Every finding on record at Cypress Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure food was properly labeled and dated in the facility kitchen refrigerator on 06/23/2026.This deficient practice could place residents who ate food served from the kitchen at risk for health complications and foodborne illnesses.Findings included:An observation on 06/23/2026, at 9:10 AM, revealed multiple food items in the facility refrigerator were stored without the required labeling and date marking. Specifically, the following items were identified as undated and unlabeled: one large plastic bag of cheese, one bag large bag of Vegetarian Burgers, one box of natural smoked bacon, one bag of turkey breast, and three containers of strawberries.In an interview on 06/25/2026, at 10:36 AM, CK H stated she was trained on labeling and dating recently, and she dated food 3 for 3 days then after the 3 days, the food would be discarded. She stated all food should be labeled and dated after it was opened, and if this was not done then residents could become sick. Currently, in the kitchen the facility used a system first in, first out.In an interview on 6/25/2026, at 10:45 AM, CK J stated he was in-serviced recently on food labeling and dating. He stated, in the kitchen, it was the facility's protocol to put the name of the item on the label, then date the item after it is opened, and when it would need to be cycled out. He stated if food items were not labeled and dated correctly, residents could become sick. He stated the facility had a system to ensure old food was never served to residents, and to ensure this, he stated they used the newest date items first, then older date items were removed from stock. In an interview on 6/25/2026, at 10:57 AM, CK I stated she was recently trained on food labeling and dating , and all items in the kitchen should be labeled and dated as soon as they were opened with the name, month, and date it was opened to prevent serving expired items to residents. She stated if residents were served food that was not properly labeled or dated, they could become sick. She stated, at the facility, to ensure residents are not served expired food, the facility uses the system first in first out.In an interview on 6/25/2026, at 11:01AM, the DM stated it was his expectation that all items in the kitchen be labeled and dated. He stated he trained his staff daily on these topics and he was trained last February by his Regional Coordinator. He stated he provided a guide for all his employees to follow regarding shelf-life timelines. He stated if food items were not labeled and dated correctly then residents could become sick. He stated when he was hired, he started the system first in first out (FIFO) which ensures that older food is used before newer stock arrives. Review of the facility's policy titled, Food Storage Dated, 6/1/2026, reflected:Frozen Meat/Poultry and Food Guidelines C. Storage: Store items promptly at 0 F or below. Foods should be stored in their originalcontainers if designed for freezing. Foods to be frozen should be stored in airtight inthe original packing containers or plastic Ziplock storage bags or wrapped in heavy-dutyaluminum foil or special laminated papers.i. Label and date all food items.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment for 2 of 4 resident halls (100-hall and 500-hall) reviewed for environment. The facility failed to ensure the carpet in the 100-hall and 500- hall was clean and free of foul odors. This failure placed residents at risk of diminished quality of life.Findings included: Observation on 06/24/2026 at 1:36 PM revealed 15 red or grey stains on the 500-hall carpet, outside of resident rooms. The red stains, of which there were three, were 3-4 inches in diameter, and the grey stains were 9-14 inches in diameter. The hall had a moderate unpleasant odor, similar to old urine, that came from the carpet. Observation on 06/25/2026 at 9:07 AM revealed 24 red or grey stains on the 100-hall carpet. The hall had a mild foul odor, similar to old urine, that came from the carpet. During an interview on 06/25/2026 at 12:30 PM, the MAINTD stated he had facilitated professional steam cleaning of the carpets a couple of times in the previous six months, but the stains and the foul odor were not coming out of the 100-hall and 500-hall carpets. He stated the carpets needed to be replaced, and there was nothing he could do until that was approved. During an interview on 06/25/2026 at 12:37 PM, the FT stated he did not have a large steam cleaner with which to clean the carpets. He stated the facility had the carpets professionally cleaned twice over the previous months. He stated he could do spot treatments and had spent hours on his hands and knees trying to get the stains out. He stated the odor was strong on the 500 and 100 hallways, and it was urine. He stated the only way to get rid of the smell was to tear up the carpets and put in new flooring. During an interview on 06/25/2026 at 2:10 PM, the HKS stated the facility had tried to have the stains and odor removed from the halls and had hand scrubbed many times, but nothing works. She stated several residents and family members had complained about the stains and especially the odor. During an interview on 06/25/2026 at 3:24 PM, the DON stated she had noticed the odor of urine on the 500-hall and 100-hall. She stated the person responsible for ensuring the resident's environment was clean and decent was everyone, but primarily housekeeping and maintenance. She stated the carpets could not be improved enough, and they needed to be replaced. She stated she was brand new to the facility and had not been privy to any interventions related to the odor and stains in the 500- and 100-halls. During an interview on 06/25/2026 at 4:01 PM, the ADM stated she was aware of the stains and foul odor on the 500-hall and 100-hall, and they were cited for it last year. She stated their previous management company would not replace the floors. She stated the carpets had been steam cleaned three times in the past six months, and she had a floor tech who would get on his hands and knees to clean stains. She stated the facility had transitioned to a new management company, and the new company had expressed plans to remove the carpet on all halls and put down new flooring. She stated it would be an unpleasant experience for a family member to visit and smell the urine and see all the stains. Review of grievances from January 2026 to June 2026 reflected the following:02/27/2026Grievance/Concern DetailSpouse voiced concern regarding an odor on 500-hall and requested it be addressed.Action TakenCarpet was professionally cleaned on 03/03/2026. Resident's floor in his room was stripped and waxed on 03/03/3026.04/02/2026Grievance/Concern DetailRoom too dark, Resident room smells like urine (500-hall resident), and paper towel dispenser needs fixing.Action TakenHousekeeping went in and cleaned the floor and replaced the paper towels. Review of policy provided by the facility in response to a request for policy on Safe, Clean, Comfortable, and Homelike Environment, dated 08/2020 and titled Maintenance Services reflected the following: PurposeTo protect the health and safety of residents, visitors, and Facility Staff.PolicyThe Maintenance Department maintains all areas of the building, grounds, and equipment.ProcedureI. The Maintenance Department is responsible for maintaining the buildings, grounds, andequipment in a safe and operable manner at all times.II. Functions of the Maintenance Department may include, but are not limited to:A. Maintaining the building in compliance with current federal, state, and local laws,regulations, and guidelines.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 13 of 17 residents (Residents #85, 67, 72, 60, 51, 36, 24, 22, 16, 8, 52, 63, and 31) reviewed for quality of life. Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16 were observed in the television room for the entire mornings of 06/23/2026, 06/24/2026, and 06/25/2026, without any activities offered beyond sitting in their wheelchairs and watching television.Residents #8 and 52 were not offered in-room activitiesResidents #63 and 31 were not offered materials for independent activities. These failures place residents at risk of boredom, depression, and loneliness.Findings included: 1. Review of the undated face sheet for Resident #16 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included transient cerebral ischemic attacks (temporary blockage of blood flow to the brain), malnutrition, and atherosclerosis (buildup of hard fat in the arteries). Review of the admission MDS assessment for Resident #16 dated 06/13/2026 reflected he did not participate in the BIMS assessment for cognition. The staff assessment reflected he had a memory problem, and his cognition was moderately impaired. The assessment for activity preferences reflected it was somewhat important to him to go outside when the weather was good and to participate in religious services. Review of the initial activity assessment for Resident #16 dated 05/19/2026 reflected the following: Attitude toward life and activities in general: interested. There was no information relating specific activity interests or notes recorded Review of the care plan for Resident #16 dated 06/12/2026 reflected the following: FOCUSRisk for depressionGOALResident will be free of signs/symptoms of depressionINTERVENTIONSObserve resident for any signs/symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious, or health related complaints, and tearfulness.There was no care planning for activity preferences. Review of the entire clinical record for Resident #16 reflected his participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #22 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included repeated falls, moderate dementia, adjustment disorder with depressed mood, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy, and muscle weakness. Review of the admission MDS assessment for Resident #22 dated 01/20/2026 reflected a BIMS score of 14, indicating intact cognition. The assessment for activity preferences included no activities that were important to her. Review of the quarterly activity assessment for Resident #22 dated 04/17/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident loves to stay in the TV room and watch shows with her friends, resident will come to the dining room and drink coffee, resident likes to come to the outside socials from time to time, resident does not participate in bingo, but does love to come most of the time to drink, coffee and watch the heat of the game! Activity Plan- Remind resident of our outside social so she can get some snacks and chat with her friends. Resident did play bowling one time, remind resident of bowling and movies that we have, might want to watch with her friends. Remind resident of bingo as well. Review of the care plan for Resident #22 dated 01/30/2026 reflected the following: FOCUSThe resident is an elopement risk/wanderer (WANDERER) r/t Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly.INTERVENTIONS-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [nothing additional here] Review of the entire clinical record for Resident #22 reflected her participation in activities was not being documented anywhere.Review of the undated face sheet for Resident #24 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction(death of brain tissue due to lack of blood flow to the brain), aphasia, following cerebral infarction, hemiplegia, and hemiparesis, following cerebral infarction, affecting right dominant side, muscle wasting an atrophy, bipolar disorder, major depressive disorder, vascular dementia, muscle, weakness, abnormalities of gait and mobility, repeated falls, anxiety, disorder, insomnia, and tremor. Review of the annual MDS assessment for Resident #24 dated 06/03/2026 reflected a BIMS score of 14, indicating intact cognition. The assessment for activity preferences included no activities that were important to her. Review of the care plan for Resident #24 dated 06/11/2026 reflected the following: FOCUSResident is dependent on staff for activities, cognitive stimulation, social interaction.GOALResident will maintain involvement in cognitive stimulation, social activities as desired through review date.INTERVENTIONS-Invite and encourage the resident to scheduled activities.