Resident 1 sustained a small laceration on the occipital (position at the back of the head) area of her head and was sent to the ER for further evaluation and treatment. Resident 1 returned from the ER and no abnormal findings were noted. IDT recommendation was to encourage the resident to use call light when she needs assistance, physical therapy will screen . Review of Resident 1's nursing note dated 1/26/22 at 12:59 a.m. indicated, .what happened, I was about to go back to my room, I turned around and my walker shift to side and fell . Resident went to bathroom unassisted and without calling for staff assist. Review of Resident 1's Fall Risk assessment dated [DATE] at 11:56 p.m. indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's Fall Risk assessment dated [DATE] at 3:53 p.m. indicated Resident 1's level of consciousness/mental state was disoriented x three at all times, had 1-2 falls in past three months and was a high risk for falls. Review of Resident 1's fall risk care plan dated 1/25/22 indicated Resident 1 had actual fall interventions including, 1. Apply pressure to laceration site to stop bleeding. 2.Transfer to hospital for further evaluation and treatment. 3. Head to toe skin check. 4. Neuro checks started. Review of Resident 1's fall care plan dated 1/25/22, indicated no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 1/25/22 at 11:56 p.m. and disoriented x three on 1/30/22 at 3:53 p.m. that increased Resident 1's risk for falls. Review of Resident 1's fall care plan dated 1/25/22, indicated no evidence the facility addressed the interventions to decrease Resident 1's risk of falls. Review of Resident 1's clinical record indicated there was no evidence the facility completed weekly at risk review meetings for all of the falls mentioned above. During observation and interview on 1/25/22 at 8:26 a.m., Resident 1 was in her bed, the bed in a low position, the call light withinin reach. Resident 1's room contained many of her belongings. Resident 1 stated she has many pretty clothes and pictures from home. She stated she hurt her arm when she fell , it still hurts. During an interview on 1/26/22 at 1:41 p.m. Registered Nurse H (RN) stated Resident 1 had a fall last night when she went to the bathroom by herself. During an observation and interview on 1/26/22 at 1:56 p.m. in Resident 1's bathroom with certified nursing assistant I (CNA) Resident 1's bathroom was observed to have two wheelchairs placed in corners of the bathroom. CNA I stated the wheelchairs should not be stored there. During interview on 1/26/22 at 2:23 p.m. with the Minimum Data Set Nurse Coordinator (MDSC), MDSC stated an At Risk for Fall assessment is done after every fall, based on the assessment, higher numbers mean better intervention is needed, if other interventions are not working. Need to find what is causing the fall, the root cause, that helps come up with better interventions. A concurrent interview and record review was done with MDSC on 1/26/22 at 2:47 p.m. with Resident 1's clinical record. Review of the clinical record indicated an IDT note was not completed following Resident 1's fall on 11/19/21. MDSC verified the IDT note was not completed and stated, there is no active care plan specific on how to prevent Resident 1's fall risk. During interview on 1/27/22 at 4:19 p.m. with licensed vocational nurse J (LVN), LVN J stated she was working on 1/25/22 when station 1 called her because there was a loud noise and Resident 1 was found on the floor. She did not call prior to getting up. During interview on 1/27/22 at 4:25 p.m., LVN J stated she was working on 6/21/21 when Resident 1 had the fall, and she broke her arm. LVN J stated most of the time she did not use the call light, we remind her, it doesn't work (reminding her). During interview on 1/28/22 at 11:54 a.m. with he rehab program director (RPD), RPD stated Resident 1 had a decline in her ADL because of limited use of her arm. She could not use the walker with her arm as she was in pain and had a sling. During interview on 1/31/22 at 3:52 p.m. with MDSC, MDSC stated Physical therapy/Occupational (PT/OT) alone is not sufficient to address the fall. Therapy (PT/OT) addresses ADLs and makes recommendations with other disciplines to address problems and coordinate care. During concurrent interview and record review on 1/31/22 at 3:36 p.m. of Resident 1's clinical record, with MDSC and the DON. MDSC stated it is important to get to the root cause. Is it cognition, needing to go to the bathroom, find the cause to get appropriate interventions for that resident. MDSC verified there are no changes in the interventions, they are repeated after each fall. During interview on 1/31/22 at 3:47 p.m. with MDSC, she stated the licensed nurse incorrectly entered information in the Fall Risk assessment dated [DATE] at 4:14 p.m. indicating no falls in the past three months. Resident 1 had a fall in October 2020. Fall risk assessment completed 1/22/21 indicated Resident 1's fall risk is low risking following her fourth fall. Resident 1 had a fall on 10/29/20. During a review of the facility's policy and procedure titled Accidents and Incidents - Investigating and Reporting dated revised 4/2016, The residents care plan will be amended to include immediate interventions if applicable and subsequent interventions During a review of the facility's policy and procedure titled Fall Management dated July 2017, the policy indicated, The IDT evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .the facility is obligated to investigate .and put into place an intervention to minimize it from recurring. Review of the facility's revised policy and procedure of Fall Management dated November 2017, indicated .The IDT should choose a consistent day of the week for the At Risk Review Meeting .Residents who have experienced actual falls will be reviewed each week during the At Risk Review Meeting .The At Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis .After the At Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review . 