Every finding on record at Crown Pointe Estates Care Center

Based on observation, staff interviews, resident interviews, Electronic Health Record (EHR) review and policy review. The facility failed to respond to call lights in a timely manner for 4 of 4 residents reviewed (Resident #12, #64, #76, and #81). The facility reported a census of 92 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #12 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. The MDS further documented Resident #12's functional abilities as substantial/maximal assistance with toileting hygiene. Observation on 8/4/26 at 9:00 AM revealed Resident #12 stated to the Staff D, Certified Nurse Assistant (CNA) that she had to wait a long time to use the bathroom. Staff D nodded and responded to Resident #12 that she knew she had been waiting a long time to use the restroom and apologized for taking that long to get to her.On 8/4/26 at 9:00 AM Resident #12 stated it takes longer than 15 minutes frequently and sometimes it takes over 2 hours for her call light to be answered. 2. The MDS dated [DATE] for Resident #64 documented a BIMS of 11 indicating moderate cognitive impairment. The MDS further documented Resident #64's functional abilities as substantial/maximal assistance with toileting hygiene. Observation on 8/3/26 at 12:32 PM revealed Resident #64 placed her call light on at 12:32 PM, and a CNA entered the room at 12:58 PM which revealed a 26 minute call light time.On 8/4/26 at 9:54 AM Resident #64 stated the staff take over 20 minutes at least 2-3 times a week to answer her call light.3. The MDS dated [DATE] for Resident #76 documented a BIMS of 15 indicating no cognitive impairment. The MDS further documented Resident #76's functional abilities as dependent assistance with toileting hygiene.On 8/3/26 at 1:42 PM Resident #76 stated they are short staffed and it takes the staff longer than 20 minutes at least 3 times a week to answer her call light.4. The MDS dated [DATE] for Resident #81 documented a BIMS of 15 indicating no cognitive impairment. The MDS further documented Resident #81's functional abilities as partial/moderate assistance with toileting hygiene.On 8/3/26 at 1:04 PM Resident #81 stated she frequently waits over 20 minutes for her call light to be answered. On 8/6/26 at 12:05 PM the Administrator stated the facility does not have a policy for call light times or expectations and acknowledged concern with call light times.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 92 residents.Findings include:Observation on the initial walk through of the kitchen on 8/3/26 at 11:05 a.m., revealed the following: a. The walk in freezer was noted to have white debris on the floor, strips of tape that had been ripped off the bag laying on the floor, a bag of frozen baked cookies open to air and a trail of black dried debris forming a line from the door to the back wall of the freezer. b. The ice machine was noted to have black substance on the inside of the ice shoot. c. In the dry storage area there was 7 cans of vegetable lentil soup with a best by date of 10/15/2025 stored and ready for service and 2 jugs of garlic parmesan wing sauce with a best buy date of 6/11/25 stored and ready for usage. d. Observation of the cutting boards stored and ready for usage revealed the following: i. 3- small white cutting boards with a fuzzy appearance ii. 2- large green cutting boards with a fuzzy appearance iii. 1- large red cutting board with a fuzzy appearance iv. 1- large blue cutting board with a fuzzy appearance Review of the facility provided policy titled Nutrition Services with a last revision date of 9/2025 revealed the following:a. the purpose of this policy is to maintain strict sanitary conditions in the nutrition services department in order to eliminate food contamination and to prevent the growth of disease producing organisms and the production of bacterial toxin. b. Cutting boards will be constructed of seamless, non-porous material. c. Storage Refrigerators and Freezers are kept clean and spills wiped up immediately. d. Food is covered, labeled and dated when stored. Interview on 8/3/26 at 12:05 p.m., with the Dietary Manager (DM) revealed she would have expected the freezer floor and the ice machine to have been clean. She stated the expired food should not have been in the dry storage area.

Based on observation, staff interviews and facility policy review the facility failed to ensure residents received the proper diet texture to meet the residents needs.The facility reported a census of 92 residents. Findings Include:During observation on 08/05/2026 starting at 10:40 a.m., of the puree process. Staff A, [NAME] dished 3 servings of cauliflower into the robo coupe (blender) and pureed the cauliflower. Staff A took a 4 ounce scoop and scooped 2 portions out of the robo coupe and dished into the dish and took the same scoop and filled it half full and placed it into a dish for service. Staff A then took 3- 6 ounce portions of hot chicken and noodles and placed into the robo coupe and blended until smooth. Staff A dished out 3- 6 ounce servings into serving dishes. Staff A had extra pureed in the canister left after dishing the food out. Asked Staff A why she had extra food left after pureeing the food and Staff A replied she didn't know. When asking if Staff A ever used the puree chart, she replied no. The Dietary Manager (DM) was standing next to Staff A and when asked about the portion she replied the portion should have been done with the volume method. Review of the facility provide policy titled Preparation and Service with a last approved date of 9/2025 revealed food is chopped, ground or pureed to meet individual diet needs. Interview with the DM on 8/5/26 at 10:55 a.m., revealed the staff should have done the measurement with the volume method and should have received the proper portion for the meal.

Based on resident interview, staff interviews and Electronic Health Record (EHR) review the facility failed to ensure 2 of 5 residents personal property was protected from loss or theft when Resident #27 and Resident #81 reported missing items. The facility failed to document personal inventory sheets upon admission to the facility or updated throughout the time living at the facility. The facility reported a census of 92 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #27 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.On 8/4/26 at 8:27 AM Resident #27 stated she was missing 2 pairs of fleece pants. Resident #27 explained she reported them 2-3 months ago to the facility and has not heard anything about it. Resident #27 denied the facility offering to replace missing items.2. The MDS dated [DATE] for Resident #81 documented a BIMS of 15 indicating no cognitive impairment.On 8/3/26 at 1:00 PM Resident #81 stated she had 2 sets of very nice and expressive pajamas, a navy blue shirt with pink dots, a dark colored shirt with pink flowers and $60.00 missing from her room. Resident #81 stated she reported the missing items 6 months ago with no response from the facility.On 8/5/26 at 8:48 AM Staff I, Social Services Coordinator #1 stated once an item is reported missing the facility staff filled out a missing items form that keeps track of what items are missing, who is notified and what has been done to find the missing item. Staff I further explained she will send out an email to the managers of what item is missing to alert the team. On 8/5/26 at 8:50 AM Staff J, Social Services Coordinator #2 stated the inventory sheets filled out at admission and throughout the residents stay are for non clothing items only. Staff J stated the facility does not inventory clothing items. Staff J further explained it was the families responsibility to label clothing items, to look through the lost and found items on the unit and to monitor the residents clothing brought in and taken out of the facility. Staff J stated it was not the facility's responsibility to monitor clothing the residents have. Staff J stated if the clothing item is not found then the Administrator will determine if the facility or the resident was at fault for misplaced items. She continued to explain if the facility is at fault for the lost item the Administrator will decide if the facility will replace the item or not. Review of facility provided document dated 2/04 titled, admission Paperwork documented the notice of responsibility that the facility is not liable for loss or damage by fire, theft or other casualty. The resident's personal possessions or any invitee of a resident unless such loss or damage is the result of negligent act or omission of the facility. The Administrator of the facility was unable to provide a policy for personal items.

Based on observations, staff interviews, Electronic Health Record (EHR) review and policy review the facility failed to implement policies and procedures regarding the technical aspect of a gastrostomy feeding tube (G-Tube) by not accurately labeling and dating the enteral nutrition bag and supplies. The facility failed to provide an appropriate care plan, comprehensive assessment, appropriate infection control and physician orders for 1 of 1 residents reviewed (Resident #6). The facility reported a census of 92 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 0 indicating severe cognitive impairment. The MDS further documented Resident #6 diagnosed with a gastrostomy tube placement, cerebral palsy and intellectual disabilities. The MDS documented Resident #6's functional abilities as staff dependent.Review of Resident #6's EHR dated 8/6/26 titled, Physician Orders failed to document an order for the mother of the resident to perform new G-Tube insertions at bedside, an order for when to insert a new G-tube, orders for parameters of placement, order for external length to be monitored and failed to document orders of when to notify physician of concerns or issues with G-Tube.Review of Resident #6's EHR dated 7/1/26 titled, Progress Notes documented a Nurse Note that Resident #6's G-Tube fell out and the facility nursing staff notified Resident #6's mother for G-Tube insertion supplies. The nurse documented the mother coming to the care facility and inserted a new G-Tube. The documentation failed to note the external length of the new G-Tube or how placement was verified after insertion. The Progress Notes failed to document the physician being notified of new G-Tube insertion.Resident #6's EHR dated 5/30/26 titled, Care Plan failed to document Resident #6's G-Tube including focus, interventions and goals.Observation on 8/3/26 at 1:31 PM revealed Resident #6's Gastrostomy Tube (G-Tube) enteral nutrition bag hanging on an intravenous (IV) pole with the extension set connector not capped and inside of the roller clamp located on the tubing. The enteral nutrition bag was not dated.Observation on 8/4/26 at 9:45 AM revealed Resident #6's G-tube extension set connector not capped and placed inside an empty nutrition bag hanging on an IV pole in the residents room.On 8/4/26 at 11:53 AM Staff E, Registered Nurse (RN) stated the enteral nutrition bag and tubing are used for all the enteral nutrition feedings during the day and then discarded after the dinner enteral nutrition feeding is administered. On 8/5/26 at 2:00 PM Staff F, Licensed Practical Nurse (LPN) stated she has worked at the facility for 4 years. Staff F stated she does not verify G-tube placement before administering feedings. She explained that she relies on the established nature of the tube rather than verifying its position. She acknowledged that there is no technical method used to confirm G-tube placement and stated there is no safe way she assesses placement prior to feedings. Staff F indicated she could assess for bowel sounds if the resident appeared nauseated, she noted the resident is non-verbal and nausea is only identifiable if the resident is actively experiencing emesis. She confirmed she had administered Zofran and held feedings when the resident had an emesis event. Staff F confirmed the G-tube lacks markings to indicate external length. Additionally, she stated there are no physician orders in the charting system regarding parameters for placement verification, instructions for when to notify a physician or authorization for family members to perform G-Tube replacements at the bedside. Staff continued to explain the family replaces the G-Tube when it becomes dislodged or required replacement and reported that when she asked the family how to verify the correct placement or if they would allow an X-ray to confirm placement, the family declined, stating it was unnecessary.On 8/5/26 at 2:36 PM Staff G, Director Of Nursing #1 (DON) stated if the G-tube is established then you do not have to check for placement or residuals. The DON explained her expectations for the nurses would be to watch for signs including vomiting and abdominal distention and let the physician know. The DON stated she does not know the extent of Resident #6's mothers knowledge on how to insert a new G-Tube. The DON further explained the policy documented an external measurement of the G-Tube at the abdomen should be documented and expressed concerns with the facilities failure to provide the documentation in regards to the policy.On 8/5/26 at 2:36 PM Staff H Director of Nursing #2 (DON) stated the mother of Resident #6 changes the G-tube at bedside and is unaware of the mothers education to perform insertion. Staff H explained she believed the physician was aware the mother performed G-Tube insertions though was unable to find or provide documentation to support the statement. Staff H acknowledged concerns with no documentation of placement, external length, physician notification, lack of information in care plan and lack of physician orders related to Resident #6's G-tube.Review of a facility provided policy dated 11/25 titled, Gastrostomy Tube (G-Tube) Care (LTC-Nursing) documented to prevent tube migration prevention and verification of tube placement with a baseline measurement of external tube will be obtained upon admission or with a new tube placement. Further documents will be documented in the Electronic Medical Record (EMR) tube feeding assessment intervention and added to the care plan. The physician to be notified and stop feeding if the placement is in question as inward movement can cause pyloric obstruction, outward movement can dislodge the tube into the stoma tract or peritoneum. An X-ray is to be requested for tube placement verification anytime proper placement is questioned. The policy further documents to monitor for clinical signs of a misplaced tube with signs and symptoms including dyspnea, tachypnea, tachycardia, pulmonary congestion and abdominal distraction, tenderness or hardness.