-Place and assist resident with using video phone. Review of the entire clinical record for Resident #24 reflected her participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #36 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis (paralysis or weakness on one side of the body), abnormalities of gait and mobility, lack of coordination, vascular dementia, muscle wasting and atrophy, dysphasia following non-traumatic subarachnoid hemorrhage (difficulty with speech and language after a bleeding event in the brain), and malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify). Review of the annual MDS assessment for Resident #36 dated 06/07/2026 reflected a BIMS score of 07, indicating moderately impaired cognition. The assessment for activity preferences reflected it was somewhat important to him to listen to music he liked, do things with groups of people, do his favorite activities, and participate in religious groups or services. Review of the initial activity assessment for Resident #36 dated 06/05/2026 reflected the following: Attitude toward life and activities in general: interested. There was no information relating specific activity interests or notes recorded. Review of the care plan for Resident #36 dated 06/17/2026 reflected the following: FOCUSThe resident is dependent on staff for activities, cognitive stimulation, social interaction R/T hemi (paralysis on one side of the body) to both sides.GOALThe resident will maintain involvement in cognitive stimulation, social activities as desired through the review date.INTERVENTIONProvide with activities calendar. Notify resident of any changes to the calendar of activities. Review of the entire clinical record for Resident #36 reflected his participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #51 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertensive heart disease (condition in which long-term high blood pressure causes damage to the heart), chronic kidney disease, abnormalities of gait and mobility, major depressive disorder, insomnia, pain, cognitive communication deficit (trouble communicating due to cognitive impairment), muscle weakness, dementia, and anxiety disorder. Review of the quarterly MDS assessment for Resident #51 dated 05/22/2026 reflected a BIMS score of 00, indicating severely impaired cognition. Review of the quarterly activity assessment for Resident #51 dated 05/19/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident likes food socials. Does not attend many activities. Activity Plan- Make sure resident is aware of parties/food socials. Review of the care plan for Resident #51 dated 06/18/2026 reflected the following: FOCUSThe resident NEEDS ASSIST WITH REMINDING OF ACTIVITIES R/T Cognitive deficits. PARTICIPATES MOSTOF THE TIME.GOALAttend/participate in activities of choice 3-5 times weekly by next review date.INTERVENTIONS-Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary Invite the resident to scheduled activities.-The resident needs assistance/escort to activity functions.-The resident's preferred activities are: BINGO, GOING OUTSIDE, CATHOLIC MASS Review of the entire clinical record for Resident #51 reflected her participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #60 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included vascular dementia, anxiety disorder, and age-related cognitive decline. Review of the annual MDS assessment for Resident #60 dated 11/14/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. The assessment for activity preferences included no activities that were important to him. Review of the quarterly activity assessment for Resident #60 dated 03/04/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident goes to book reading, and social/parties when family is visiting. Activity Plan- Remind family of parties and social so resident has family to sit with and socialize with. Review of the care plan for Resident #60 dated 06/18/2026 reflected the following: FOCUSThe resident has little or no activity involvement r/t Disinterest.GOALThe resident will express satisfaction with type of activities and level of activity involvement when asked through the review date.INTERVENTION-Establish and record The resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.-Explain to the resident the importance of social interaction, leisure activity time.-Encourage the resident's participation inviting to all appropriate activities-Invite/encourage the resident's family members to attend activities with resident in order to support participation.-Modify daily schedule, treatment plan PRN to accommodate activity participation as requested by the resident.-Monitor/document for impact of medical problems on activity level.-Remind the resident that the resident may leave activities at any time, and is not required to stay for entire activity.-The resident needs a variety of activity types and locations to maintain interests.-The resident needs assistance/escort to activity functions. Review of the entire clinical record for Resident #60 reflected his participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #67 reflected [AGE] year-old admitted to the facility on [DATE]. His diagnoses included cerebral infarction (death of brain tissue due to lack of blood flow to the brain), hypertensive heart disease (condition in which long-term high blood pressure causes damage to the heart), mood disorder, abnormalities of gait and mobility, cognitive communication deficit, lack of coordination, and muscle weakness. Review of the quarterly activity assessment for Resident #67 dated 05/19/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Spending time with his son and watching TV.Activity Plan- N/A Review of the admission MDS assessment for Resident #67 dated 11/17/2025 reflected a BIMS score of 13, indicating intact cognition. The assessment for activity preferences reflected it was somewhat important to him to keep up with the news. Review of the care plan for Resident #67 dated 04/08/2026 reflected the following: FOCUSThe resident has a mood problemGOALThe resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety orsadness) through the review date.INTERVENTIONS-Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.-Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of the entire clinical record for Resident #67 reflected his participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #72 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included age-related cognitive decline, muscle wasting and atrophy, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit, and history of falling. Review of the annual MDS assessment for Resident #72 dated 06/11/2026 reflected she could not participate in the BIMS assessment for cognitive function. The staff assessment reflected she had memory problems and her cognition was severely impaired. The assessment for activity preferences reflected it was very important to her to go outside when the weather was good and somewhat important to have books, magazines, and newspapers to read, to listen to music she liked, to do her favorite activities, and to spend time with groups of people. Review of the quarterly activity assessment for Resident #72 dated 06/11/2026 reflected the most recent activity assessment was in the system, but had not been filled out. Review of the care plan for Resident #72 dated 04/23/2026 reflected the following: FOCUSThe resident has a psychosocial well-being problem.GOALThe resident will demonstrate adjustment to nursing home placement by/through review dateINTERVENTIONEncourage participation from resident who depends on others to make own decisions.There was no care planning specific to activity interests. Review of the entire clinical record for Resident #72 reflected her participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #85 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included vascular dementia, repeated falls, muscle weakness, lack of coordination, muscle wasting and atrophy, disorder of the autonomic nervous system, cognitive communication deficit, major depressive disorder, and anorexia. Review of the annual MDS assessment for Resident #85 dated 12/13/2025 reflected a BIMS score of 03, indicating severe cognitive impairment. The assessment for activity preferences reflected it was somewhat important to her to participate in her favorite activities. Review of the quarterly activity assessment for Resident #85 dated 03/13/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident listens to DAR reading every Thursday, will come outside socials with supervision. Likes to watch TV with other residents. Activity Plan- Bring resident to reading every Thursday, remind family of socials so resident can enjoy them with family.Review of the entire clinical record for Resident #85 reflected her participation in activities was not being documented anywhere. Review of the care plan for Resident #85 dated 06/18/2026 reflected the following: FOCUSThe resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Immobility. Needs assist and reminding of activities r/t dementia.GOALThe resident will maintain go to at least two group activity a week through review date.INTERVENTIONS-Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate.-Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary.-Introduce the resident to residents with similar background, interests and encourage/facilitate interaction.-Invite the resident to scheduled activities.-Thank resident for attendance at activity function.-The resident needs assistance with ADLs as required during the activity.-The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events.-The resident needs assistance/escort to activity functions.-The resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities.-The resident's preferred activities are: country gospel music, Bible study, live music events, visiting with her son and sister. Observation on 06/23/2026 at 9:13 AM to 11:48 AM revealed Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16 were in their wheelchairs in the central television room. Observation and an interview on 06/24/2026 at 10:16 AM revealed a Hospice chaplain in the sitting room holding a religious activity. There were three residents present in the activity, and none of them were Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16. At the end of the activity, the chaplain stated he came to the facility every week to hold Bible study and singing hymns, and there were seldom more than two or three people in the activity. He stated he really wished that the staff would bring some of the residents who spent all day sitting in the television room to the religious activity. He stated he always checked in with those residents, and they did not talk or answer questions, but they could have easily been moved in their wheelchairs to the sitting room. He stated he had mentioned this to the staff a couple of time, but he had not filed any formal grievance about it. Observation on 06/24/2026 at 9:00 AM to 11:50 AM revealed Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16 were in their wheelchairs in the central television room. Observation on 06/25/2026 at 9:13 AM to 12:00 PM revealed Residents #85, 67, 72, 60, 51, 36, 24, 22, and 16 were in their wheelchairs in the central television room. Observation from 9:00 AM to 10:00 AM revealed the AD did not enter the television room to invite any residents to an activity. An interview was attempted with all nine residents, and the only one who responded with any more than eye contact was Resident #24, who shook her head when asked at 9:55 AM if she wanted to go outside. Observation on 06/25/2026 at 10:01 AM revealed the AD on the front porch with two residents, none of whom were Residents #85, 67, 72, 60, 51, 36, 24, 22, or 16, facilitating an exercise activity. Observation on 06/25/2026 at 2:30 PM revealed an ice cream social in the dining room. Five residents were involved in the activity. None of them were Residents #85, 67, 72, 60, 51, 36, 24, 22, or 16. 