2. During review of Resident 24's clinical record, it indicated she was admitted with multiple diagnoses including [CONDITION(S)] [CONDITION(S)] (blood has a lower-than-normal number of red blood cells), [CONDITION(S)] (temporary loss of being awake and aware of one's surroundings) and collapse (falling down), hypertension (high blood pressure) and a history of falling. Review of Resident 24's Minimum Data Set (MDS, an assessment tool), dated 9/1/21, it indicated Resident 24's mental status evaluation revealed moderate impairment. During review of Resident 24 's clinical record, the clinical record indicated Resident 24 had falls on the following dates: 9/11/21, 9/26/21, 11/10/21 and 1/8/22. Review Residents 24's fall risk assessments dated 3/16/19, 9/11/21, 9/26/21, and 1/9/22, indicated Resident 24 was at high risk for falls due to multiple problems including intermittent confusion, a history of falls, gait/balance problems, medications and predisposing disease. During a review of Resident 24's fall risk care plan dated 3/16/19, the care plan indicated Resident 24 was at moderate risk for falls related to history of falls [TRUNCATED]

Based on interview and record review, the facility failed to ensure the critical potassium level (helps regulate fluids and mineral balance in and out of body cells) of one of three sampled residents (1) was communicated to the attending physician (AP). This failure resulted in a delay of treatment and an increase of Resident 1's potassium blood level. Findings: Resident 1's clinical record was reviewed. She had [DIAGNOSES REDACTED]. Review of Resident 1's Medication Administration Record [REDACTED]. A progress note dated 1/22/16, indicated [MEDICATION NAME] with potassium chloride increases the risk of [MEDICAL CONDITION] (high potassium level in the bloodstream), and the serum potassium concentration (amount of potassium in the blood) should be monitored. Resident 1's physician telephone order dated 1/25/16, indicated to perform a complete blood count (CBC, a blood test used to evaluate overall health and detect a wide range of disorders) and basic metabolic panel (BMP, a blood test which measures the sugar level, electrolyte, fluid balance and kidney function) lab test on 2/2/16. Resident 1's BMP lab result dated 2/2/16, printed at 10:34 p.m. indicated there were two elevated results. The blood urea nitrogen (BUN, measures the amount of nitrogen in the blood which comes from waste product urea) level was critically high, 92 milligrams per deciliter (mg/dl, a unit of measure), the normal range is 7-25 mg/dl. The potassium level was critically high, 6.3 milliequivalents per liter (mEq/L, unit of measurement), the normal range is 3.5-5.1 mEq/L. A note from the AP on the BMP lab result indicated she was not notified regarding Resident 1's potassium level. Review of Resident 1's BMP lab results dated 2/2/16, printed at 10:34 p.m., indicated the BUN level was called to the facility and read to a staff member on 2/2/16, at 2:07 p.m. The potassium level was called to the facility and read to a staff member on 2/2/16, at 3:08 p.m. Review of Resident 1's MAR indicated [REDACTED] Review of Resident 1's nursing note on 2/2/16, at 11:14 p.m. indicated the facility received the potassium level result for Resident 1 then called and left a message to the on call doctor. During an interview with the AP, on 3/2/16, at 10:50 a.m., she stated she was not notified regarding Resident 1's potassium level. The AP stated she even called on 2/2/16 and asked about the lab result. The AP stated she did not find out about Resident 1's potassium level until the next day when she came to the facility. During an interview with registered nurse D (RN D), on 3/2/16, she stated the on-call doctor for the AP was notified regarding Resident 1's potassium level. RN D stated the medical director was not notified when the on call doctor did not respond about the lab result. During an interview with the director of nursing (DON), on 3/2/16, at 11:30 a.m. and 1:20 p.m., she stated she was not notified by the staff regarding Resident 1's potassium level. The DON stated the staff should speak directly with the doctor when there are critical laboratory results. Resident 1's BMP laboratory result collected on 2/3/16, at 7 a.m., indicated the potassium level was critically high. Review of Resident 1's physician order [REDACTED]. The facility policy and procedure titled Laboratory Management dated 8/2012, indicated if the results of the lab tests are abnormal or critical values, the AP should be notified immediately at the time the results are received. If a resident's AP or their on-call coverage cannot be reached to report a critical or abnormal value, the facility medical director and the DON should be contacted with the results.