Based on observations, staff interviews, resident interviews, Electronic Health Record (EHR) review and policy review the facility failed to perform proper hand hygiene during personal cares (Resident #12), gastrostomy tube (G-tube) cares (Resident #6) to cap the G-tube connector after completing an enteral feeding and reused the same contaminated feed tubing for the next scheduled feeding (Resident #6) , to apply Personal Protective Equipment (PPE) during catheter care (Resident #3), for 3 of 5 residents reviewed. The facility reported a census of 92 residents.Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 0 indicating severe cognitive impairment. The MDS further documented Resident #6 diagnosed with a gastrostomy status, cerebral palsy and intellectual disabilities. The MDS documented Resident #6's functional abilities as staff dependent. Observation on 8/3/26 at 1:31 PM revealed Resident #6's G-tube enteral nutrition bag hanging on an intravenous (IV) pole with the extension set connector not capped and inside of the roller clamp located on the tubing. The Enteral nutrition bag was not dated. Observation on 8/4/26 at 9:45 AM revealed Resident #6's G-tube extension set connector not capped and placed inside an empty enteral nutrition bag hanging on IV pole. Observation on 8/4/26 at 11:43 AM revealed Staff E, Registered Nurse (RN) entered Resident #6's room, did not perform hand hygiene, applied gown and applied gloves. Staff E removed the previously used enteral nutrition bag from the IV pole with noted extension set connector not capped and hanging inside of the enteral nutrition bag into the residents restroom to fill with formula for feeding. After Staff E added formula and 45 ml of water to the enteral nutrition bag. Staff E cleansed the resident's G-tube stoma at abdomen and connected tubing for feed. Staff E unclamped roller clamp to begin enteral nutrition when she stated Resident #6 needed a split gauze dressing applied to the resident's abdomen. Staff E removed gauze packaging from the shelf, removed split gauze and placed gauze around G-tube stoma. Staff E removed gown, removed gloves, did not perform hand hygiene and exited Resident #6's room. On 8/4/26 at 11:53 AM Staff E stated the feeding bags and tubing are used for all three G-tube enteral nutrition intake each day for the AM, NOON and PM feeding times and discarded after the last dinner feeding in the evening. 2. The MDS dated [DATE] for Resident #12 documented a BIMS of 11 indicating mild cognitive impairment. The MDS further documented Resident #12's functional abilities as substantial/maximal assistance with toileting hygiene. On 8/4/26 at 9:05 AM an observation revealed Staff D, Certified Nurse Assistant (CNA) entered Resident #12's room, performed hand hygiene, applied gait belt to resident, applied gloves, assisted resident with walker into the bathroom and removed resident's pants and the brief while assisting resident to sit on the toilet. After Resident #12 was finished using the toilet, Staff D used paper towel squares sprayed with cleanser and continued to provide personal care to buttocks using one square each wipe and threw away x3, did not remove soiled gloves, did not perform hand hygiene, pulled up residents brief, adjusted residents sweater, pulled up residents pants, adjusted residents shirt, removed gloves , did not perform hand hygiene and assisted resident back to her chair. Staff D handed the resident her call light, handed the resident a blanket and moved the bedside table to the resident's side, performed hand hygiene and exited the resident's room. On 8/5/26 at 5:07 PM the Director of Nursing (DON) acknowledged concerns with hand hygiene. Review of a facility provided policy dated 8/2026 titled, Gastrostomy Tube (G-tube) Care (LTC-Nursing) documented the principles of food safety will be applied to preparation, storage, delivery and administration of tube feeding. The policy further documented to wash hands, wear gloves when caring for the tube and stoma site, to use only a closed delivery system and to use a clean technique. 3. Observation on 8/6/26 at 11:08 a.m., of Staff B, Certified Nurse Aide (CNA) entered Resident #3 room and performed hand hygiene and applied gloves. Staff B emptied the catheter bag and cleaned supplies and returned items to where they belonged. Staff B performed hand hygiene upon exiting the room. Staff B was asked if she ever wears a gown when emptying the catheter bag and she stated that she does not. Review of the facility provided policy titled Transmission Based Precautions and Enhanced Barrier Precautions with a last revised date of 10/23/25 revealed EBP are used during high contact resident care activities for the following residents: indwelling medical device including urinary catheter. Interview on 8/6/26 at 11:23 a.m., with Staff C, Assistant Director of Nursing revealed staff are to wear the gowns and all EBP when emptying the catheter.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #46) reviewed for PASRR requirements. The facility reported a census of 89 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #46 documented diagnoses of anxiety disorder, and prescribed antipsychotics. The MDS included a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. The Medical Diagnosis list for Resident #46 revealed the following diagnoses: a. Hallucinations b. Anxiety disorder c. Dementia with Parkinsonism The Clinical Orders for Resident #46 revealed the following medications: a. Depakote extended release 250 milligram (mg) twice a day for aggressive behavior b. Remeron 7.5 mg at bedtime for depression c. Seroquel 25 mg at bedtime for dementia with Parkinsonism The Provider Communication form dated 11/14/24 for Resident #46 showed an order for a behavioral health consult. The Visit Notes dated 6/10/25 for Resident #46 showed behavior health services received. In an interview on 6/25/25 at 2:25 PM, the Director of Nursing, (DON) reported she expected the PASSR to be updated and submitted with changes in medication, diagnoses, and behavioral health services related to mental health. The DON reported the facility failed to have a policy related to PASSR.

Based on interviews, chart and policy review the facility failed to ensure that staff provided adequate and timely assessments and interventions for 1 of 20 residents reviewed. Resident #143 had a fall on the overnight shift, the staff failed to call the doctor and did not reassess the resident until 4 hours later when he was unable to bear weight on the left leg. Resident #142 was sent to the hospital 7 hours after the fall, and was found to have a fractured hip. The facility reported a census of 89 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #143 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit.) At the time of admission, the resident was independent with sit to lying, chair to bed transfer and toilet transfers. The Care Plan updated on [DATE], showed Resident #143 had weakness, impaired balance and congestive heart failure. He used a walker for mobility, was independent with transfers, and toileting. The resident had increased shortness of breath, accompanied with cough, lower extremity edema and staff were to monitor for vital signs and injuries. An Event Report dated [DATE] at 12:15 AM, showed Resident #143 had an unwitnessed fall in his room. He was found lying on his left side and told the staff that he got dizzy. He did not remember if he had hit his head or not. His initial blood pressure after the fall was 105/55. The resident complained of pain in his left leg, was given Tylenol and transferred back into the recliner. A document titled: Neuro Checks for Resident #143, showed that on [DATE] at 1:13 AM, the pupil reaction was brisk, pupil shape was round, eye movement, tracking and peripheral visual fields were intact. A follow up neuro checks at 4:15 AM, showed the same eye assessment responses and then indicated that the resident was sleeping. The chart lacked vitals during this assessment. On [DATE] at 12:27 PM, Staff D, Registered Nurse (RN) said that she worked the morning shift on [DATE] and got report from the overnight nurse. The nurse told her that Resident #143 had a fall and he was having hip pain. Staff D went and assessed the resident and when she assessed the range of motion on his left leg, the resident yelled out in pain. Staff D then called the doctor and had the resident sent to the hospital. She told the overnight nurse that if there was any suspected fracture, or if the resident was having pain, staff should have called the on-call doctor for guidance. According to the Vitals tab in the electronic chart on [DATE] at 6:20 AM, Resident #143 had a blood pressure of 83/45. The Emergency Department Note dated [DATE] at 7:10 AM, showed that the resident had a closed intertrochanteric fracture of left hip and hypotension. The patient had been struggling with worsening of his heart failure and dyspnea on exertion. He'd had a drastic decline since moving to nursing home. The resident was admitted to the hospital for possible surgery. The Hospital History and Physical dated [DATE] at 2:16 PM, showed the Assessment and Plan indicated Resident #143 had sepsis, hypotension, and a closed intertrochanteric fracture of left hip. On [DATE] at 3:48 PM, the hospital report showed Resident #143 was critically ill with worsening hypoxemia (low oxygen) hyperkalemic (high potassium) and was in rapid deterioration. He was sent to the Intensive Care Unit and expired on [DATE] at 8:28 AM. On [DATE] at 10:44 AM, Staff G, Registered Nurse (RN) said that on the overnight shift of [DATE], Resident #143 woke up and tried to go to bathroom and fell. The Certified Nurse Aide (CNA) found him on the floor and the two of them transferred him back into the recliner. Staff G said that he checked the Range of Motion (ROM) of his legs and he was moving them but the left one was painful. Staff G administered some Tylenol and the resident said he was feeling okay. Staff G said that they kept checking on him throughout the night and he continued to have some pain. Staff G said that he tried to call the Director of Nursing (DON) at the time but the call didn't go through. He said that he did not contact doctor by phone, but sent a fax. It was his understanding that if it was after 11:00 PM, unless there was an emergency, the morning nurse would contact the family. On [DATE] at 9:28 AM, Staff F, CNA, said that Resident #143 was getting up to go to the bathroom by himself and ended up falling backwards. She and Staff G went in when they heard a thud, the nurse assessed him and they transferred him back into the recliner. The resident said that he was having leg pain so the nurse gave him something. Staff F said that she checked on him throughout the night and around 4:00 AM, he said he had more pain. She and Staff G tried to get him up to clean him because he was wet, but the resident could not stand because he had too much pain in the left leg at that time. According to a summary of a conversation between the DON and Staff G, the DON asked the nurse why he hadn't sent the resident to the hospital when he was unable to bear weight. Staff G was then educated that when a resident had decreased ROM, and unable to bear weight, staff should call the emergency room doctor, and call the family. According to the policy titled: Falls Follow up Documentation last review 8/2024, for an unwitnessed fall or fall with suspected heard injury, staff would complete vital signs and neurologic checks to be done at the time of the fall, then neuro checks every 4 hours x 24 hours then each shift x48 hours. Vital signs were to be obtained every shift x72 hours. On [DATE] at 11:15 AM, the DON and the Administrator agreed that the overnight nurse should have called the doctor and the family sooner. When asked about the falls follow up policy, and standards of care for vitals and neuro checks after unwitnessed falls, they said that policy had been in place for a while but they would revisit it to see if they needed to make any changes.

Based on observation, infection control policy and staff interview, the facility failed to wear Enhanced Barrier Precautions (EBP) with wound care with 1 of 4 residents (Resident #66) observed for wound care. The facility reported a total census of 89 residents. Findings include: Observation on 6/24/25 at 1:52 p.m., Staff A, Certified Nursing Assistant (CNA) and Staff B, Registered Nurse (RN) providing toileting assistance for Resident #66. Staff A assisted Resident to a standing position using a mechanical lift. Staff B removed mepelix dressing off of the resident's coccyx area. Area observed and noted to have an open wound under the dressing. Staff B cleansed the area and reapplied a mepelix dressing to the area. Staff A finished assisting resident with toileting and dressing. Staff A and Staff B did not wear any EBP during personal cares and wound dressing with Resident #66. Interview on 6/24/25 at 2:17 p.m., with Staff B revealed the open wound was found on 6/18/25 and was addressed by the physician and stated dressing changes twice weekly were ordered. Review of the facility provided policy titled Transmission Based Precautions and Enhanced Barrier Precautions with a last reviewed date of 10/10/24 revealed EBP are used during high contact resident care activities for the following residents and should be implemented as facilities are able include wound requiring a dressing, regardless of MDRO status. If this applies a gown and gloves must be used during high contact resident care activities including, dressing, transferring, providing hygiene, changing briefs or assisting with toileting and wound care (any wound requiring a dressing). Interview on 6/25/25 at 12:29 p.m., with the Staff C, Co-Director of Nursing revealed Resident #66 should be on EBP as she put the supplies in the room and did not know why the sign was not on the door and why EBP was not being used as it should be.

Based on interviews, record and policy review the facility failed to notify the doctor and family after a resident had a fall with injury. Resident #143 had a fall around midnight, he was assessed at that time and again at 4:00 AM. At 6:30 AM, the resident was sent to the hospital and found to have a fractured hip. The facility reported a census of 89 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #143 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit). At the time of admission, he was independent with transfers and ambulation. The Care Plan updated on 2/16/25, showed that Resident #142 had weakness, impaired balance and Congestive Heart Failure (CHF). The resident had increased shortness of breath accompanied with cough and lower extremity edema related to CHF. He was at risk for falls due to impaired balance, staff were to monitor vitals and for injuries. An Event Report dated 3/28/25 at 12:15 AM showed that Resident #143 had an unwitnessed fall in his room. He was found lying on his left side and told the staff that he got dizzy. He did not remember if he had hit his head or not. The initial blood pressure was 105/55. The resident complained of pain in his left leg, was given Tylenol and transferred back into the recliner. The report showed that a Fax was sent to the doctor. (According to the Nursing Notes, the fax was acknowledged by the doctor on 3/31/25 at 4:58PM.) On 6/24/25 at 10:44 AM, Staff G, Registered Nurse (RN) said that on the overnight shift of 3/28/25, Resident #143 woke up and tried to go to bathroom and fell. The Certified Nurse Aide (CNA) found him on the floor and the two of them transferred him back into the recliner. Staff G said that he checked the Range of Motion (ROM) of his legs and he was moving them but the left one was painful. Staff G administered some Tylenol and the resident said he was feeling okay. Staff G said that they kept checking on him throughout the night and he continued to have some pain. Staff G said that he tried to call the Director of Nursing (DON) at the time but the call didn't go through. He said that he did not contact doctor by phone, but sent a fax. It was his understanding that if it was after 11:00 PM, unless it was an emergency, the nurse in the morning would contact the family. According to a summary the DON had a conversation with Staff G on 3/28/25 and asked him why he hadn't sent the resident out he said around 5:00 AM they went in to toilet him but the resident was unable to get up he couldn't bear weight on his leg. Educated on decreased ROM, not being able to bear weight to call the ER doc and call the family. On 6/26/25 at 11:15 AM, the DON and the Administrator agreed that the overnight nurse should have called the doctor and the family sooner. A facility policy last reviewed 10/2024 titled: Hot Tracking, the charge nurse would assess change in status and the physician and family would be notified if applicable. The doctor would be notified for review of resident's condition as needed to advise nursing if any changes were needed. Notify family of significant change in residents status and care plan if applicable.