2. Review of the undated face sheet for Resident #8 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cognitive communication deficit, muscle weakness, muscle, wasting and atrophy, and mild cognitive impairment. Review of the annual MDS assessment for Resident #8 dated 09/01/2025 reflected a BIMS score of 10, indicating moderate cognitive impairment. The assessment for activity preferences included no activities that were important to him. Review of the quarterly activity assessment for Resident #8 dated 03/20/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident goes outside with (FM) every day, (FM) does ask if the resident would like to participate, but he would rather stay outside with her. Resident does come to holiday celebrations with (FM). Loves to listen to his music in his room and watch movies.Remind (FM) of social/parties on holiday events. Review of the care plan for Resident #8 dated 06/18/2026 reflected the following: FOCUSThe resident has impaired cognitive function/dementia or impaired thought processes r/t Impaired decision making.GOALThe resident will be able to communicate basic needs on a daily basis through the review date. Review of the entire clinical record for Resident #8 reflected his participation in activities was not being documented anywhere. During observation and an interview on 06/23/2026 at 9:24 AM, Resident #8 stated he had not been at the facility for very long, and they did not give him much to do, but he mostly watched television. He stated he did not know the AD and no staff had asked him about activities. He stated his FM visited frequently. He stated he liked to chat with intelligent people, but he was not interested in group activities. Review of the undated face sheet for Resident #52 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart disease, dementia, cognitive communication deficit (trouble communicating due to cognitive impairment), lack of coordination, anxiety disorder, major depressive disorder, muscle weakness, chronic pain syndrome, and malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify). Review of the annual MDS assessment for Resident #52 dated 08/23/2025 reflected a BIMS score of 14, indicating intact cognition. The assessment for activity preferences included no activities that were important to her. Review of the quarterly activity assessment for Resident #52 dated 04/15/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident has come to the women's tea party, comes to some socials with (FM). Activity Plan- Remind (FM) of social events and holiday events. Get resident up to go to the women's tea party. Review of the care plan for Resident #52 dated 06/18/2026 reflected the following: FOCUSThe resident is CONFINED TO BED. NEEDS INDIVIDUAL ACTVITIES. HAS DX: MILD DEMENTIA, CHRONIC PAIN AND Immobility.GOALThe resident will do at least 3 individual activities a week through review date.INTERVENTIONS-Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: word find puzzle books watching TV, and nails done-The resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. Review of the entire clinical record for Resident #52 reflected her participation in activities was not being documented anywhere. During an interview on 06/23/2026 at 9:40 AM, Resident #52 stated no staff had offered her any activities. She stated she did not like to get out of bed and participate in group activities, but she did like to chat with people, and she would love to be read to. She stated she also wanted to send a note to a friend of hers, but she could no longer write, so she wanted some help with that. During an interview on 06/23/2026 at 12:40 PM, Resident #52 stated no staff had offered her any activities. During an interview on 06/24/2026 at 11:41 AM, Resident #52 stated no staff had offered her any activities.During an interview on 06/24/2026 at 1:47 PM, Resident #52 stated no staff had offered her any activities.During an interview on 06/24/2026 at 1:54 PM, Resident #52 stated no staff had offered her any activities. 3.Review of the undated face sheet for Resident #31 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (death of brain tissue due to lack of blood flow to the brain), memory deficit following other cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, lack of coordination, Alzheimer's disease, major depressive disorder, and anxiety disorder. Review of the admission MDS assessment for Resident #31 dated 03/27/2026 reflected a BIMS score of 03, indicating severely impaired cognition. The assessment for activity preferences reflected it was very important to her to do things with groups of people and to do her favorite activities and somewhat important to her to have books, magazines or newspapers to read. Review of the initial activity assessment for Resident #31 dated 03/29/2026 reflected Attitude toward life and activities in general: interested. There was no information relating specific activity interests or notes recorded. Review of the care plan for Resident #31 dated 06/17/2026 reflected the following: FOCUSThe resident is an elopement risk/wanderer (SPECIFY) r/t Disoriented to place, Impaired safety awareness,Resident wanders aimlessly, significantly intrudes on the privacy or activitiesINTERVENTIONSDistract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [nothing additional here]. Review of the entire clinical record for Resident #31 reflected her participation in activities was not being documented anywhere. Review of the undated face sheet for Resident #63 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic kidney disease, morbid obesity, chronic obstructive pulmonary disease (COPD), depressive episodes, muscle weakness, and repeated falls. Review of the annual MDS assessment for Resident #63 dated 10/10/2025 reflected a BIMS score of 09, indicating severe cognitive impairment. The assessment for activity preferences reflected it was somewhat important to her to participate in her favorite activities. Review of the quarterly activity assessment for Resident #63 dated 05/01/2026 reflected the following: Describe resident's favorite activities, special accomplishments, and/or new interests. Resident enjoys watching TV and participating in the facility. Smoke breaks. Activity Plan- Will continue to encourage resident to attend activities of interest. Review of the care plan for Resident #63 dated 04/15/2026 reflected the following: FOCUSThe resident is dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t Physical Limitations. Has DX: depression. Has limited mobility R/T bilateral BKA. Uses W/C for mobility. Needs encouragement to attend activities.GOALThe resident will be out of room daily and do at least one activity a day through review date.INTERVENTIONS-Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate.-Introduce the resident to residents with similar background, interests and encourage/facilitate interaction.-Invite the resident to scheduled activities.-Provide with activities calendar. Notify resident of any changes to the calendar of activities.-Review resident's activity needs with the family/representative.-Thank resident for attendance at activity function.-The resident needs assistance with ADLs as required during the activity.-The resident needs assistance/escort to activity functions. Review of the entire clinical record for Resident #63 reflected her participation in activities was not being documented anywhere. Observation on 06/23/2025 at 11:27 AM, revealed Resident #31 was walking around the facility with her walker and talking about needing to go find her car. She stated she was not working there and needed to find where her car was parked. She was seen walking from door to door looking out the windows to see if she could find her car. She had a wander guard on which did alarm when she got close to the front door. During an interview on 06/24/2026 at 1:43 PM, Resident #63 stated she did not like to participate in group activities, but she did like to color, and wished she had some pencils, markers, or crayons to color in her coloring book. She stated she had some coloring books in a white bag in her closet, but she could not reach them and needed help. After a search of her closet, drawers, and under her bed, the coloring books could not be found. She stated the AD did not talk to her very much. During an interview on 06/25/2026 at 1:11 PM, LVN C stated he and the CNAs got residents up for activities if they were asked to, but that rarely ever happened. He stated the AD walked through the halls and invited people to the group activities, but he never saw her go into the rooms and have one-to-one activities with residents who spent most of their time in bed. During an interview on 06/25/2026 at 1:50 PM, CNA G stated she did not see anyone doing one-to-one activities with the residents on her hall. During an interview on 06/25/2026 at 2:38 PM, the AD stated she had worked at the facility for a year and three months. She stated there were a few volunteers who came in to hold activities regularly, but she did not have an activity aide. She stated when she was not in a group activity, she was typically having one-to-one visits or updating the activity calendar. She stated she was not sure if she asked any of the residents in the television room if they wanted to come to any of the group activities. She stated those residents did not want to go to group activities. She stated they had a huge event once a month and almost everybody came to those. She stated Resident #31 did not want to participate in any activities. She stated she did not know what Resident #31 did for a living or as a younger person and did not think that would help her to identify any possible recreational activities she would like. She stated she did not know Resident #8. She stated she did one-to-one visits with Resident #52, and the last time she did one was probably two weeks ago. She stated she used to document activities in the POC system with the old management company, but there was no documentation system yet with the new management company. She stated the potential negative impact of not receiving activities was it could really bring them down. During an interview on 06/25/2026 at 4:01 PM, the ADM stated she was responsible for overseeing the activities program. She stated ultimately it was also her responsibility to ensure the one-to-one and independent activities were offered. She stated she monitored for compliance by looking around the building and looking at the activity calendar as well as morning meeting. She stated the potential negative impact on residents of not having activities offered was they might be depressed. Review of the facility's policy dated 06/2020 and titled Activities Program reflected the following: PurposeTo encourage residents to participate in activities to make life more meaningful, to stimulate andsupport physical and mental capabilities to the fullest extent, and to enable the resident to maintainthe highest attainable social, physical and emotional functioning.PolicyI. The Facility provides an Activity Program designed to meet the needs, interests, and preferencesof residents. The activities are varied and work to address the needs and interests identifiedthrough the assessment process. The Activity Program may address areas including, but notlimited to:A. Social activities;B. Indoor and outdoor activities;C. Activities away from the Facility;D. Religious programs;E. Opportunity for resident involvement for planning activities;F. Creative activities;G. Educational activities; andH. Exercise activities.II. A variety of activities should be offered on a daily basis, which includes weekends and evenings.III. Activities are developed for individual, small group, and large group participation.IV. The activit