Based on interview, record and policy review the facility failed to use proper safety equipment to ensure safe transfers and ambulation for 1 of 3 residents reviewed. Resident #38 had a change in status with increased weakness, and fell at 4:40 AM on 5/17/25. Later that morning, staff failed to use a gait belt while assisting the resident with ambulation and transfers, and the resident had another fall. The facility reported a census of 89 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #38 had a Brief Interview for Mental Status score of 15 (intact cognitive ability.) She was independent with toileting, dressing, walking and transferring. The Care Plan updated on 1/21/25, showed Resident #38 had pain related to a fracture, and ovarian cancer. She was independent with transfers and ambulation with the use of a walker. The resident was admitted to Hospice on 4/14/25. On 5/17/25 she had an unwitnessed fall in the bathroom, and was reminded to use her call light for assistance. After a second fall on 5/17/25, staff attached a sign to her walker to call for assistance, and staff were instructed to use a gait belt and keep her oxygen in place. An Incident Report dated 5/17/25 at 4:40 AM, showed Resident #38 was a high risk for falls and she was found on the floor after attempting to go to the bathroom. She was supine with feet facing the bathroom door and her walker was in front of her near her feet. The resident had been very confused throughout the night and had not slept, and many times she attempted to get out of her recliner. She had an acute change in mental status. The Incident Report dated 5/17/25 at 9:45 AM, showed Resident #38 was assisted back to her room from dining room following breakfast. Her gait was unsteady and she fell backwards. All staff were made aware of change to ambulation assist of one with gait belt and walker in room. The aide had momentarily let go of the resident to straighten pad on the chair, that's when she fell. Due to new confusion and fall earlier in day, staff had been educated on the increased fall risk. On 6/25/25 at 12:00 PM, Staff H, Registered Nurse (RN) said that the night shift reported Resident #38 had a fall earlier that morning and was more confused. Staff H was checking very frequently. Resident #38 eventually wanted to come out to the dining room. She said she asked Staff I to assist the resident back to her room. When they were in the room getting ready to sit down Staff I reached down to adjust something in the chair, and turned from her. That was when she fell. The med aide was not using a gait belt and the staff had been directed to monitor her closely. On 6/25/25 at 11:09 AM Staff I Certified Medication Aide (CMA) said it had been passed on in morning report that Resident #38 had been very weak that morning. She came out for breakfast and Staff I helped her walk to the table for breakfast. She walked her back to her room. They got to the room, and the resident leaned over to straighten the cushion in her chair before sitting. Staff I said that she would do it for her and momentarily let go of the resident and turned away from her. That's when she fell. The resident had her walker in front of her and was holding onto the handle with one hand. Staff I said she was holding onto the back of her pants and did not use a gait belt. After that fall, the resident was instructed to call for assistance, and they tried to keep eye on her. She said that they had discussed with the nurse that morning that the resident had a change in status and needed close monitoring. On 6/26/25 at 11:15 AM the Director of Nursing and Administrator agreed that Resident #38 had a change in status and staff should have used a gait belt while assisting with ambulation and transfers. According to a facility policy titled: Gait Belt Usage, last reviewed 9/2024 showed that gait belts would be used by all employees with any resident and/or patient who needed assistance with ambulating and/or transferring.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility for 1 of 1 residents reviewed (Residents #7). The facility reported a census of 89 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of hypertension, anemia and hyponatremia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. Review of Progress Notes revealed the following: a. On 5/7/25 at 10:38 a.m., resident received orders from the local hospital to be admitted due to high potassium. b. On 5/10/25 at 4:31 a.m., late entry for 5/7/25 hospital called resident had been admitted for observation. The family gives verbal consent for bed hold. c. On 5/11/25 at 12:14 p.m., 11:25 a.m., return to the facility with sister. Review of the bed hold dated 5/7/25 revealed verbal authorization from Resident #7 ' s representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the facility provided policy titled Bed hold with a last revised date of 7/2024 revealed the facility will inform residents and their representatives through written and verbal notice at the time of admission and at the time of transfer for hospitalization or therapeutic leave.

Based on observation, staff interviews, and policy review, the facility failed to store food in accordance with professional standards for 91 of 91 residents. The facility reported a census of 91 residents. Findings include: A continuous observation on 7/29/24 between 10:40 AM - 11:00 AM during the initial kitchen tour revealed cooked ground beef in a metal steam table container dated 7/22/24. Small fried food freezer with a bag of chicken strips, a bag of chicken patties, and a bag of breaded pork all undated and open. On 7/29/24 at 11:15 AM the Kitchen Supervisor stated all the food open in bags in the mini cafe freezer should be dated when the bags were opened, stated the hamburger with the date of 7/22/24 should have been thrown away by now stated leftover food is only good for 3 or 5 days after being prepared when stored. Review of policy titled, Departmental Services: Nutrition Services revised 7/24 documented food should be covered, labeled, and dated when stored. Prepared food that needs to be stored will be cooled per food code guidelines. Request for a policy with regards to acceptable number of days for stored leftovers resulted in no policy provided by facility management or administration.

Based on Electronic Health Records (EHR), staff interview, and observation the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #22). The facility reported a census of 91 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. Review of Physician's Order dated 3/5/24 for Resident #22 documented silver foam bordered to wound on coccyx 3x's a week and PRN. Review of order detail in Resident #22's EHR revealed Physicians Order written 3/6/24 that reads silver foam bordered to wound on coccyx 3x's a week and PRN- May use silver foam resident already has cut to fit. Found in her cupboard outside of her room. To be changed every Sunday, Wednesday, and Friday at 7am. During a continuous observation on 7/31/24 at 12:34 PM Staff A, Certified Nursing Assistant (CNA) and Staff B CNA completed catheter care and peri care on Resident #22. Staff A removed a dressing with feces on the bottom that was dated 7/26/24. On 7/31/24 at 12:45 Staff A stated the dressing had a date of 7/26/24 after removing from Resident #22. On 7/31/24 at 1:01 PM Staff C, Licensed Practical Nurse (LPN) stated the dressing on Resident #22's coccyx was to cover a pressure area. Staff C stated Resident #22's dressing was to be changed Sunday, Wednesday, and Friday. On 7/31/24 at 3:00 PM Staff D RN/ADON stated that if the order read to change Sunday, Wednesday, and Friday that the dressing would have been changed at those times. Staff D stated the facility had no policy on following physician orders or completion of physician orders. Staff D stated the facility's expectation was that professional standards would be followed and the dressing would have been changed according to the physician's order.

Based on clinical record review, resident interview and facility policy, the facility failed to complete a bed hold notice with the resident or resident's responsible person when residents transferred out of the facility for 1 of 3 residents reviewed (Residents #29 and #45). The facility reported a census of 91 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 documented diagnoses of renal failure and heart failure. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. Review of Resident #29's Progress Notes revealed the following information: On 9/10/23 Resident #29 taken to the emergency department per family request for increased swelling in the left lower calf. The resident left the facility at 7:10 PM. On 9/12/23 Resident #29 returned to the facility at 1:48 PM. Review of the Resident #29's Census tab revealed the following information: 9/10/23 hospital start date. 9/12/23 hospital end date. Review of Resident #29's clinical record revealed the facility lacked a bed hold notice for the hospital admission on 9/10/23. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #45 documented diagnoses of heart failure, renal failure and Diabetes Mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of Resident #45's Progress Notes revealed the following information: On 11/29/23 at 12:58 PM resident leaves on stretcher with EMS at 12:57 PM. On 11/29/23 at 6:12 PM the charge nurse notified of Resident #45 admission to hospital at 5:51 PM. Review of the residents #45's Census tab revealed the following information: 11/29/23 hospital start date. 12/4/23 hospital end date. Review of Resident #45's clinical record revealed the facility lacked a bed hold notice for the hospital admission on 11/29/23. The Bed Hold policy last reviewed July 2024 identified the facility will inform residents and their representatives through written and verbal notice at the time of the admission and at the time of transfer for hospitalization or therapeutic leave, of the duration of the state bed hold policy, during which the resident is permitted to return and resume residence in the nursing facility, the bed hold payment policy, and the nursing facilities policies regarding bed hold periods. In an interview on 07/29/24 at 2:10 PM, the Administrator reported she expected staff to complete bed hold forms with the resident and/or representative for hospital transfers. When asked what happened, the Administrator stated, we previously noticed an issue, and are now auditing the bed hold notices.

Based on observation, Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 2 of 26 residents reviewed (Resident #22 and 41) The facility reported a census of 91 residents. Findings include 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. An observation on 7/31/24 at 1:18 PM of Staff E, AM [NAME] serving Resident #22's lunch plate revealed Staff E scooped 3 spoonful of noodles and 3 spoonful of beef onto Resident #22's plate with a soup spoon. Review of a Physician's Order for Resident #22's diet documented a diet of International Dysphagia Diet Standardisation Initiative (IDDSI) 6 soft and bite-sized diet. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 1 indicating severe cognitive impairment. An observation on 7/31/24 at 12:20 PM of Staff E, AM [NAME] serving Resident #41's lunch plate revealed Staff E scooped 3 spoonful of noodles and 3 spoonful of beef onto Resident #41's plate with a soup spoon. Review of a Physician's Order for Resident #41's diet documented a diet of International Dysphagia Diet Standardisation Initiative (IDDSI) 6 soft and bite-sized diet. On 7/31/24 at 1:20 PM Staff E stated he ran out of measuring devices for the IDDSI 6 diets and just used a soup spoon. Staff E stated he should have used a 3 oz scoop for the beef tips and 1/2 cup or 4 oz scoop for the noodles. Staff E stated when he does not have enough measuring devices he will just estimate because he pretty much knows what 3 oz and 4 oz are just by eyeing the amount. Staff E stated he used the soup spoon when he served Resident #22 and Resident #41's lunch plate. Review of document titled, CPCC Menu A 2024 - Week 4 documented IDDSI level 6 should be served 3 oz of beef tips and 4 oz of noodles for the date 7/31/24. On 7/31/24 at 3:31 PM Staff F, Certified Dietary Manager (CDM) stated the facility's expectation was the appropriate scoop size would have been used to serve the IDDSI level 6 diets. Request for a policy with regards to following the menu and utilization of appropriate scoop sizes resulted in no policy provided by facility management or administration.

Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing wound care and catheter care for 1 of 1 residents (Resident #22). The facility reported a census of 91 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment. MDS also indicated Resident #22 utilized an indwelling catheter. An observation on 7/30/24 at 9:02 AM of Staff G changing Resident #22's right knee dressing revealed Staff G completed hand hygiene, donned gown and gloves. Staff G removed Resident #22's old dressing on the right knee. Staff G removed gloves and applied new gloves. Staff G then cleansed the area around the wound on Resident #22's right knee. Staff G removed gloves and applied new gloves. Staff G then applied a date to the new dressing and applied the new dressing to the right knee of Resident #22. Staff G removed gloves and applied new gloves. Staff G applied a lidocaine patch to the area above Resident #22's right knee. Staff G removed gloves, completed hand hygiene, and applied new gloves. Staff G applied artificial tears to bilateral eyes. Staff G applied the fall mat to the floor. Staff G collected garbage, removed the gown, and removed gloves. Staff G completed hand hygiene when she left the room with hand sanitizer outside of the door. An observation on 7/31/24 at 12:34 PM of Staff A completing catheter care and peri care on Resident #22 revealed Staff A closed the window shade, completed hand hygiene, donned gown, and gloves. Staff A removed brief and completed peri care, and catheter care on Resident #22. Staff A removed gloves, pushed sleeve up, completed hand hygiene, and applied new gloves. Staff A completed peri cares on Resident #22's buttocks. Staff A removed gloves, completed hand hygiene and applied new gloves. Staff A applied a new brief to Resident #22. Staff A removed gown, removed gloves and completed hand hygiene. Staff A's sleeves remained up throughout all cares after the first glove removal. On 7/31/24 at 12:59 PM Staff A stated she typically wears the gown with her sleeves covering her wrist but when she washed her hands she pushed them up and forgot to push them back down during care with Resident #22. On 7/31/24 at 3:00 PM Staff D Registered Nurse (RN) / Assistant Director of Nursing (ADON) stated she expected hand hygiene would have been completed every time gloves were soiled, after going from dirty to clean, and when gloves were changed. Staff A stated when wearing a gown related to enhanced barrier precautions (EBP) she would expect the sleeves of the gown would remain in place through all gown required contact with the resident. Review of policy titled, Transmission Based Precautions and Enhanced Barrier Precautions documented EBP were used during high contact resident care activities for residents with indwelling medical devices regardless of MDRO status such as urinary catheters. Hand hygiene would be completed upon entering the residents room, leaving the residents room, and after removal of personal protective equipment (PPE). Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 7/11/24 and updated 7/12/22 revealed recent changes included, additional rationale for the use of Enhanced Barrier Precautions (EBP) in nursing homes, including the high prevalence of multidrug-resistant organism (MDRO) colonization among residents in this setting. Expanded residents for whom EBP applies to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status). Expanded MDROs for which EBP applies. Clarified that, in the majority of situations, EBP are to be continued for the duration of a resident's admission. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Based on observations, record review and interviews the facility failed to use a mechanical stand to avoid hazards and prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 87 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 identified the Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS indicated Resident #1 totally dependent on staff for transfers, bed mobility, personal hygiene, and toileting. The MDS included a diagnosis of stroke and hemiplegia or paralysis of one side of the body. The Care Plan dated 1/6/23 identified Resident #1 required a mechanical stand, also known as a mechanical aide, and the assistance of 2 staff members for all transfers. The Nurse Note dated 6/24/23 for Resident #1 documented resident lowered to the ground this morning at 0700. CNA was getting her ready for the day and the resident refused to use stand aid or hoyer and wanted pivot transfer. Resident was unable to pivot well and CNA lowered the resident to the floor. The note went on to document the CNA education on the importance of using the stand lift with assistance of two staff members. In an interview on 9/6/23 at 3:21 PM, Staff A, Certified Nurse ' s Assistant (CNA), reported Resident #1 refused to use the mechanical stand on the morning of 6/24/23. Staff A explained Resident #1 requested assistance to stand and pivot from the bed to the wheelchair. Staff A then failed to follow the care plan by then attempting to transfer Resident #1 independently. Staff A stated, it didn' t work, the resident became weak, so I lowered her to the ground. Staff #1 reported that she usually followed the care plan but now couldn' t remember what the care plan instructed for Resident #1 related to transfers. Staff A added, I don' t think the care plan said anything, otherwise I would have followed it. When asked if she received education after this incident regarding what action should be taken if a resident refused the mechanical lift, Staff A stated, yes in a meeting. In an interview on 9/11/23 at 2:06 PM, Staff B, Registered Nurse (RN), Care Coordinator, reported that they managed Resident #1' s care plan. Staff B explained Resident #1 required the mechanical stand for transfers. When asked if the care plan at any time instructed staff to pivot the resident, Staff B stated, not that I can remember. When asked if Staff A should have pivoted Resident #1 independently, Staff B responded, no. Staff B further explained if a resident refused the mechanical lift the next step would be for the CNA to report the nurse. The nurse would then be expected to talk with the resident about using the mechanical stand for safe transfers. In an interview on 9/11/23 at 3:32 PM, Resident #1 reported that she could not recall the details of this incident but could recall that she refused the mechanical lift in the past. Resident #1 reported that she now uses the mechanical lift to prevent harm to herself and staff. In an interview on 9/21/23 at 3:57 PM the Administrator reported staff received education regarding mechanical lifts and directions for when a resident refused a mechanical lift transfer.The Administer further explained if a resident refused a mechanical lift transfer the CNA should not transfer the resident. The CNA is then required to inform the nurse who will speak with the resident about safety precautions regarding the use of mechanical lifts. The Administrator reported the CNA received education immediately upon the incident, other staff received education during morning huddles and education was added to the Daily Communication Book. In an interview on 9/25/23 at 2:29 PM, the DON reported she expected staff to follow the care plan when transferring residents. The DON explained if the resident refused, the CNA is required to inform the nurse who would then be expected to talk with the resident. When asked about a policy, the DON explained the facility lacked a policy with specific information regarding a resident' s refusal to use a mechanical stand.

Based on observation, facility policy, and staff interview, the facility failed to post a paper copy of daily staffing in each unit of the facility. The facility reported a census of 82 residents. Findings include: Observation on 5/9/23 at 3:24 PM of each of the 3 facility units, 2 of the units had daily nursing department staffing handwritten written on reusable white boards and not posted on paper. In an interview on 5/9/23 at 3:23 PM, Staff E, Certified Medication Assistant (CMA) reported there was no paper copy of the daily staff posting out for residents to see. In an interview on 5/9/23 at 3:27 PM, Staff F, Licensed Practical Nurse (LPN) reported there was no paper copy of the daily staff posting out for residents to see. In an Electronic Mail (email) on 5/10/23 at 8:31 AM, the Administrator reported we don ' t have a policy for the daily posting of census and nursing hours. In an interview on 5/11/23 at 10:50 AM, Staff J, Assistant Director of Nursing (ADON), reported that each unit receives a daily printed copy of nursing staff posting and this is posted in each unit. Staff J reported she was unsure where the paper copy of the daily nurse staffing was posted since this is a newer unit. The information from these paper copies was used to write the staffing information the white boards.

Based on observation, facility policy, and staff interview, the facility failed to have kitchen staff wear hair nets in the kitchen. The facility reported a census of 82 residents. Findings include: Observation on 5/9/23 at 10:45 AM revealed Staff A, Nutrition and Food Service Assistant; Staff B, Baker; Staff C, Cook; Staff D, Cook. All 4 staff were in the kitchen, not wearing hair nets. Staff B wore a baseball cap, Staff C and Staff D wore mesh topped skull style caps. The Dress Code and Appearance policy last approved date of 4/23 revealed: 1. Purpose to outline a code of dress that provides direction in promoting and enhancing a professional and respectful image of the facility as well as to remain in compliance with issues such as infection control, safety, and security. 2. Hair nets that confine all hair, including bangs and beard, are required for all employees when in food preparation areas. If desired, team members may wear the approved mesh skull cap over the hair net. In an interview on 5/10/23 at10:41 AM, the Registered Dietician (RD) reported that she would expect all staff to wear hair nets in the kitchen.

Based on clinical record review, observations, staff interviews, facility policy review and physician interview, the facility failed to assure that staff provided appropriate nursing supervision for one resident who exited the facility unsupervised on two separate occasions,(Resident #1). This failure resulted in exposure to subzero winter elements and a fall that resulted in injury and one visit to an emergency room for treatment for the resident, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The facility also failed to maintain the safety and security of one resident during the transfer process which resulted in a serious injury.(Resident #8). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on December 24, 2022 on January 12, 2023 at 12:15 A.M and was given the IJ template. The Facility Staff corrected the Immediate Jeopardy on January 13, 2023 through the following actions: a. Placement of new and more audible alarms on the exit doors in the resident's neighborhood. b. Staff education on the different types of alarms and the audible sounds of each. c. Moving the resident to a more secured area of the neighborhood and close to the nurse's station. The scope was lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 76 residents. Findings Include: During an interview with the State Climatologist on 1/10/22 at 8:41 a.m. the temperature on 12/24/22 registered -4 degrees Fahrenheit (F), humidity at 76%, winds West to North West (NW) at 14 miles per hour (mph) gusting to 20 mph so wind chill registered at -24 degrees F with no clouds. The weather conditions on 12/29/22 at 2:42 a.m. registered 34 degrees F, humidity 93%, winds NW at 9 mph so the wind chill registered at 27 degrees F with a cloud cover low and mid- level with snow in the area at the time of the elopement. On 12/26/22 the office registered four (4) inches of snow on the ground. 1. A Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 with diagnosis that included Parkinson's Disease, Alzheimer's, Arthritis and Peripheral Vascular Disease (PVD). The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills)and required extensive assistance of 1 staff member with ambulation and locomotion with a walker. A MDS BIMS interview form dated 11/2/22 at 12:40 p.m. documented the resident with a score of 8 (moderately impaired cognitive skills). An Elopement Risk form dated 11/2/22 at 3 p.m. documented the resident jokingly stated he planned to leave out the back door of the facility however the scale indicated no risk for elopement. A Care Plan documented the resident as admitted to the facility on [DATE] at 1:37 p.m. The Care Plan identified the following problem areas and interventions as dated: a. Activities of Daily Living (ADL) status related to a diagnosis of Dementia and an unsteady gait. Dated 11/2/22 at 1:37 p.m The interventions included the following: 1. Transferred with 1 staff assistance, a four wheeled walker (4 WW) and a gait belt assistive device. Dated 11/2/22 at 10:25 a.m 2. Ambulation/locomotion with 1 staff assistance, 4 WW and a gait belt. Dated 11/2/22 at 10:25 a.m. b. Cognitive status as evidenced by a short term memory problem, long term memory problem, impaired decision making, problem understanding others and a diagnosis of mixed Alzheimer's with vascular dementia. Dated 11/2/22 at 1:02 p.m. c. Fall risk related to a diagnosis of Dementia, history of falls and a diagnosis of an unsteady gait. Dated 11/2/22 at 1:32 p.m. 1. 12/29/22: Staff told the nurse the resident's call light had been on and the door alarm sounded in the other hallway as she observed that information on the monitor at the Certified Nursing Assistant (CNA) desk. Staff hurried to the hallway and found the resident as he sat on the ground outside and leaned against the wall approximately 10 feet from the outside door. When asked what he had done he indicated he planned to get his pickup and go to his daughter's house. He had been able to state his name but not where he had been located or the time of day. With the assistance of 4 staff members and gait belt staff transferred him to a wheel chair and brought him inside. He wore a t-shirt, pajama pants and gripper socks. Once inside staff assessed skin tears to his right arm as bruising started to appear. A Long Term Care (LTC) Provider Communication form dated 12/24/22 at 12:34 p.m. included the following documentation: Resident found outside near entrance by visitors at approximately 10:30 a.m. with long sleeved shirt, long pants, sock and shoes as he walked with a front wheeled walker (FWW). Visitors guided the resident to their car then called the facility at 10:40 a.m. Staff applied coat and assisted the resident back into the facility with a FWW. The resident noted to have been more confused than normal. Brought w/c to resident in the service hallway near the loading dock entrance where he rested on a bench and warmed up. Brought him back to his neighborhood and wrapped in a blanket. Temperature at 11 a.m. registered 95.4 degrees F. The facility notified his daughter and suggested he had been outside for 10-15 minutes. An Emergency Department (ED) note dated 12/24/22 at 12:22 p.m. documented the resident's body temperature at 97.7 degrees F. An Assessment and Plan form from the local hospital dated 12/25/22 at 1:37 p.m. included the following documentation: An [AGE] year old man with Alzheimer's, Vascular Dementia, Coronary Artery Disease, Type II Diabetes Mellitus (DM), presented with cold exposure of unknown duration. He apparently wore long sleeved clothing with no coat. He exhibited swelling of is left distal pinky and with bilateral swollen feet however it had been difficult to say if that was caused from his heart failure or from the cold. A Nurse Note dated 12/25/22 at 5:14 p.m. documented the resident returned from an overnight observation at the local hospital after hypothermia with frost bite on the left finger. During an interview on 1/11/23 at 4:30 p.m. the visiting Pastor confirmed he observed the resident outside on 12/24/22 with just a T-shirt, pants but no coat, hat or gloves. The resident appeared confused and not located near any door to the facility but rather in the parking lot. The Pastor told him he wanted to get him inside so they walked towards the nonfunctional front door because of a big snow drift in front of the door. By the time the Pastor noticed the functionality of the front door he retrieved his car and helped the resident into the car for warmth. The Pastor drove the resident to a door to get him inside but by that time another person came up and called the facility to get the resident. The Pastor stated he acted immediately because the resident appeared not fit. The Pastor asked the resident where he planned to go and the resident said something about a pick up and going somewhere but the resident had not looked like he had the ability to drive and the Pastor just wanted to make sure he warmed up. The Pastor confirmed the resident had a walker with him and he was actually first located at the bottom of an incline and up against the curb where there was snow. During an interview on 1/11/23 at 4:26 p.m. the other resident's family member who assisted the Pastor with the resident indicated she came around the corner and observed a visiting Pastor and the resident as they walked outside and she found that different because of the cold weather and the fact the resident wore a shirt and sweat pants but no jacket or hat. This family member called the nurse in the facility and informed her of the situation because the front door of the facility remained locked at that time. During an interview on 1/11/23 at 7:45 a.m. the facilities Senior Services Officer indicated she investigated the elopement herself and was able to track the resident's footsteps out the door at the end of hall 900 to where he was located by a Pastor coming to visit some of his parishioners. Additionally, another resident's family member assisted the resident into the Pastor's car and back to the building where staff greeted him, positioned him in a w/c and given a blanket. To date she had been unable to retrieve the time of exit from the facilities door alarm system due to a malfunction however she knew he returned around 10:40 a.m. The Senior Services Officer indicated there were 3 nursing staff who worked that day however no staff member heard the door alarm due to having been behind other resident's closed doors as they provided care. However a kitchen personal heard the alarm but assumed it was a delivery person and failed to appropriately respond and/or communicate the sounding alarm to nursing staff. During an interview on 1/11/23 at 10:35 a.m. the Senior Services Officer reviewed the facility map and identified the resident went out the 900 exit door on the NW corner of the building went around the building and up 2 stairs with walker. The Senior Services Officer indicated there had been very little if any ice but due to slightly blown snow she tracked the resident's footsteps. During an interview on 1/11/23 at 9:11 a.m. Staff A, Certified Medication Aide (CMA)/CNA indicated on the date of 12/24/22 the facility had been short a CNA. At 10:15 a.m. she told another CNA she planned to bath a resident on the 800 hallway so she planned to answer resident call lights and assist the last resident up for the day. At the same time Resident #1 sat at the dining room table right in front of the serving table. She had been unable to hear the door alarm sound because when located in the whirlpool room staff could not hear anything outside of the room. At 10:35 a.m. the staff member finished up in the whirlpool room and the nurse asked for a w/c but she could not safely leave the resident she cared for at that time. Around 10:40-10:45 a.m. when left she left the whirlpool room she could still hear the 900 door exit alarm as it sounded. During an interview on 1/12/23 at 10:36 a.m. Staff D, Registered Nurse (RN) confirmed she worked 12/24/22. The staff member indicated when she first knew about situation had been when she received a call from a daughter of another resident in the parking lot who informed her a male resident had been located in the parking lot without a coat. She responded right away and asked him what he had been doing but she could tell he needed to get back into the facility due to the fact his head shook and he failed to speak to anyone The staff member asked the Pastor, who had him in a car to back him to the loading dock so they could return him into the building. The staff member removed her coat and placed it around the resident, entered the building, sat him down and placed his hands under his armpits. The staff member then called for a w/c as they waited for about 5-10 minutes and tried to get him warmed up. Then took him to nurse's station, assessed his vitals and she thought his temperature registered 95 degrees F at that time and he had been in the building for approximately 10 minutes at that point however his skin remained cold and red. During an interview on 1/12/23 at 9 a.m. Staff B, CNA confirmed she worked 12/24/22 but failed to hear the door alarm when Resident #1 exited the facility unattended as she cared for another resident at the time. Staff C indicated Staff D, RN asked Staff C, Dietary about the alarm as she had been aware of the sound. Staff B stated when she completed her cares with a resident at the end of the 800 hallway she faintly heard the alarm. The staff member confirmed she failed to hear any alarms as they went off but she had been located down the 800 hallway as she checked other resident's vital signs which she completed around 10:30 a.m. and returned to the nurse's station when she heard a faint sound and asked Staff C, dietary if she had something in her oven or something. The dietary staff member denied cooking so Staff S went to the galley station and heard the alarm. Both of the staff members went down the 900 hallway, shut off the alarm, went out of building almost to the corner but observed no tracks so they returned into the facility. Staff D returned to the nurse's station at which time she received the call from another resident's daughter. During an interview on 1/12/23 at 8:21 a.m. the Dietary Manager (DM) stated the dietary staff member who originally heard the alarm had currently been in [NAME] but she had spoken with her following the event. The staff member stated she left the kitchenette to go to the main dining room of he facility at which time the resident sat at an unknown dining room table. When she returned the resident had no longer been present so she thought someone took him back to his room. The DM confirmed when in the main dining area a staff member could not hear an alarm if it sounded in a neighborhood. The DM had been unaware if Staff C heard the alarm sound however the Senior Services Officer had been the person who formally interviewed Staff C. During an interview on 1/11/23 at 12:29 p.m. the resident's daughter stated that she shared with the facility staff upon admit that he had episodes when he lived with her of a fluctuating cognitive function. The daughter indicated her father had another episode a couple times after this said event where he got to the door and out, the door alarm sounded and staff responded however she had been unsure if those had been an witnessed event. A typed statement from the Senior Services Officer started on 12/24/22 included the following documentation in addition to the above documented information on the resident's Care Plan: The resident set off the 800-door alarm on 12-29-22, at 2:40 a.m., but staff responded quickly, and returned right back into the household. 2. A MDS assessment form dated 10/18/22 documented Resident #8 with diagnosis that included Alzheimer's dementia, hip and knee replacements and a displaced intertrochanteric fracture of the left femur. The assessment documented the resident with a short and long term memory deficit, moderately impaired cognitive skills, dependent on 2 staff with bed mobility, extensive assistance of 1 staff with transfers and a fall risk. A Care Plan addressed a problem with ADL status dated 10/12/22 at 12:51 a.m. The interventions included the following: a. Transferred with 1 staff assistance and a gait belt. A Fall Risk Assessment form dated 1/12/23 documented the resident at a high risk fall precautions. An Incident Report form dated 1/15/23 at 12:05 a.m. documented while staff assisted the resident out of bed she sustained a laceration to her right shin that measured 15 centimeters (cm), staff transferred the resident to the emergency room for repair and admission. An emergency room report dated 1/15/23 at 12:15 a.m. documented the resident presented in the ER via the ambulance service with a significant bleed/stellate laceration to the right lower leg that measured 15 cm. The physician had been able to repair the area with quite a bit of pressure and there had been tearing of the skin. A Care Assessment form dated 1/17/23 at 11:10 a.m. documented the resident with an L shaped, upside down,wound with sutures not well approximated at that time. The wound appeared open, purple and red and measured 8 centimeters (cm) by (x) 14.5 cm with entire wound area that measured 116.0 cm. The surrounding tissue appeared purple, bruised, edematous and moist with the surrounding tissue erythema measured greater than 2.5 cm. The site appeared with a small amount of serosanguinous to bright red blood with a mild odor. A typed statement dated 1/15/23 (no time) from the Senior Services Director included the following documentation: Staff E, Registered Nurse (RN) and Staff F, Certified Nursing Assistant (CNA) shared different versions of what happened in the resident's room prior to the discovery of her skin tear. Photos were taken of the resident's room and her wheel chair as well as the charting desk where she sat prior the transfer to her room for the night. The Senior Services Director asked the physician the measurement from the distance of the laceration to the bottom of the resident's foot and it measured 16 inches which matched directly to the part of the wheel chair that the leg rests attached to the wheel chair with blood noted on top outer edge on the top pin base at the connector site. Staff F explained to the Senior Services Director that when they transferred the resident from the bed to her wheel chair for an observation of the cause of the small drops of blood on the resident's sheets, Staff E turned the wheel chair towards the resident from behind her, but the resident's right foot became caught behind the wheel at the time the resident said ouch. The resident and the Senior Services Director measured in similar heights so when the Director stood where Staff F said her foot had been located and the chair turned, that rough spot on the top pin base went right across my leg at the same spot. The discrepancies in the staff statements included the following: 1. When her leg started bleeding (for a laceration that large, it couldn't have happened before she laid down, or the bed pad would have more blood on it. According to an email dated 2/8/23 at 4:08 p.m. the Senior Services Director confirmed staff failed to use a gait belt assistive device during the transfer. During an interview on 1/15/23 (no time documented) the Director interviewed Staff F which included the following information: I took Resident #8 to her room. I lowered the bed down to be level with the wheel chair. I said give me a hug and she responded some type of remark, but raised her arms up. I transferred her to her bed without any fussing. All in one motion by pivot transfer and laid her down on her back and her legs on the bed. I saw the nurse in the dining room, as she came into the resident's room. The resident's feet had been positioned on top of her covers. When I moved the covers from under her feet, the nurse had already been in the room at the foot of the bed, the resident cried out, just hollered. When I picked her feet up I saw the blood stain on the chux, I laid her feet down and said, she is bleeding from somewhere. I pulled her right leg up to her knee and there noticed no blood, then I looked at the left and noted no blood. I remembered she had a bandage on her right leg that she picked at, so I checked it, but noted no blood. The nurse said, well lets just get her up and I will take her with me. I said that is good, then I can get caught up. The resident's left leg had moved closer to the wall, so I pulled her legs around and as the resident reached for the railing and pulled herself up as I stood at the foot of the bed. The resident sat on the edge of the bed calmly with her feet on the floor. The nurse reached for the back of the resident's pajamas slacks, I had my right arm extended, we said 1, 2,3 and transferred her. The nurse turned the chair around and I saw her foot was behind one of the wheels, I then saw blood on her foot, said stop, pulled her pants up and saw the blood. I'm sure that during the transfer the wheel chair, the spot where the foot pedals attached to the wheel chair cut her shin/leg. I think the turn during the transfer caught an edge of the chair and cut her leg. She hollered, owie, then became calm. During an interview on 1/15/23 (no time documented) the Director interviewed Staff E which included the following information: I responded to the resident as she yelled, Stop it and went to her room but never witnessed the alleged event. Staff E went into the resident's dark room. I saw the CNA as he moved her legs over and said lay on down. I turned on the light as the resident sat on her bed. I said she would not stay in bed while he covered her legs with her comforter. I replied we could get her up and she could have been a one on one with me until you finished your rounds. At this point the resident already pushed the comforter off of her legs with her hands when I saw blood as it dripped from her right shin and went down her left side of her leg. I asked where is the blood came from. Staff F said I don't know. Then he lifted both her legs and I didn't see right away where the blood came from as she had long pink silky pajama pants on. Then we got her up into the wheel chair as I stood behind her and he stood in front of her. We got her into the wheel chair and the pajama pant came up and I saw the blood and the wound. I said Oh my God, how did this happen? as the blood gushed out of the wound. I ran and got gauze and Kerlix and wound cleanser. I came back and applied pressure.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure residents received adequate supervision to protect against accidents. Clinical record review and staff interviews revealed the facility failed to provide a safe method of transfer for Resident #64. Resident #64 fell and sustained non-displaced fractures of the bones in the left and right feet when staff failed to use a gait belt during transfer. Clinical record review and resident and staff interviews additionally revealed the facility failed to evaluate the ability of Resident #50 to safely operate a power mobility device in the facility which resulted in a fall with major injury to Resident #29, when struck by Resident #50 while operating the mobility device. Additionally, the medication cart was unsecured and unattended in a resident care area. The facility reported a census of 66 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with a reference date of 4/27/18 for Resident #64 identified a Brief Interview for Mental Status (BIMS) score of 14 indicative of intact cognition. According to the MDS, the resident required the extensive assistance of one staff for transfers, bed mobility and personal hygiene, toilet use and dressing. A balance during transition and walking test identified the resident as not steady but able to stabilize without staff assistance when moving from a seated to standing position. The MDS further identified no functional limitation in range of motion on both lower and upper extremities. The resident had [DIAGNOSES REDACTED]. The MDS further identified the resident normally used a wheelchair (manual or electric) mobility device. A resident note dated 7/5/18 at 9:54 AM documented CNA (Certified Nursing Assistant) transferred resident from bed to commode, resident lost her balance and her left arm slipped on the armrest and the CNA lowered her to the ground. Gaitbelt was not utilized. A provider notification note communicated the resident had a fall 7/5/18 at 7:05 AM, the resident complains of middle right foot pain. The physician documented Left foot 3rd -5th distal intratarsal fracture, and Right for 2nd metatarsal fracture. Resident returned to the facility with an order for [REDACTED].>A Radiology report dated 7/5/18 diagnosed : a nondisplaced [MEDICAL CONDITION] distal 3rd, 4th and 5th metatarsals (foot bones) and nondisplaced [MEDICAL CONDITION] metaphysis first distal phalanx (foot bones). A document titled Care Practice Standards directed gait belt will be used for all assistive transfers and ambulation as a safety measure. The fall care plan for the resident dated as initiated on 12/16/16 directed assist of one with walker for all transfers/ambulation, A Fall Risk assessment dated [DATE] documented the resident scored 15, a score of 10 or more indicated a high risk for falls and identified gait belt as a safety device. A document titled (YEAR) Staff Feedback documented Staff B, CNA educated on 7/5/2018 to use gait belt for all transfers and documented on 8/6/2018 staff in-service included discussion of gait belt expectations. In an interview on 10/29/18 at 2:30 PM the Director of Nursing (DON) confirmed the staff failed to use a gait belt when the resident transferred on 7/5/18 which resulted in a fall with injury. The DON confirmed facility expectation to use a gait belt with all assist transfers for safety and to prevent falls. 2. The Minimum Data Set (MDS) assessment with a reference date of 9/28/18 for Resident #50 identified a Brief Interview for Mental Status (BIMS) score of 15 indicative of intact cognition. According to the MDS, the resident required the limited assistance of one staff for transfers, bed mobility and personal hygiene and independent for walk in room and locomotion on and off the unit. A balance during transition and walking test identified the resident as not steady but able to stabilize without staff assistance when walking and turning around and facing the opposite direction while walking. The MDS further identified functional limitation in range of motion on both sides for upper extremities. The resident had [DIAGNOSES REDACTED]. The MDS further identified the resident normally used the following mobility devices: a walker and wheelchair (manual or electric). An event note dated 10/23/18 at 10:50 AM documented facility staff witnessed Resident #29 walking back from an activity and was hit from behind by Resident #50 driving an electric scooter. Resident #29 fell to the floor hitting her left side, the resident was seen in the emergency room due to her injuries where an X-ray report dated 10/23/18 revealed a pelvic fracture. In an interview on 10/30/18 at 9:44 AM the Director of Nursing (DON), stated the facility had failed to evaluate Resident #50's ability to safely operate the power mobility device prior to the incident on 10/23/18, and further stated the facility failed to have a policy that addressed assessment of resident ability to safely operate a power mobility device. The DON clarified the facility only assessed ability if need identified. The DON admitted that after the incident she had been made aware that Resident #50 had previously run into to the wall with power mobility device which required repair by maintenance, but confirmed this had not been reported or investigated. The DON further stated the power mobility device had been removed from the resident until settings on mobility device were adjusted, and the resident was evaluated with the new settings. Further interview with the DON on 10/30/18 at 2:30 PM revealed she had further questioned staff and was now aware that on 10/12/18 Resident #50 had been observed running into a nurse's foot at the flu clinic, and had also become aware staff had observed the resident running into table legs at the dining table. The DON stated would have expected staff to report these observations and concerns when made aware of or witnessed. Additionally, the DON confirmed aware Resident #50 had purchased a new mobility device on 6/7/18 and again admitted the resident had not been assessed for ability to safely operate new equipment and acknowledged facility responsibility to determine to provide a safe environment for residents. The DON provided a proposed policy that would require assessment of residents ability to safely operate power mobility devices, this had not been formally approved, however the DON stated had now assessed Resident #19 and Resident #40 who also have power mobility devices at the facility. A care plan intervention dated as initiated 11/28/16 directed Resident #50 used an electric wheelchair independently outside the room for longer distances. In an interview on 10/30/18 at 9:05 AM Resident #50 stated she had an accident with her scooter last week and the facility had taken away. Reported she would need to go to therapy to be evaluated for safety before can get back. Stated she had run into another resident on the way back from an activity when the other resident stopped in front of her and she couldn't get stopped in time. A PT (Physical Therapy) evaluation dated 10/24/18 documented a visit for assessment of scooter safety. The evaluation documented the resident had run into another resident causing that resident to fall resulting in a fracture. The evaluation identified a safety concern after tested the residents reaction time, specifically:1 second response time from a stop to command to go, however a 3 second response time when the resident was in motion and given the command to stop until the scooter actually stopped. 2. Observation on 10/30/18 at 9:16 a.m., revealed an unlocked an unattended medication cart on Pod C, inside the medication cart revealed the following resident items: oral medications insulin pens lancets scissors inhalers eye drops During an interview on 10/30/18 at 9:20 a.m., Staff H (nursing) confirmed and verified that the medication cart needed to be locked at all times and proceeded to lock the medication cart.