Based on, interview, and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 8 of 8 months (October 2025-May 2026) of Resident Council minutes reviewed. The facility failed to ensure all grievances that arose in the Resident Council meetings from October 2025 to May 2026 were resolved. This failure placed residents at risk of not controlling their own lives and home.Findings included: Review of Resident Council minutes reflected the following requests/grievances arising from the Resident Council:October 2025Residents requested more activities on the weekend.Request requesting more staff in the dining room during mealsWould like to see housekeepers, clean the restrooms betterWould like to have more hot chocolateNovember 2025Residents requested nurses introduced themselves when agency is being usedResidents requested when staff moves the over bed table they remember to move it back. Same with turning on the light. If it wasn't on when they walked in, they need to turn it off when they leave.Residents requested meat from the kitchen, be more tender.Residents requested hot cocoa be available.Residents would like the busy board to be updated more frequently.Residents feel CNAs are on their phones too often.Residents would like CNAs to be reminded to knock before entering.December 2025Food is cold sometimes. They like the meals, just want them warm. Wanting food to be a little softer. Wondering why toast isn't toasted.Wanting some more crafts, possible art show like activities.Staff on their phones. Residents requested nurses introduce themselves when agencies being used.January 2026Would like bread to be toasted in the morning a bit more.February 2026Would love to try beef enchiladas, one of the months!March 2026Activities: would like to start a gardenWant to try beef enchiladasApril 2026Try making coloring and activity.May 2026Activities: would like to have more tea partiesWant snacks passed out in the hallwayResidents would like to go through the no-name clothes more often for donations.June 2026Food is good but sometimes too salty. Review of grievances from October 2025 to June 2026 reflected no grievances created for any of the concerns/requests listed on the Resident Council minutes from October 2025 to June 2026. During a confidential group interview, seven residents stated the facility staff did not follow up with them on grievances discussed in the monthly Resident Council. They stated the facility staff said their concerns were small things, but the concerns were not small to the residents. They said there were ongoing issues with food, housekeeping, and facility administration as well as activities they had requested that were not happening. They stated the facility had recently undergone a change of management, and the new company had new rules, such as the staff could not warm up resident food in the microwave. They stated this was their home, and they should be able to warm up food. They stated there was also a new rule about visiting hours only being from 8:00 AM to 8:00 PM. During an interview on 06/25/2026 at 2:05 PM, the SW stated she was the grievance official and distributed the grievances to appropriate departments heads after she received them. She stated she was not sure she had received any grievances from Resident Council since she began working at the facility in August 2026. She stated she always received grievances from the Resident Council at previous nursing facilities where she worked, but she had not thought about it. She stated now that she was thinking about it, it was odd that she had not received any grievances from the Resident Council. She stated she had not been told one way or the other if the Resident Council grievances were her responsibility. During an interview on 06/25/2026 at 2:38 PM, the AD stated she attended the Resident Council meetings and took minutes. She stated any grievances arising from the Resident Council were written on a separate piece of paper and given to the ADM. The AD stated she did not know what happened after that or who addressed the grievances. She stated she did not think about sharing a resolution to the grievances with the Resident Council and assumed whoever addressed the grievances did that. She stated that as she remembered it, most of the Resident Council grievances were about food. During an interview on 06/25/2026 at 4:01 PM, the ADM stated the AD wrote grievances on separate pieces of paper and gave them to her (the ADM) to address. The ADM stated she felt she had addressed all the Resident Council grievances. She stated some issues continued to arise over and over again, and these might not have continued to be addressed. She did not describe these grievances. She stated the grievance about staff not microwaving resident food was a policy of the new management company, and the corporate leaders of the new management company had met with the Resident Council to discuss changes. She stated she did not know if minutes were taken at that meeting but said she would inquire (as of 06/30/2026, the corporate staff for the new management company had not responded to her request for documentation of the meeting). She stated it was her who was ultimately responsible for all systems in the facility, but the AD was responsible for conveying grievances to her (the ADM). She stated she monitored for compliance by talking to residents. She stated the potential negative impact of not addressing Resident Council grievances was they would not feel like they had a say in their lives. Review of facility policy dated 06/2020 and titled Resident Council reflected the following: PurposeTo promote the exercise of a resident's right to organize and participate in resident groups at theFacilityPolicy I. The Facility encourages residents' involvement and input in the operation of the Facility throughthe Resident Council.II. The Facility must provide a resident council with a private space to meet.III. The purpose of the Resident Council is to provide a forum for:A. Residents to have input in the operation of the Facility;B. Discussion of residents' concerns;C. Consensus building and communication between residents and Facility Staff; andD. Staff to disseminate information and gather feedback from interested residents andfamily groups.ProcedureII. Responsibilities of the Resident Council:A. Making recommendations for the improvement of resident services provided by theFacility;B. Suggesting new activities;C. Reviewing reports submitted to the Council and making recommendations and/or takingappropriate action;D. Studying problem areas and making recommendations for their solution;E. Serving as an advisory group between the residents and management;F. Maintaining minutes of all meetings and submitting a copy to the Administrator forhis/her review; andG. Other responsibilities as appropriate or as may be requested by the Council and approvedby the Administrator.IV. Meeting MinutesA. Council members may appoint a resident member to record the minutes. Otherwise,minutes will be recorded and maintained by the designated Staff member.B. The minutes will include the following information: include names of the Councilmembers and any guests present, issues discussed, recommendations from the Council tothe Administrator, and follow-up on prior issues.C. Minutes may be recorded on Resident/Family Council Minutes.D. The Administrator reviews the minutes and any responses from departments within theFacility. Responses are presented at the next meeting, or sooner, if indicated.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Residents #13 and #52) reviewed for ADL care. The facility failed to ensure Resident #13 was offered nail care and showers in accordance with his shower schedule and Resident #52 was offered showers according to her shower schedule or assisted with changing her clothes from 06/23/2026 to 06/25/2026. This failure placed residents at risk of skin problems, body odor, and embarrassment.Findings included: Review of the undated face sheet for Resident #13 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis (paralysis or weakness on one side of the body), sequela of cerebrovascular disease (long-term or residual effects of an event such as a stroke), muscle weakness, type two diabetes mellitus, cognitive, social or emotional deficit following cerebral infarction (death of brain tissue due to lack of blood flow to the brain), attention and concentration deficit following cerebral infarction, cognitive communication deficit (trouble communicating due to cognitive impairment), vascular dementia (disease caused by lack of blood flow to the brain, causing cognitive decline and memory loss), and pain in both wrists. Review of the quarterly MDS assessment for Resident #13 dated 06/04/2026 reflected a BIMS score of 14, indicating intact cognition. It reflected he required partial to moderate assistance with personal hygiene tasks and was totally dependent on the assistance of staff for bathing. Review of the care plan for Resident #13 dated 06/17/2026 reflected the following: FOCUSThe resident has an ADL self-care performance deficit r/t Hemiplegia to right side. Needs limited to extensive assist with all ADLs. able to feed himself and assist with some ADLs.GOALThe resident will maintain current level of function in eating through the review date.INTERVENTIONS-BATHING/SHOWERING: The resident needs extensive assist (2) staff to provide bathing at least 3 times a week and as necessary.-PERSONAL HYGIENE/ORAL CARE: The resident needs extensive assist on (2) staff for personal hygiene and oral care. Review of POC tasks (CNA documentation system) for Resident #13 reflected no task item for nail care where nail care attempts could be documented. Review of bathing tasks for Resident #13 reflected only one bath from 05/26/2026 to 06/25/2026 documented on 06/24/2026. Review of handwritten shower sheets for Resident #13 from 05/01/2026 to 06/25/2026 reflected one on 06/19/2026. The shower was documented as refused. During observation and interview on 06/23/2026 at 12:20 PM Resident #13 was seated in the dining room. His fingernails were long and dirty with a brown substance. He stated he did not know about his fingernails and then pulled his hat off and showed his hair, which he said was greasy. He said he did not get all of his showers and did not know how this made him feel. He would not answer any more questions. Review of the undated face sheet for Resident #52 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included heart disease, dementia, cognitive communication deficit(trouble communicating due to cognitive impairment) , lack of coordination, anxiety disorder, major depressive disorder, muscle weakness, chronic pain syndrome, and malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify). Review of the annual MDS assessment for Resident #52 dated 08/23/2025 reflected a BIMS score of 14, indicating intact cognition. Tit reflected she required substantial/maximal assistance with the activity of bathing. Review of the undated care plan for Resident #52 reflected the following: FOCUSThe resident has an ADL self-care performance deficit r/t Dementia, Limited Mobility. Will refuse baths and some careat times.GOALThe resident will be able to feed herself through the review date.INTERVENTIONS-BATHING/SHOWERING: The resident is totally dependent on (1) staff to provide SPECIFY bath/shower AT LEAST ONCE A WEEK and as necessary. WILL REFUSE BATHS AT TIMES. PREFERS TO HAVE ONLY ONE BATH A WEEK-DRESSING: The resident requires EXTENSIVE ASSIST by (1) staff to dress. Review of POC tasks (CNA documentation system) for Resident #52 reflected no task item for nail care where nail care attempts could be documented. Review of bathing tasks for Resident #52 reflected only one bath from 05/26/2026 to 06/25/2026 documented on 06/11/2026. Review of handwritten shower sheets for Resident #52 from 05/01/2026 to 06/25/2026 reflected two: one on 05/07/2026 and one on 06/20/2026.During observation and interview on 06/23/2026 at 9:40 AM, Resident #52 was lying in bed in a hospital gown. She stated she was not getting bed baths very often, but she did get them. She stated her memory was not great so she did not remember when she last got a bath. She stated she did not want showers, but she wanted bed baths. She stated she was okay with wearing the hospital gown. She stated she had clothes and would like to wear a t-shirt sometime. During observation and interview on 06/23/2026 at 12:40 PM, Resident #52 was lying in bed still in the hospital gown from earlier in the day. She stated the hospital gown was depressing, but she was used to it.During observation and interview on 06/24/2026 at 11:41 AM, Resident #52 was lying in bed still in the same hospital gown from the day before. Observation in her closet revealed she had several t-shirts and pairs of pants. She stated she had not received assistance with a change of clothing and had not received a shower.Observation on 06/24/2026 at 1:47 PM revealed Resident #52 was still in the same hospital gown.Observation on 06/25/2026 at 1:54 PM revealed Resident #52 was still in the same hospital gown. Her hair was greasy and there was an odor of old skin oils and faint urine in her room. During an interview on 06/25/2026 at 2:04 PM, CNA G stated Resident #52 refused showers sometimes and they only offered her one bath per week. She stated she forgot to fill out shower sheets sometimes. She stated she worked PRN, so she was not always on the hall. She stated she did not give Resident #52 a shower that day (06/25/2026). She stated she did not have a reason why she did not give the bed bath. She stated Resident #52 got very combative when they tried to dress her and would start hitting them, so they did not really try. She stated Resident #13 did not typically refuse showers. She stated she did not know why he had so few showers documented over the previous months, because she did not always work. She stated she gave him a shower the day before (06/24/2026) but did not provide nail care because somebody else was supposed to do that. She stated she was not sure who was supposed to do that, but she thought it was scheduled for Sundays, and she did not work Sundays.During an interview on 06/25/2026 at 1:58 PM, CNA J stated she was working the 500-hall that day but did not usually. She stated she did not know who refused showers or baths. During an interview on 06/25/2026 at 1:11 PM, LVN C stated Resident #52 refused bathing, but she would usually agree to it if he spoke to her. He stated he relied on the CNAs to let him know if she was refusing. He stated the CNAs should have documented on the shower sheets and the POC and come to him to report if a resident refused an ADL. He stated he did not realize Resident #52 had not been out of a hospital gown all week. He stated that was the CNA's responsibility, but if they had come to him, he could have helped her feel more comfortable getting changed. LVN C stated that Resident #13 refused nail care and tried to take care of his nails himself, but he did not refuse showers, and LVN C was confused about why Resident #13 would only have two showers documented in a month and a half. During an interview on 06/25/2026 at 2:25 PM, the WCN stated she was responsible for overseeing the bathing program for residents. She stated the CNAs would occasionally let her know when people refuse their showers, but she did not know that Resident #13 and Resident #52 were refusing or not receiving baths. She stated she monitored for compliance with the bathing program by reviewing shower sheets, but there were certainly some gaps in the system that she had not corrected, yet. She stated the potential negative impact of residents not receiving assistance with bathing was skin problems and worsening wounds. During an interview on 06/25/2026 at 3:24 PM, the DON stated bathing should have been offered three times per week or according to resident preference. She stated the procedure should have been for CNAs to check the schedules, complete the bathing task, and then document in the POC and the paper shower sheet, and then communicate verbally with the charge nurse about any new skin issues or refusals. She stated she monitored for compliance by reviewing shower sheets in morning meeting and pulling reports from the POC as well as in-servicing staff. She stated a potential negative impact of residents not receiving assistance with ADLs was skin issues or infections. During an interview on 06/25/2026 at 4:01 PM, the ADM stated the person responsible for ensuring nail care and bathing was offered was the WCN, and she was supposed to ensure bathing was being done. She stated if she noticed bathing was not being done, she went to the DON and ADON to investigate why they were not being done and the root cause. She stated she monitored for compliance by discussing ADLs in the morning meeting. She stated the potential negative impact of the resident not being offered bathing, dressing, and nail care was they might not get baths. Review of facility policy dated 01/2026 and titled Activities of Daily Living (ADLs) reflected the following: PurposeTo promote dignity, independence, and quality of life by providing individualized support with Activities of Daily Living (ADLs) and ensuring compliance with federal, state, and local regulations.PolicyThis policy establishes guidelines for assessing, planning, documenting, and assisting residents with Activities of Daily Living (ADLs). The facility will ensure all residents receive the necessary services and support to maintain or improve their ability to perform ADLs, unless the resident(s)' clinical condition makes it nonviable.ProcedureI. Definition: Activities of Daily Living (ADLs) include:a. Bathingb. Dressingc. Groomingd. Toiletinge. Transferringf. Eatingg. MobilityV. Staff will provide assistance, cueing, or supervision with ADLs as identified in the care plan.VI. Adaptive equipment and assistive devices will be provided when appropriate.VII. ADL performance and staff assistance levels will be documented in the resident's medical record, including changes in the resident's ability or refusal to participate in the ADL task.VIII. Residents have the right to refuse care, and refusals will be documented and addressed as necessary.IX. Direct care staff will be trained in ADL assistance techniques, resident rights, infection control and documentation procedures upon hire, annually, and as needed. Review of facility policy dated 01/2026 and titled Grooming and Care of the Fingernails and Toenails reflected the following: PurposeTo provide nail care to maintain hygiene, prevent complications, and ensure the safety and comfort of residents. Review of facility policy dated 01/2026 and titled Showering a Resident reflected the following: PurposeA shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors.PolicyResidents are offered a shower at a minimum of once weekly and given per resident request.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 13 residents (Residents #16, #22, #31, #8, #67, and #72) reviewed for care plans. The facility failed to ensure that Residents #16, #22, #31, #8, #67, and #72 had care planning for activity preferences. This failure placed residents at risk of not having recreational interventions in their care.Findings included: Review of the undated face sheet for Resident #16 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included transient cerebral ischemic attacks (temporary blockage of blood flow to the brain), malnutrition, and atherosclerosis (buildup of hard fat in the arteries). Review of the admission MDS assessment for Resident #16 dated 06/13/2026 reflected he did not participate in the BIMS assessment for cognition. The staff assessment reflected he had a memory problem, and his cognition was moderately impaired. The assessment for activity preferences reflected it was somewhat important to him to go outside when the weather was good and to participate in religious services. Review of the care plan for Resident #16 dated 06/12/2026 reflected the following: FOCUSRisk for depressionGOALResident will be free of signs/symptoms of depressionINTERVENTIONSObserve resident for any signs/symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious, or health related complaints, and tearfulness.There was no care planning for activity preferences. Review of the undated face sheet for Resident #22 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included repeated falls, moderate dementia (decline in function and memory severe enough to interfere with living), adjustment disorder with depressed mood (excessive emotional responses to identifiable stressors), need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, muscle wasting and atrophy, and muscle weakness. Review of the admission MDS assessment for Resident #22 dated 01/20/2026 reflected a BIMS score of 14, indicating intact cognition. The assessment for activity preferences included no activities that were important to her. Review of the care plan for Resident #22 dated 01/30/2026 reflected the following: FOCUSThe resident is an elopement risk/wanderer (WANDERER) r/t Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly.INTERVENTIONS-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [nothing additional here]There was no care planning for activity preferences. Review of the undated face sheet for Resident #31 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (death of brain tissue due to lack of blood flow to the brain), memory deficit following other cerebrovascular disease (memory deficit following cerebral infarction), muscle weakness, abnormalities of gait and mobility, cognitive communication deficit (trouble communicating due to cognitive impairment), lack of coordination, Alzheimer's disease (dementia caused by a buildup of proteins in the brain), major depressive disorder, and anxiety disorder. Review of the admission MDS assessment for Resident #31 dated 03/27/2026 reflected a BIMS score of 03, indicating severely impaired cognition. The assessment for activity preferences reflected it was very important to her to do things with groups of people and to do her favorite activities and somewhat important to her to have books, magazines or newspapers to read. Review of the care plan for Resident #31 dated 06/17/2026 reflected the following: FOCUSThe resident is an elopement risk/wanderer (SPECIFY) r/t Disoriented to place, Impaired safety awareness,Resident wanders aimlessly, significantly intrudes on the privacy or activitiesINTERVENTIONSDistract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [nothing additional here].There was no care planning for activity preferences. Review of the undated face sheet for Resident #8 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cognitive communication deficit (trouble communicating due to cognitive impairment), muscle weakness, muscle, wasting and atrophy, and mild cognitive impairment. Review of the annual MDS assessment for Resident #8 dated 09/01/2025 reflected a BIMS score of 10, indicating moderate cognitive impairment. The assessment for activity preferences included no activities that were important to him. Review of the care plan for Resident #8 dated 06/18/2026 reflected the following: FOCUSThe resident has impaired cognitive function/dementia or impaired thought processes r/t Impaired decision making.GOALThe resident will be able to communicate basic needs on a daily basis through the review date.There was no care planning for activity preferences. Review of the undated face sheet for Resident #67 reflected a [AGE] year-old admitted to the facility on [DATE]. His diagnoses included cerebral infarction (death of brain tissue due to lack of blood flow to the brain), hypertensive heart disease (condition in which long-term high blood pressure causes damage to the heart), mood disorder, abnormalities of gait and mobility, cognitive communication deficit (trouble communicating due to cognitive impairment), lack of coordination, and muscle weakness. Review of the admission MDS assessment for Resident #67 dated 11/17/2025 reflected a BIMS score of 13, indicating intact cognition. The assessment for activity preferences reflected it was somewhat important to him to keep up with the news. Review of the care plan for Resident #67 dated 04/08/2026 reflected the following: FOCUSThe resident has a mood problemGOALThe resident will have improved mood state (SPECIFY: happier, calmer appearance, no s/sx of depression, anxiety orsadness) through the review date.INTERVENTIONS-Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills.-Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols.There was no care planning for activity preferences. Review of the undated face sheet for Resident #72 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included age-related cognitive decline, muscle wasting and atrophy, lack of coordination, muscle weakness, repeated falls, cognitive communication deficit (trouble communicating due to cognitive impairment), and history of falling. Review of the annual MDS assessment for Resident #72 dated 06/11/2026 reflected she could not participate in the BIMS assessment for cognitive function. The staff assessment reflected she had memory problems and her cognition was severely impaired. The assessment for activity preferences reflected it was very important to her to go outside when the weather was good and somewhat important to have books, magazines, and newspapers to read, to listen to music she liked, to do her favorite activities, and to spend time with groups of people. Review of the care plan for Resident #72 dated 04/23/2026 reflected the following: FOCUSThe resident has a psychosocial well-being problem.GOALThe resident will demonstrate adjustment to nursing home placement by/through review dateINTERVENTIONEncourage participation from resident who depends on others to make own decisions.There was no care planning for activity preferences. Review of the activity calendar reflected the following:06/23/20269:30 Outside Yoga10:00 am Watergun Painting11:00 am Communion1:30 pm [NAME] Snowglobes3:00 PM Bingo!06/24/20269:30 am Outside Stretching10:00 am Bible study11:00 AM Summer Wordsearch1:30 PM Woman's Tea Party06/25/20269:30 am Outside Yoga10:30 am Coffee & Chat11:00 AM Summer Coloring2:00 PM Ice Cream3:00 PM Loteria! During observation and an interview on 06/23/2026 at 9:24 AM, Resident #8 stated he had not been at the facility for very long, and they did not give him much to do, but he mostly watched television. He was lying in his bed with his remote control and a bedside table over him. He stated he did not know the AD and no staff had asked him about activities. He stated his FM visited frequently. He stated he liked to chat with intelligent people, but he was not interested in group activities. Observation on 06/23/2026 at 11:27 AM, Resident #31 was walking around the facility with her walker and talking about needing to go find her car. She stated she was not working there and needed to find where her car was parked. She was seen walking from door to door looking out the windows to see if she could find her car. She had a wander guard on which did alarm when she got close to the front door. Observation on 06/25/2026 at 9:13 AM to 12:00 PM revealed Residents #67, #72, #22, and #16 were in their wheelchairs in the central television room. Observation from 9:00 AM to 10:00 AM revealed the AD did not enter the television room to invite any residents to an activity. An interview was attempted with all four residents, and none of them responded with anything more than eye contact. During an interview on 06/25/2026 at 2:38 PM, the AD stated she was responsible for the care plans but could not elaborate. She stated they all worked as a team and reached out to her and that was typically how they did things. During an interview on 06/25/2026 at 3:24 PM, the DON stated the MDSN was responsible for care plans. She stated they held regular care plan meetings and discussed changes to the plans of care during morning meeting. During an interview on 06/25/2026 at 3:43 PM, the MDSN stated this was her first MDS position, and she was learning since the new management company took over that she had been doing things for the old company incorrectly since 12/2025. She stated they were still working out the best way to ensure care plans were updated and comprehensive. She stated she did not know who was responsible for entering care planning for activity preferences, but she thought it was probably the AD. She stated she would have to ask how not having care planning for activities might negatively impact residents. She stated it was important to have care plans in place to make sure they had everything done that could be done for the residents. During an interview on 06/25/2026 at 4:01 PM, the ADM stated the care plans were updated when the AD entered the information into the daily assessment tool. She stated the AD was responsible for entering in the care plan information for activity preferences, but the MDSN, or somebody, was then responsible for adding the information to the comprehensive care plan. She stated the person who was supposed to do it was the AD, but the person who actually did it was the MDSN. She stated she monitored for compliance by conducting care plan audits. She stated she had not noticed that several residents did not have care planning for activity preferences during her audits. She stated a potential negative impact of residents having no care planning for activity preferences was staff would not be aware of what activities they liked or did not like. Review of facility policy dated 06/2020 and titled Activities Program reflected the following: II. Care [NAME]. After completion of the initial Activity Assessment and the MDS, an individualized CarePlan will be developed and implemented for each resident.B. The Care Plan should be reviewed with the resident and/or the resident's family to ensurethat the resident approves of and understands the Plan.C. The resident's activity plan will be reviewed and up-dated at least quarterly and with anychange of condition.D. As needed, activities are tailored to meet the needs of residents with cognitiveimpairment or other special needs.E. Once the IDT has identified relevant activities for the resident, the resident is given anopportunity to choose when, where, and how he or she will participate in activities andsocial events. If the resident prefers not to attend organized group programs, room visitswill be provided based on the assessed interests of the resident. Review of facility policy dated 10/24/2022 and titled Care Planning reflected the following: PurposeTo ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.PolicyThe Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines.The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.ProcedureVIII. A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative. B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment;XI. The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed Nurse who has responsibility for the resident; D. The Dietary Supervisor and/or registered dietician; E. Social Service staff member responsible for the resident; F. The Activity Director; G. Therapists as applicable; H. Consultants (as appropriate); I. The Director of Nursing (as applicable); J. Certified Nursing Assistants and/or RNAs responsible for the resident's care; K. The resident and/or his/her family or legal representative; i. If the resident and his/her resident representative participation is determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #5, Resident #41, Resident #53, and Resident 76) reviewed for infection control. RN A failed to cleanse the blood pressure cuff after use on resident #53 and prior to use on Resident #41 during an observation of medication pass on 06/24/2026 at 8:48 a.m. The facility failed to ensure CNA D was following the hand hygiene policy procedures while going in and out of Resident #5's room on 06/24/2026 The facility failed to ensure CNA F was following infection control protocol during providing incontinent care for Resident #76 on 06/24/2026 These deficient practices had the potential to place residents at risk for cross contamination and the spread of infection.Findings included: Record review of Resident #41's Annual MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #41 had diagnosis of chronic obstructive pulmonary disease (an ongoing lung condition making it difficult to breath), atrial fibrillation (an irregular heart rate), peripheral vascular disease (a narrowing of the veins and arteries obstructing blood flow), and muscle weakness. She had a BIMS score of 15 indicating she was cognitively intact. Resident #41 required set up or clean up assistance for dressing, grooming, and personal hygiene. Record review of Resident #53's Quarterly MDS dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnosis of Alzheimer's disease (a brain disease that slowly destroys memory), type 2 diabetes mellitus (elevated blood sugar), moderate protein calorie malnutrition, and hyperlipidemia (high cholesterol. She had a BIMS score of 5, indicating her cognition was severely impaired. Resident #53 required set up or clean up assistance for dressing, grooming, and personal hygiene. In an observation on 06/24/2026 at 8:37 a.m., RN A checked Resident #53's blood pressure with an electronic wrist blood pressure cuff prior to administration of medications. RN did not clean the cuff after use. At 8:48 am, using same unclean blood pressure cuff, RN A checked Resident #41's blood pressure and then administered medications. RN A failed to clean the blood pressure cuff before or after use. In an interview on 06/24/2026 at 9:33 a.m., RN A stated she should have cleaned the blood pressure cuff between Resident #53 and Resident #41 with her sanitary wipes. The sanitary wipes were available and kept in the bottom drawer of her medication cart. She stated she had just forgotten to clean the blood pressure cuff between residents. RN A stated she had been educated by the DON through in-services on infections control and cleaning of reusable medical equipment. She stated negative effects for not cleaning the blood pressure cuff included spreading germs from residents to residents that could lead to infection. In an interview on 06/25/2026 at 12:29 p.m., the DON stated nurses were expected to clean the blood pressure cuff between each resident and after use. The nurses were trained on infection control and cleaning reusable medical equipment was part of that training. The DON monitors infection control practices by having routine skills checked off quarterly, annually, and as needed. The skills check off is also part of the nursing visual competency evaluations that are completed annually which include cleaning of reusable medical equipment. Negative effects for residents for not cleaning the blood pressure cuffs between uses includes transmission of infections between residents. Record review of Resident #5's undated face sheet reflected a [AGE] year-old female admitted to the facility 05/29/2026. Herdiagnoses included displaced trimalleolar (all three major bone structures supporting the ankle joint -the lateral malleolus, medial malleolus, and posterior malleolus are broken and have shifted out of their normal