Based on record review, observation, staff interview and policy review the facility failed to always put new interventions in place to prevent further falls and injury for 2 of 4 residents reviewed. (Resident #1 & #4) The facility identified a census of 68 current resident. Findings include: 1. According to the MDS (minimum data set) dated 12/8/17 Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status score of 7 which indicated severe cognitive impairment. The MDS identified the resident required limited assistance with bed mobility, transfers, ambulation, dressing and toilet use. According to the MDS the resident occasionally incontinent or urine. The care plan dated 7/3/17 directed staff to do the following interventions for fall risk: a. Restorative therapy. b. Assess the environment to provide clutter free environment. c. Encourage use of call light and wait for assistance. e. Monitor for fatigue or other risk factors. d. Keep call light in reach when in room. e. Front wheeled walker for all ambulation/transfers. f. Wheelchair as needed. g. Transfer and ambulation: Assist of 1 with front wheeled walker. Frequently non-compliant and will self-rise. Review of the Fall Risk assessment dated [DATE] revealed the resident had a fall risk total score of 24 which indicated the resident at a high risk. Review of the Radiology Diagnostic Imaging report dated 12/20/17 reveled the resident had a fractured right hip. Review of the List Resident Notes dated 7/29/17 at 10:30 AM revealed the resident came out of the bathroom and stated she had been dizzy and lost her balance. The roommate turned her call light on for assistance. Range of motion within normal limits, hit her head on the bathroom door and no new skin issues noted. Assisted to her feet with a gait belt and assistance of 2. Review of the document identified toilet schedule dated 12/19/17, Tuesday night revealed the resident checked, remained dry and turned at 12:00 AM and 2:00 AM. At 4:00 AM the resident had a fall and moderate bowel movement. Review of the Resident Change In Care Plan dated 11/16/18 revealed the resident intervention no shoes and use gripper socks. Review of the List Resident Notes dated 8/21/17 at 12:24 PM revealed the CNA had been bring the resident from the dining room to the chair in her bedroom. The chair slid out as she sat down and caused her to hit the floor with her bottom. Denies hitting her head or additional pain. Intervention included to have Maintance to check chair for stability. Review of the List Resident Notes dated 8/25/17 at 3:49 PM revealed the resident found on the floor. Attempted to toilet self without using her call light. Denied pain or hitting her head. Intervention encourage resident to ask for assistance. Review of the List Resident Notes dated 11/12/17 at 4:55 AM revealed staff found the resident on the floor by her bed. The resident stated she had been on her way back to bed from going to the bathroom. Her walker in the bathroom. She denied hitting her head. Vital signs and range of motion within normal limits. The resident assisted up with a gait belt and assist of 2 and transferred back to bed without difficulty. Intervention to wear gripper socks at night, staff check on her during 4:00 AM rounds and remind her to call for assistance to the bathroom. Review of the List Resident Notes dated 11/13/17 d at 4:16 AM revealed Resident ambulated with the CNA on the way back from the bathroom with staff assistance and a gaitbelt and fall occurred. The CNA stated the resident had been along side of the bed and lost her footing, stumbled and then proceeded to let go of her walker. The CNA unable to prevent the fall. CNA stated the resident's ambulation very unsteady at the time of the fall. Intervention to have therapy assess for safe transfers/ambulation due to 2nd fall in 24 hours and care plan updated to use standard as needed for gait instability/difficulty with transfers. Review of the List Resident Notes dated 12/20/17 at 4:00 AM revealed CNA reported to nurse that resident on the floor in the bathroom. The resident stated she had been trying to sit on the toilet and slid to the floor. Resident cannot straighten her right leg due to pain and left range of motion within normal limits. The resident brought up to the toilet with a gait belt and assistance of 2 due to the resident stated she had to go to the bathroom. Intervention included to check on the resident during rounds for toileting. At 4:30 AM County dispatch notified and at 4:52 AM the resident transferred by ambulance. Review of the Patient Care System dated 11/13/17 revealed the PTA assessed the resident due to recent falls. The assessment revealed the resident took small steps and needed cues. The resident also required moderate assist of staff to move from sit to stand position. Review of the Nurses Notes dated 11/20/17 at 8:07 AM revealed the post fall assessment completed for falls on 11/12/17 and 11/13/17. No major injury received from either fall. The resident denied any new pain/discomfort from falls. Range Of Motion and activity with in normal limits for the resident. The resident bears full weight and ambulation with 1 assist and walker per usual. All fall interventions reviewed and will initiate gripper socks when not wearing shoes and have Physical Therapy to assess for safe ambulation/transfers. Dated 12/20/17 revealed the resident on the floor in the bathroom. The resident stated she had been trying to sit on the toilet when she slid to the floor. The resident denied hitting her head, vital signs taken. The resident unable to straighten her right leg due to pain and left range of motion within normal limits. The resident brought up to toilet with a gait belt and assist of 2 due to she stated she had to go to the bathroom. Intervention included to check on the resident during rounds for toileting. During an interview with Staff D, CNA on 6/28/17 at 2:10 PM she stated the resident did get up on her own quite a lot and go to the bathroom. Sometimes the resident called for help on the call light. When interviewed on 6/29/18 at 6:00 AM Staff E reported when the resident's call light came on she was in another room assisting another resident. She stated she finished with the resident whom was a slow walker. She waited until the resident walked back to bed and she gave her the call light. She then went to the residents's room and found the resident on the floor in her bathroom. And called the nurse to come to the Pod. She further stated the resident had gotten up on her own several times and she found her walking or already in the bathroom. She stated the resident always wore gripper socks and had them that night. During an interview with Staff F, RN (Registered Nurse) on 6/29/18 at 7:50 AM she stated the facility looks at the cause of a fall. If needed they re-educate staff. If interventions are there and working and followed but not to full extent staff re-educated. She stated if new interventions are made for a resident or a change, it goes on the resident change in care plan sheet. Staff sign off that they are aware and educated. She further stated the MDS coordinator responsible to update the care plan with the new interventions. She stated the facility had 4 Pods (halls) and 1 CNA scheduled per Pod on the night shift (10:00 PM to 6:00 AM) and one (1) nurse on the night shift who help when a CNA calls for assistance. 2. According to the MDS dated [DATE] Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs score of 11 which indicated moderately impaired cognition. According to the MDS the resident required extensive assistance with bed mobility and extensive assistance with transfers, ambulation, dressing and toilet use. The care plan dated 1/19/17 directed staff to transfer the resident with 2 to 3 staff assistance and use a wheelchair for distances from one place to another. Do not leave unattended in the wheel chair. Transfer to other chair. Observation on 6/28/18 at 8:05 AM revealed the resident sat in the wheelchair in the dining area. Staff G pushed the resident to the lounge area for a distance of approximately 20 feet. The resident held his feet up off the floor with his ankles crossed. At 9:45 AM the resident requested to lay down. Staff G and Staff B, CNA transferred him from the recliner to the wheelchair. The resident appeared to have difficulty holding his feet above the floor. Staff B grabbed his pant leg and held his feet up while Staff G pushed the wheelchair to his room. Review of the Policy and Procedure titled Falls Prevention and Interventions dated 4/14 directed staff to do the following: a. Initial Fall Follow-up completed. b. Fall Risk Assessment filled out. c. Fall Care plan reviewed. d. Appropriate intervention put in place. e. Interdisciplinary team reviews falls and intervention on first week day following incident and request Physical therapy referral as appropriate. f. Post Fall huddle completed.

Based on record review, resident and and staff interviews, the facility failed to ensure that each resident received adequate supervision to prevent an accident for 1 of 15 residents reviewed (Resident #2). A Certified Nurse Aid (CNA) placed a gait belt on Resident #2, assisted the resident to a standing position, left the resident's side and failed to keep the resident within her eyesight. The resident fell and sustained two rib fractures. The facility reported a census of 69 residents. Findings included: According to a Physician order [REDACTED].#2's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment with a reference date of 6/9/17, revealed the resident required assistance from staff with transfers, walking, toilet use and identified the resident as only able to stabilize with staff assistance when walking and turning around. The resident utilized a walker for mobility and had a history of [REDACTED]. A score of 14 identified the resident's cognition or mental status as intact. The MDS identified the resident's initial admitted to the facility as 6/2/16. A Care Plan with a review date of 11/17/2016 revealed staff identified the resident had a potential for falls related to a fall with a fracture prior to admission to the facility and a mild memory deficit. The Care Plan included approaches for the resident to have supervised to limited assistance from staff with transfers. A Post Fall assessment dated [DATE] revealed staff documented the resident had self transferred his/her self to a wheelchair (without the assistance from staff) , fell and sustained a left hip fracture. A Fall Risk Assessment 6/2/17, identified the resident at a high risk for falls (scored 22). The resident's most current Plan of Care, with a print date of 7/17/2017, identified the resident remained at risk for falls and included the intervention (with an initiation date of 11/16/16) for the resident to ambulate with a walker and stand by by assist from staff in his/her room. The Plan of Care directed staff to toilet the resident with assistance from staff. During interview on 7/17/17 at 3:05 P.M., Staff C, Registered Nurse (RN)/Clinical Care Coordinator state night shift staff are expected to complete rounds and offer toileting at 12:00 A.M., 2:00 A.M., and 4:00 A.M. Staff C stated staff is expected to document the times a resident is offered toileting. Review of Resident #2's round sheet on the night shift of 6/1/17 (and into the early morning hours of 6/2/17) revealed night staff documented the following: watching twins, sleeping, not sleeping and refused toilet. The sheet lacked documentation of the times staff completed his/her rounds and lacked documentation if toileting had been offered each time the resident had been checked while awake. An Event Information form dated 6/2/17 at 7;10 A.M., revealed staff documented the resident stood in his/her room, a CNA stepped into a bathroom to get gloves, the resident bent down to pull up his/her briefs, lost balance and fell . Review of a Educational Conversation form dated 6/2/17, the facility educated Staff F,CNA in charge of the resident's care at the time of the fall, to gather supplies prior to standing a resident and do not leave a resident unattended. A Resident Note dated 6/2/17 at 12:45 P.M., revealed staff documented the resident initially denied pain at the time of his/her fall on 6/2/17 at 7:10 A.M. At the time a nurse administered the residents medications, the resident complained of pain in his/her upper back and right rib area and the resident was transferred to an emergency room at 9:00 A.M. for further evaluation. An emergency room Visit Note dated 6/2/17, revealed a Physician documented the resident sustained [REDACTED]. According to Medication Administration record beginning 6/2/17, Resident #2 received PRN (whenever necessary) pain medication Hydrocodone/Acetaminophen (opiod or narcotic pain medication) 5/325 milligrams (mg) on the following dates for rib and/or back pain: 6/2/17 at 6:45 P.M. 6/4/17 at 2:30 A.M. 6/5/17 at 9:48 A.M. 6/6/17 at 8:31 A.M. 6/7/17 at 9:33 A.M. 6/8/17 at 9:30 A.M. 6/9/17 at 8:22 A.M. 6/10/17 at 9:30 A.M. 6/12/17 at 4:00 A.M. 6/13/17 at 7:53 A.M. 6/17/17 at 12:09 P.M. According to a Medication Administration record beginning 6/2/17, Resident #2 received PRN Acetaminophen (Tylenol) 650 mg for rib and/or back pain of the following dates: 6/2/17 at :14 A.M. 6/3/17 at 4:33 P.M. 6/5/17 at 12:50 P.M. 6/5/17 at 6:18 P.M. 6/16/17 at 1:05 P.M. During interview on 7/17/17 at 12:10 P.M., Staff F, stated she entered the resident's room on 6/2/17 at approximately 7:00 A.M. to assist the resident with his/her morning cares. Staff F placed a gait belt around the resident's waist, stood the resident from a recliner chair, reported the resident's brief heavy with urine and the brief slid down between the resident's legs. Staff F stated she had no gloves available to remove the wet brief, walked approximately 7-8 paces into the resident's bathroom, and retrieved gloves from a drawer in the bathroom. Staff F stated the resident was not within her eyesight, heard the resident say her pants were falling and Staff F stated the resident reported she bent over to pull up his/her brief, lost his/her balance and fell . During interview on 7/17/17 at 2:40 P.M., Resident #2 stated at the time of his/her fall on 6/2/17 at 7:10 A.M., he/she described his/her brief as really loose on the sides. He/she reported she began to walk around a recliner chair without a walker as there was no room for the walker between the chair and the closet. The resident stated the brief ended up around his/her ankles and while he/she walked with the brief around his/her ankles, he/she fell to the floor. During interview on 7/17/17 at 12:45 P.M., Staff G, RN, stated if a resident required the use of a gait belt with ambulation, staff needed to stay with the resident at all times . During interview on 7/17/17 at 12:50 P.M., Staff H, CNA stated she would never leave a resident stand alone if the resident required the use of gait belt due to a fall risk. During interview on 7/17/17 at 12:52 P.M., Staff I, CNA, state if a resident required the use of a gaitbelt, she would never leave the resident's side due to a risk for falls. During interview on 7/18/17 at 9:10 A.M., Staff C (registered nurse) stated at the time of the resident's fall on 6/2/17 at 7:10 A.M., Resident #2 required the use of gait belt with assistance from staff. Staff C stated she expected staff to constantly supervise a resident at the time a gait belt is used with ambulation. A policy and procedures titled, Gait Belt Usage (revised 1/11) directed the employees to use gait belts with any resident who needs assistance with ambulation and/or transfer. The procedure included direction for staff to stay close to a resident with the use of a gait belt.

Based on record review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 67 residents. Findings include: Resident #2 had a Minimum Data Set (MDS) assessment with a reference date 9/11/15. The MDS reflected the resident reflected the resident had a Brief Interview of Mental Status (BIMS) score of 10. The resident required extensive assistance of one staff for transfer, toileting and hygiene. Resident #2 was totally dependent upon staff for locomotion on and off the unit. A balance during transitions and walking test identified the resident as not steady and only to stabilize with staff assistance when walking, turning around, moving from seated to standing position, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. Resident #2 had a fall since the prior assessment, and sustained injury such as skin tear, abrasion or laceration. According to the MDS Resident #2 used a walker and wheelchair for mobility. The Care Plan, revised on 9/17/15, identified Resident #2 at risk for falls related to history of right hip replacement and history of left hip pinning and had a [DIAGNOSES REDACTED]. The interventions included and directed the staff use a walker for short distances, wheelchair for long distances and ambulation with staff assistance. The Care Plan also directed staff remind Resident #2 the need to rise slowly due to history of blood pressure dropping. A fall incident note dated 11/4/15 at 3:01 p.m. indicated upon entry to Resident #2's room Staff A, registered nurse (RN) observed Resident #2 lying on the floor half way between his/her bed and the bathroom. Staff D, certified nurses aide (CNA), was holding a cloth on the resident's right eye. The nurse assessed the resident and noted he/she had extreme pain when range of motion was attempted. The nurse obtained a physician's orders [REDACTED]. Staff A documented the immediate intervention implemented to prevent future falls included staff education to not leave the resident unattended while in a standing position. An x-ray report dated 11/4/15, reflected Resident #2 sustained a comminuted fracture of the inner and inferior aspect of the acetabulum. Interview on 11/23/15 at 12:01 p.m. revealed Staff A, registered nurse (RN) stated Resident #2 required staff assistance for transfer. Upon entry to the resident's room, she observed Resident #2 on the floor approximately 2 feet from the bathroom and Staff D with a cloth on Resident #2's right eye. Staff A stated during transfer Staff D left the resident's side to turn on the bathroom light and Resident #2 fell . Staff A stated the fall occurred on Staff D's first shift as a CNA. Staff A indicated she provided written education and directed Staff D never leave a resident's side if they are fall risk. Staff A confirmed Resident #2 was a fall risk. Interview on 11/23/15 at 12:10 p.m. revealed Resident #2 stated Staff D entered his/her room to provide transfer assistance to the bathroom. Resident #2 stated he/she fell when Staff D walked ahead of him/her to turn on the bathroom light. Resident #2 stated lost his/her balance and went down to the floor. Interview on 11/23/15 at 3:05 p.m. revealed Staff D stated she provided transfer assistance and failed to apply a gait belt prior to Resident #2's fall. Staff D stated she stepped away from the resident to turn on the bathroom light and while unattended by Staff D, Resident #2 fell . Staff D stated Resident #2 hit his/her head on the wall and Resident #2's hip landed on the floor. Staff D indicated she placed a towel on Resident #2 head to stop the bleeding. Staff D stated she did not apply a gait belt prior to transfer because she was unable to recall who required a gait belt, and that the fall occurred on her first shift following her orientation as a CNA. Staff D confirmed Staff A and the DON provided additional education and was aware a gait belt is required for any resident that requires staff assistance. Staff D stated she learned the hard way you can not leave a resident that is a fall risk. On 11/23/15 at 11:38 a.m. the Director of Nursing (DON) stated she provided education to Staff D on 11/12/15 regarding the use of a gait belt for residents that require assistance with transfer. The DON stated all staff received education on the facility Transfer Safety Policy. The facility policy titled Transfer Safety Policy, updated 11/15, directed gait belts are to be used for transferring residents and ambulating residents who need assistance.