alignment) fracture of right lower leg, subsequent encounter for closed fracture with routine healing, age-related osteoporosis (chronic bone disease that causes bones to become porous, brittle, and highly susceptible to fractures from minor falls or daily activities) with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing, polyosteoarthritis unspecified (degenerative joint disease that affects multiple joints, typically five or more simultaneously. It involves the progressive breakdown of protective cartilage and underlying bone, resulting in widespread joint pain, stiffness, and reduced mobility, where the specific joints are not explicitly detailed). Record review of Resident #5's comprehensive MDS assessment, dated 06/01/2026, reflected a BIMS score of 14 which indicated intact cognition. The MDS reflected Resident #5 was dependent on helper for toileting hygiene. Record review of Resident #5's undated care plan reflected a Focus which included: Enhanced Barrier Precautions r/t Wounds. Date initiated -06/23/2026. This problem area included the following interventions: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting, assistance, and/or caring for indwelling medical devices like central lines, feeding tube, tracheostomy/ventilator. Date initiated: 06/23/2026 Staff to follow standard precautions. -Date initiated: 06/23/2026. Resident # 5's care plan also reflected a Focus which included: The resident is at risk of infection of the right hip ORIF (Open Reduction and Internal Fixation-a major orthopedic surgical procedure used to repair severe or displaced bone fractures. -Date initiated: 05/31/2026.This problem area included the following interventions: Administer antibiotic as per MD orders. Maintain universal precautions when providing resident care. -Date initiated: 05/31/2026 Observation on 06/23/2026 at 9:24 a.m. revealed CNA D went to Resident #5's room without performing hand hygiene. CNA D did not sanitize her hands when she came out of Resident #5's room and went down the hallway. Further observation revealed CNA D returned to Resident #5's room holding a box of cereal; she did not sanitize her hands before entering the room. CNA D placed the box of cereal on the resident's overbed table and then she lowered that table and pushed it closer to the resident. CNA D came out of Resident #5's room and sanitized her hands. In an interview on 06/24/2026 at 2:21 p.m. with CNA D, she stated that she has been trained in infection control. She stated that her last infection control in-service training was about month ago. That training covered hand hygiene, using PPEs when providing direct care to the residents in EBP rooms. Staff were to sanitize hands before entering residents' rooms and right after exiting the rooms. CNA D stated that she forgot to sanitize her hands when she went to Resident #5's room, and she did not sanitize her hands after she left Resident #5's room to bring resident a box of cereal. CNA D stated that she did not sanitize her hands before entering Resident #5's room with a box of cereal. She stated that not sanitizing hands before entering the residents' rooms and after exiting the rooms, could potentially cause residents infections. In an interview on 06/25/2026 at 10:48 am with LVN D, he stated he had been working in the facility for 5 years. LVN D stated he was provided with infection control in service training every month. These in service training covered hand hygiene, wiping down medical equipment, changing gloves between ADLs, and what PPEs to be used when going to the residents' rooms on EBP. He stated that staff was to sanitize hands before and after going to the residents' rooms. He stated that not following hand hygiene by staff could potentially cause cross contamination, residents could get infection and get sick. LVN D stated it was nurses' responsibility to ensure staff were sanitizing their hands when they were going in and out of the residents' rooms. In an interview on 06/25/2026 at 2:03 p.m. with CNA E, she stated she was working in the facility for 4 months. She stated she had been trained in infection control during the job onboarding, and she had monthly infection control in-services. She stated that the infection control in-service covered hand hygiene procedures, use of PPEs, and when it used. She stated that staff must sanitize hands before going into the residents' rooms and right after coming out of the residents' rooms. If staff were providing direct care, staff were to wash their hands with soap and water and put on gloves. CNA E stated that not following hand hygiene procedures, may spread infection from one resident to another. In an interview on 06/25/2026 at 3:33 p.m. with the DON, she stated she had been working in the facility since April of that year. She stated her last infection control in-service was last week, it covered use of PPEs and why it was used, hand washing, hand sanitizing. She stated that staff were expected to sanitize their hands before going into residents' rooms and after exciting the rooms, and staff was expected to be washing their hands after visiting 3 residents' rooms. She stated hand hygiene was important to prevent transmission of infection; to prevent potential outbreaks of infection. She stated that all nurse management, including administration, were to monitor staff for following hand hygiene procedures. In an interview on 06/25/2026 at 3:51 PM with the ADM she stated that she had infection control in-service training every month. The ADM stated that monthly infection control training covered proper hand washing, wearing PPEs, gowning up if care was provided to the residents in EBP rooms, properly disrobing. She stated that staff were expected to follow infection control procedures because residents were at risk of potentially getting infections which could require taking them antibiotics. The ADM stated hand sanitizing was not required if staff were not touching anything in the residents' rooms. She stated every hall in the facility had ambassadors to oversee if staff were following the proper infection control protocols. 3. Record review of Resident #76's undated face sheet reflected an 81-year male with admission date 06/08/2026. Resident #76 had diagnoses that included end stage renal disease (final, irreversible stage of chronic kidney disease), renal osteodystrophy is a serious bone disease that develops as a complication of chronic kidney disease), cognitive communication deficit (communication difficulty caused by disrupted brain function rather than a primary language disorder) Record review of Resident #76's comprehensive MDS assessment, dated 06/08/2026 reflected no BIMS score was indicated. Record review of Resident #76's undated care plan reflected Enhanced Barrier Precautions r/t Foley catheter and dialysis. Date initiated -06/23/2026. This problem area included the following interventions: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting, assistance, and/or caring for indwelling medical devices like central lines, feeding tube, tracheostomy/ventilator. Date initiated: -06/23/2026 Staff to follow standard precautions. -Date initiated: 06/23/2026.The care plan also reflected a Focus which included: The Resident #76 has renal failure r/t end stage disease Date initiated: 06/09/2026. This problem area included the following intervention: Assist resident with ADLs and ambulation as needed Date initiated: 06/09/2026. During an observation of incontinent care on 04/22/2026 at 9:41 a.m. CNA F and ADON D revealed, as they were prepared to perform perineal care for Resident #76, they both put on PPE before entering the high-risk Resident #76's room. Resident #76 was lying supine (on his back) in bed. CNA F explained her intention to perform peri care; resident verbalized a response. CNA F and ADON D washed their hands, then came out and donned (putting on an article of clothing, an accessory, or a piece of equipment) clean gloves. CNA F performed incontinent care using one cleaning wipe for one swipe, front to back. CNA E and ADON D assisted Resident #76 to turn to his left side, where the resident's buttocks were exposed. Resident #76 had a small bowel movement. CNA F donned clean gloves after sanitizing her hands and pulled out a one clean wipe. She swiped Resident #76's right side of buttocks and using the same wipe CNA F applied the wipe on Resident #76's fecal matter and removed it. She removed her soiled gloves, performed hand hygiene and donned clean gloves. CNA F and ADON D assisted Resident #76 with positioning him on his back and applied a clean brief. CNA F changed gloves and gathered the trash. CNA F and ADON D removed their gloves and washed hands. In an interview on 06/24/2026 at 12:45 p.m. with ADON D, she stated that she was a nurse educator. She stated she observed that CNA F did not thoroughly clean Resident #76's buttocks and anal areas before applying a new brief. She stated she was assisting CNA F with repositioning Resident #76 during the peri care. She stated she was to start incontinent and peri care in -service training for staff. ADON D stated that not following proper perineal care protocol could potentially cause residents of developing skin infections. In an interview on 06/25/2026 at 8:24 AM with Resident #76's FM she stated that she wanted her brother to be cleaned properly. She stated, I want it to be done right. I want them to clean my brother thoroughly. He recently had a UTI and he is going for dialysis three times a week so any skin infection can affect his health negatively. In an interview on 06/25/2026 at 2:45 p.m. with CNA F, she stated that she had been working in the facility for 3.5 years. She stated that that she was very nervous while providing peri care to Resident #76. She stated she should have thoroughly cleaned resident's anal area to remove feces using one wipe for one swipe and both sides of resident's buttocks were to be cleaned as well. CNA F stated if incontinent care was not provided thoroughly, it could have irritated the skin and potentially causing skin breakdown and infection. In an interview on 06/25/2026 at 3:33 p.m. with the DON, she stated staff were expected to follow proper peri care and infection control protocols. She stated that that staff was expected to use as many wipes as it takes to thoroughly clean residents during perineal care. DON stated that residents could get skin irritation, skin breakdowns and skin infections if staff did not follow the perineal care procedures and thoroughly clean residents' skin during perineal care. In an interview on 06/25/2026 at 3:51 PM with the ADM, she stated that staff were expected to completely clean residents' skin while providing perineal care to prevent infection, UTIs, and skin breakdowns. She stated that staff were provided with multiple steps for providing proper perineal care to the residents during orientation to the job, during staff competencies and skill check offs. Record review of the facility's policy titled Disinfection of Resident-Care Equipment dated October 2022 reflected Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infections. Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. Multiple-resident use equipment shall be cleaned and disinfected after each use. Record review of the facility's Hand hygiene Policy dated 06/2020 reflected: Purpose- To ensure that all individuals use appropriate hand hygiene while at the Facility.Policy- The Facility considers hand hygiene the primary means to prevent the spread of infections.B. Alcohol-based hand hygiene products can and should be used to decontaminate hands:i. Immediately upon entering a resident occupied area (single or multiple bedrooms,procedure or treatment room) regardless of glove use.ii. Immediately upon exiting a resident occupied area (e.g., before exiting into acommon area such as a corridor) regardless of glove use.iii. Before moving from one resident to another in a multiple-bed room or procedurearea regardless of glove use. Record review of the facility's document titled, Hand hygiene policy revised on 06/2020 reflected: Purpose-To maintain cleanliness of the genital area, to reduce odor, and to prevent infection and skin breakdown.Policy-Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need.Procedure:.VI. Wash the pubic area.[NAME]. Turn resident to side.VIII. Wash, rinse and dry buttocks and peri-anal area without contaminating perinea.