Based on record review and staff interview, the facility failed to ensure resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 4 residents reviewed (Resident #1). Resident #1 fell and fractured his/her hip on 08/08/13. Resident #1 had 10 additional falls after the hip fracture. The facility failed to follow care plan interventions to prevent falls on multiple occasions including routine toileting, making sure alarms were hooked up, not leaving the resident unattended on the toilet, and using devices to discourage the resident from self-rising. Resident #1 sustained skin injuries from several falls and a fractured ankle 02/06/14. The facility reported a census of 66. Findings include: According to the Minimum Data Set (MDS) assessment, dated 01/31/14, Resident #1 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #1 required the assistance of one staff with activities of daily living (ADL's) including bed mobility, dressing, and personal hygiene; and the assistance of two staff with transfers and toilet use. The MDS documented Resident #1 occasionally incontinent of bladder. Resident #1's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 did not have pain. A Fall Risk assessment dated [DATE] scored Resident #1 at 20, with a score of 10 or above indicating high risk for potential falls. A Care Plan dated 08/01/12, reviewed 11/14/14 identified Resident #1 with a potential for injury related to a history of falls, orthostatic hypotension, dementia, and on 08/2013 a fall with a femur fracture. The approaches included: a. Frequently remind to use the call light and wait for assistance. b. Allow to sit on the side of the bed a few minutes before rising. c. Bed and chair alarm (discontinued 01/15/14). Restarted bed alarm 02/06/14. d. Hoyer (mechanical lift) transfer with 2 assist. e. Toilet routinely on rounds at night. f. Noodle under outside edge of mattress. g. Bed in low position when in it. h. If restless put in recliner on pod even during the night if needed. i. 12/16/13 timed toileting upon rising, after breakfast, before dinner, before activity, mid afternoon, suppertime, bedtime, and with rounds at night. Resident #1's falls: 1. A Post Fall assessment dated [DATE] at 6:04 a.m. documented Resident #1 walked to use the bathroom. Resident #1 did not use the call light for assistance. An alarm sounded. Staff found Resident #1 on the floor beside his/her chair right before the bathroom. Resident #1 went to the ER for evaluation. The clinical record lacked documentation of the last time toileted. A History and Physical dated 08/08/14 documented Resident #1 had right distal femur fracture. 2. A Post Fall assessment dated [DATE] at 2:18 a.m. documented a CNA reported finding Resident #1 on the floor next to the bed. Resident #1 reported sliding out of bed attempting to go to the bathroom. To prevent another fall they were to continue hourly checks, low bed, sensor alarm, and move recliner on pod if restless. The clinical recorded lacked documentation of the last time the resident toileted. 3. A Post Fall assessment dated [DATE] at 6:40 a.m. documented a CNA found Resident #1 sitting with his/her back against the bed. The right leg appeared shorter, but unable to tell if externally rotated. The personal alarm sounded. To prevent further fall check hourly, low bed, and to recliner on pod if restless. Resident #1 to the ER for evaluation. 4. A Post Fall assessment dated [DATE] at 3:35 a.m. documented Resident #1's sensor alarm sounded in his/her room. A CNA found Resident #1 on the floor mat at the foot of the bed. Resident #1 had urinated on the floor and the mat. Resident #1 stated going to the bathroom. To prevent another fall to do 1/2 hour checks for 24 hours, put in recliner on pod, and toilet routinely during the night. 5. A Post Fall assessment dated [DATE] at 6:20 a.m. documented Resident #1's sensor pad sounded. A CNA found Resident #1 on the mat next to the bed. Resident #1 stated getting up to go to the bathroom. The new intervention added to toilet Resident #1 at 5:00 a.m. The clinical record lacked documentation of the last time Resident #1 toileted (if toileted on rounds per care plan). 6. A Post Fall assessment dated [DATE] at 5:16 a.m. documented the alarm was sounding and staff found Resident #1 lying on the mat next to the bed. Resident #1 stated he/she had to go to the bathroom. Resident #1 to be toileted at 5:00 a.m. The CNA assisted another resident. Resident #1 assisted to the toilet after the assessment. The clinical record lacked documentation of the last time Resident #1 toileted (if toileted on rounds per care plan). 7. A Post Fall assessment dated [DATE] at 11:05 a.m. documented the nurse found Resident #1 sitting on the floor in the bathroom. Resident #1 had sat in the wheelchair in his/her room with no alarm hooked up. Resident #1 stated having to go to the bathroom and had no call light to push. After assessing, staff lifted Resident #1 with the lift to the stool. Resident #1 hit his/her head. Staff educated to make sure to hook the alarm up and not to leave Resident #1 in his/her room unattended. A Skin Irregularity assessment dated [DATE] at 2:30 p.m. documented Resident #1 had a laceration to his/her left eye measuring 1 by 1.5 centimeters (cm) with bloody drainage, pressure applied and bleeding stopped. They applied a bandage for protection. At 8:51 p.m. Resident #1 complained of pain to the laceration of the upper left eye socket. The area continued to bleed at times, and they changed the bandage frequently. 8. A Post Fall assessment dated [DATE] at 12:40 p.m. documented A CNA told the nurse Resident #1 was on the floor in the bathroom. Staff left Resident #1 unattended on the stool with no lift used to place Resident #1 on the stool. Staff assisted Resident #1 to wheelchair. Resident #1 hit his/her head. To prevent further falls, staff to follow the care plan to use the Hoyer lift for all transfers, and not to leave Resident #1 unattended while on the stool. A Skin Irregularity assessment dated [DATE] at 3:05 p.m. documented Resident #1 had a skin tear to his/her right forearm measuring 0.1 by 3.5 cm with bloody drainage. The skin tear was treated with a Tegaderm dressing. A Typed note dated 11/19/13 documented a discussion with Staff H CNA regarding the fall that occurred with Resident #1 on 11/17/13. Staff did not follow the care plan leaving Resident #1 unattended on the toilet. Staff H received a verbal warning and education. A Typed note dated 11/20/13 documented a discussion with Staff I CNA regarding the fall that occurred with Resident #1 on 11/17/13. Staff did not follow the care plan leaving Resident #1 unattended on the toilet. Staff I received a verbal warning and education. A Physical Therapy Initial Evaluation dated 11/25/13 documented nursing staff stated Resident #1 had a difficult time even sitting on the edge of the bed. About a week earlier Resident #1 fell off the toilet because he/she could not even maintain his/her balance sitting on the toilet. Resident #1 sat in a recliner out in an open living room area. He/she had quite a large ecchymosis on his/her right cheek from falling off the toilet. Physical therapy hoped to increase Resident #1's trunk control so he she would no longer be a fall risk sitting on the edge of the bed or sitting on the toilet. During an interview on 03/20/14 at 10:01 p.m. the Physical Therapist stated she thought one of the CNA's told her about Resident #1's difficulty sitting up. She said it was the 1st thing they worked on after the evaluation on 11/25/13; trunk control. After looking at her notes, the physical therapist thought they probably went from a lift transfer to a pivot transfer the end of December (2013). During an interview on 03/20/14 at 10:49 a.m. Staff H CNA stated Resident #1 fell off the toilet after breakfast, after he/she had just eaten. She said they pivot transferred Resident #1 to the toilet. Usually they pulled the door 1/2 way shut and stayed in the room, but both of the staff went to answer other lights. When Staff H went back to the room, she asked Resident #1's roommate if he/she was ready, and Resident #1 hollered from the bathroom. When Staff H got to the bathroom, Resident #1 laid on the floor. Staff H stated Resident #1 remained weak from a previous hospitalization . Resident #1 would lean to the side when sitting. They would remind Resident #1 to sit up, but he/she couldn't hold him/herself up. During an interview on 03/20/14 at 10:57 a.m. Staff I CNA stated on 11/17/14 they pivot transferred Resident #1 to the toilet. She said they left Resident #1 in the bathroom and went to answer call lights. Resident #1 fell . Staff I didn't think they would leave Resident #1 if he/she had trouble sitting up. Staff I said they did not toilet Resident #1 routinely because he/she would let them know if he/she had to go. Staff I did not know the care plan directed routine toileting. During an interview on 03/19/14 at 2:27 p.m. Staff J Clinical Coordinator and the Restorative/Clinical Coordinator could not determine when Resident #1's transfer status changed from a lift to a pivot transfer. 9. A Post Fall assessment dated [DATE] at 9:00 a.m. documented Resident #1 sat on the edge of the bed while a CNA attempted to get him/her ready for a whirlpool. The CNA turned around to grab a bath blanket and Resident #1 fell forward hitting his/her head on the floor. Resident #1 had 2 skin tears on the right side of his/her face. Resident #1's pupils did not react to light. Resident #1 went to the ER for evaluation. Resident #1 to be assist of 2 at all times with all cares. A Physician visit form dated 11/26/13 documented Resident #1 sat on the edge of the bed and fell forward onto the floor with 2 skin tears to the right side of his/her face and a swollen neck. emergency room Visit Notes dated 11/26/13 documented Resident #1 status [REDACTED]. The Patient Visit Information dated 11/26/13 documented Resident #1 seen for contusion of multiple sights, head, face and neck injury. Patient instructions reviewed for minor head injury. During an interview on 03/20/14 at 12:20 p.m. Staff K CNA stated when Resident #1 fell off the bed she had taken him/her off the bedpan, and assisted him/her to a sitting position. She said another CNA assisted Resident #1's roommate, and would help with the lift when finished. Staff K stated having a gait belt on Resident #1. Resident #1 asked for a drink and Staff K turned to get it. She didn't know if she had a hold of the gait belt, but Resident #1 fell forward on his/her face. Staff K didn't know Resident #1 had trouble sitting up. 10. A Post Fall assessment dated [DATE] at 4:05 a.m. documented the CNA informed the nurse she found Resident #1 sitting on the floor. The nurse noted Resident #1 sitting on the floor with his/her legs extended in front of him/her, crossed. Resident #1 complained of some ankle pain, with no injuries noted. Resident #1 moved all extremities within normal limits. Resident #1 appeared alert and oriented per norm with confusion, as Resident #1 stated getting up to go to the bathroom. Staff assisted Resident #1 back to bed, and placed a sensor alarm for safety. A Skin Irregularity assessment dated [DATE] at 8:23 p.m. documented Resident #1 had a hematoma to his/her left elbow measuring 20 by 10 cm related to fall at 3:50 a.m. At 8:31 p.m. Resident #1 had a bruise and swelling to the right lateral ankle 7.5 by 7 cm related to the fall. They were to keep the leg elevated to decrease swelling. A Physicians Orders and Progress Note dated 02/07/14 at 8 a.m. documented to apply ice to Resident #1's ankle 15 minutes 3 times a day for 3 days. A Physician Response Needed form dated 02/10/14 notified the practitioner Resident #1's ankle remained swollen and tender. Resident #1's family wondered if it should be x-rayed. The facility received new orders for an x-ray of the right ankle for [DIAGNOSES REDACTED]. A Radiology--Diagnostic Imaging report dated 02/10/14 documented Resident #1 had a nondisplaced fracture of the medial/posterior malleolus right ankle, suspected stress response/nondisplaced fracture of the posterior calcaneus, and suspected nondisplaced distal fibular fracture, moderately extensive disuse osteopenia, moderately severe diffuse soft tissue swelling. A Fall Interview on 02/10/14 with Staff B revealed Staff B reported Resident #1 last toileted around 1 a.m. and then she did hourly rounds and at 2 a.m. and 3 a.m. Resident #1 slept soundly. Staff B returned from assisting another resident when she heard a noise. Staff B found Resident #1 on the floor in front of the bed. Resident #1 told Staff B he/she rolled out of bed, which was in the low position. Resident #1 had bare feet because he/she usually used the bedpan at night. Resident #1 was alert and oriented with confusion per usual with a [DIAGNOSES REDACTED]. A Fall Interview form dated 02/10/14, Staff G Registered Nurse (RN) noted the fall occurred at 3:45 to 3:50 p.m. Staff G reported Resident #1's floor was dry and no incontinence noted. Resident #1 did not have footwear on. Resident #1 told Staff G he/she got up to go to the bathroom. Resident #1 complained of some right ankle pain but range of motion within normal limits with no visible signs of injury. The physician's orders [REDACTED].#1 more irritable and unable to express pain with a recent history of malleolar fracture, so would treat with scheduled pain medication. To add scheduled Norco 5/325 milligram, 1 tablet, 2 times a day and as needed if awake at night. A Physician visit form dated 02/12/14 documented the reason for the visit was right ankle pain. Resident #1 had a right malleolar fracture. The physician ordered non weight bearing for 6 weeks, and remove the CAM walker for hygiene. A post fall assessment dated [DATE] at 10:00 a.m. documented assessment completed for fall on 02/06/14. Resident #1 received a major injury of a fracture to the right ankle and skin issues. Resident #1 non weight bearing status, and transferred via lift only. Resident #1 wore a CAM boot, removed only for hygiene. Staff reinstituted a bed alarm at the time of the fall. All fall interventions reviewed/updated and remained appropriate. A typed note dated 02/21/14 at 7:35 a.m. stated Staff J, Clinical Coordinator did talk to Staff B CNA about toileting Resident #1 on rounds. Staff B stated Resident #1 used to be toileted at 5 a.m.. Staff J showed and told Staff B it was on the resident report info sheet they picked up every night. During an interview on 03/19/14 at 9:58 p.m. Staff B CNA stated they had 1 CNA scheduled for each pod at night, and 1 nurse on duty. She said she could call the nurse or another CNA if she needed assistance. She said Resident #1 used the bedpan because he/she was a lift transfer with assist of 2. She said on 02/06/14 when Resident #1 fell she did 12 o'clock rounds, and probably around 1 a.m. Resident #1 used the bedpan, because he/she was awake when Staff B went in the room. She said Resident #1 probably urinated. At 2 a.m. and 3 a.m. Resident #1 slept. Staff B stated routine toileting meant they would toilet the resident routinely. Staff B stated Resident #1 had previously been a 5 a.m. toileting, and she missed the change to routine toileting. During an interview on 03/20/14 at 9:37 a.m. Staff G RN stated previously Resident #1 would try to get up frequently on his/her own, but he/she had not tried to get out of bed for a while. She said they checked every 2 hours to see if he/she needed to go to the bathroom, so he/she wouldn't try to get up on his/her own. Staff G stated when Resident #1 fell that night, he/she said needing to get up to the bathroom. As far as Staff G knew, Resident #1 had toileted or been offered toileting every 2 hours. 11. A Post Fall assessment dated [DATE] at 1:00 a.m. documented staff noted Resident #1 on his/her left side, laying with his/her back towards the bed on the mat at the bedside. The bed was in the low position and call light in reach. Resident #1 had been checked 1 hour prior and given the opportunity to use the bedpan. Resident #1 stated he/she needed to go to the bathroom. They noted no injury. The bed alarm was in place and sounding. What could be done to prevent another fall included re-education of staff on safety devices that needed to be in place. During an interview on 03/20/14 at 10:25 a.m. Staff E RN stated they were toileting Resident #1 every 1-2 hours and he/she didn't try to get up. She said regarding the 2/26/14 incident the noodle was not in place when Resident #1 fell (as per the care plan interventions). During an interview on 03/19/14 at 2:01 p.m. Staff D RN stated being fairly new to the facility. She thought Resident #1's fall with fracture occurred before she started or when she started. She understood if Resident #1 called, they toileted him/her. She was not positive they toileted on rounds, but staff had report sheets that told them what to do. During an interview on 03/19/14 at 4:24 p.m. Staff F RN stated when Resident #1 had a urinary tract infection he/she soul try to get up more. Staff F didn't know they had discontinued the alarm prior to the ankle fracture. Staff F stated they toileted Resident #1 when he/she called at night. She did not believe they toileted him/her routinely on rounds. During an interview on 03/20/14 at 9:30 a.m. Staff C CNA stated prior to Resident #1's fall and fractured ankle, he/she had not tried to get up on his/her own for awhile. She said they offered the bedpan on 12-2-4 o'clock rounds. She said they told them to offer the bedpan on rounds so Resident #1 would not try to get up on his/her own and that seemed to work. During an interview on 03/19/14 at 2:27 p.m. the Restorative/Clinical Coordinator stated they had recently started the post fall huddle because they were seeing things that needed identification at the time of the falls.