Based on observation, interviews, and reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for Resident #1.The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen, so the resident's information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm, and decreased quality of life. Findings included:Observation on 12/06/2025 at 10:22 PM, during med pass on the 500-hall, revealed that the tablet on the medication cart was open, showing a resident's information on screen. The LVN was in a resident's room for approximately 3 minutes. The LVN then returned to the computer and locked the screen. In an interview on 12/06/2025 at 10:28 am, the LVN stated that the laptop should not be left open with residents' information on it. The LVN stated that was a HIPAA violation. The LVN stated that anyone walking by would be able to see the residents' medical information if the laptop was open. The LVN stated she had not seen any co-workers leaving their laptops open with resident information on the screen. The LVN stated if she saw a laptop open showing resident information, then she closed the laptop and reminded the person that they needed to close the laptop. LVN stated she had been in-serviced on resident rights and privacy.In an interview on 12/06/2025 at 12:30 am, RN A stated that when she walks away from the computer, it is supposed to be locked so that nobody can see the screen and the residents' information. RN A stated that residents' information should never be left open for people to see. RN A stated that if the screen is left open, it is a HIPAA violation and a violation of a resident's privacy rights. RN A stated she is an agency nurse and is there working under contract. RN A stated that when she was hired, all her in-service training was in the packet, and she was trained on HIPAA and resident rights. In an interview on 12/06/2025 at 12:30 am, RN B stated that when she left the computer, she would lock the screen, then give medications to the resident. RN B stated that is a HIPAA and resident's privacy rights violation to leave the residents information visible on the computer. RN B said she had in-service training on HIPAA and resident rights about 4 weeks ago. RN B said that if the screen is left open, someone passing by could get the residents information. In an interview on 6/19/2025 at 3:18 p.m., the ADON stated that staff had been trained on HIPAA laws. The ADON stated that when staff walk away from the medication cart, the laptop screen should be locked or minimized. He stated that if the screen is left open, then someone passing by could get the residents' information. The ADON said he has never seen any staff leave the laptop open with the residents' information on the screen. The ADON stated if she sees a staff leave the laptop open, then she would shut it, and talk to the staff. ADON stated the all the staff would get in-serviced training on resident rights and privacy if residents' information is on the screen visible to see.Record Review of the facility's undated Electronic Medical Records policy Reflected: Only authorized persons who have been issued a password and user code will be permitted access to the electronic medical records system. Permission to access medical records data is based on the need to access the data. Restrictions permit staff only to access data that must be viewed or modified by them. The Administrator and Director of Nursing Services maintain a listing of each user code. Such listing is confidential and secured.

Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 9 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility failed to ensure CNA D communicated respectfully to Resident #1 and #2 when removing their food trays and answering call lights. This failure could place residents at risk of feeling not being valued or cause psychosocial harm and emotional distress. Findings included:Findings included:Record review of Resident #1's face sheet dated 11/25/2025 revealed Resident #1 was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes breathing difficulties due to narrowed airways and damaged air sacs), type 2 Diabetes Mellitus (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels), rheumatoid arthritis (a chronic autoimmune disease causing joint inflammation, pain, swelling, and stiffness, most often affecting joints on both sides of the body like the fingers, wrists, and knees), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and a loss of interest or pleasure in daily activities, affecting an individual's ability to function), hypertensive heat disease (a heart problem caused by long-standing high blood pressure).Record review of Resident #1's admission MDS Assessment, dated 10/01/2025, reflected a BIMS score of 15 which is indicative of intact cognition. Record Review of Resident #1's care plan, dated 9/29/2025, revealed Resident #1 is on hospice with goal of receiving appropriate care and services and remain comfortable. The resident had depression and goal to remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. Interventions were identified in care plan: administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #2's face sheet dated 11/25/2025, indicated her admission on [DATE] with diagnosis of chronic obstructive pulmonary disease (a progressive lung disease that causes breathing difficulties due to narrowed airways and damaged air sacs), gastro-esophageal reflux disease (a chronic digestive disorder where stomach acid or contents leak back into the esophagus, causing symptoms like heartburn and regurgitation), insomnia (a sleep disorder characterized by difficulty falling or staying asleep, leading to daytime fatigue and irritability), and major depressive disorder (a mental health condition characterized by persistent feelings of sadness and a loss of interest or pleasure in daily activities, affecting an individual's ability to function). Record Review of Resident #2's care plan, dated 11/24/2025, revealed Resident #2 is on hospice with goal of receiving appropriate care and services and remain comfortable. The resident had a diagnosis of depression and a goal to remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. The following interventions were identified in the care plan for Resident #2: Administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #2's admission MDS Assessment, dated 11/17/2025, reflected a BIMS score of 15 indicated intact cognition. During an interview on 11/25/2025 at 11:36 a.m., Resident #1 revealed that CNA D is acting like she is the boss around here and not very patient with her. She stated that CNA D took her coffee cups and milk carton from her table without asking her first. She stated that she told RN A regarding CNA D's rude behavior several times and specifically on 11/25/2025.During an interview on 11/25/2025 at 12:05pm, Resident #2 stated that CNA D behaved like she did not want to help her. When Resident #2 asked CNA D for pain medication last night, she answered the call light stating, what do you want now?, I told you to be patient. She stated that she did not want CNA D to take care of her anymore because she was not patient and was rude to her. She stated she tried to talk to CNA D nicely and she could not understand why she treated her that way. She stated that the behavior of CNA made her feel sad. She stated she told RN A without recalling exact dates about CNA D and did not report her to anybody else. During interview on 11/25/25 at 2:35 p.m. with CNA D she said she worked with nursing staffing agency sending her to different facilities and on as needed bases she worked at this facility since 2020. She stated that she worked on hall 100 for a while on 2-10 p.m. shifts. She stated that she always asked residents if they were done eating before taking their trays and coffee cup if they were dirty to clean resident's tables. She took two cups of coffee from Resident #1's table because she had too many cups on her table. She stated that she did not remember when she had her ANE training. She stated that she knows different types of abuse, neglect and exploitation. She gave an example of verbal abuse when staff talked to residents with disrespect and using offensive words toward them. She said that any signs of ANE should be reported to the administrator immediately. She stated that Resident #1 was using offensive words towards her several times, and she was always professional towards her or any other residents she worked with. During an interview on 11/25/2025 at 11:58 a.m. social worker stated she had worked at this facility for seven months. She stated that she did not hear any complaints about abuse, neglect or exploitation from residents or staff. She had ANE training in September this year where she learned what abuse is, signs of abuse and reporting immediately to administrator. She stated that when she was interviewing residents on 100 hall, Resident #2 today, 11/25/2025, she told her that CNA D was impatient with her and impolite. During an interview on 11/25/2025 at 1:40pm, RN A revealed that Resident #1 did not complain to her about somebody physically abusing her. Resident #1 told her on multiple occasions that CNA D was acting like she was a boss around her, taking her tray without asking her. RN A stated that she talked to CNA D last Monday regarding her approach to Resident #1 and asked to modify it. She stated that she brought Resident #1's complaints to the morning clinical meeting with the DON on 11/25/2025. She stated that DON told her she will look into this complaint. She said that one more resident complained to her regarding CNA D's attitude. She stated that she had ANE training a month ago and periodically through the year. She stated that any signs of abuse, neglect and exploitation should be reported immediately to Administrator. During interview on 11/25/2025 at 1:47 p.m., with CNA B, she stated that she had ANE training last month. She learned the different types of abuse and being mindful while transferring residents explaining what they were doing before providing care. Signs of abuse when residents looked scared of staff. She said if she noticed something unusual in residents' behavior, ask this resident, and report it to a charge nurse. Notify the abuse coordinator, which is the administrator. During interview on 11/25/2025 at 1:56 p.m., LVN C revealed that he did not recall Resident #1 reporting any ANE signs and symptoms. He stated that he had ANE in service in last three months, where he learned to report any suspected ANE to the administrator immediately. During an interview on 11/25/2025 at 5:12 p.m., the DON said she was trained on ANE sometimes in September 2025 and stated any signs of abuse, neglect and exploitation including suspected ANE should be reported to the administrator, who is abuse coordinator, immediately. She stated that verbal abuse including yelling at the patient, demeaning them, bossing around, providing care without explanation would be considered abuse. She stated that RN A did not talk to her regarding complaint of Resident 1 during the morning meeting. RN A came at 11:30 a.m. to her office doorway and stated that Resident 1 had issues with her tray being taken away without specifically pointing to CNA D's actions. She stated that she was going to investigate that report later that day. She stated that she never heard any ANE allegations from any residents or staff regarding CNA D before. During interview on 11/25/2025 at 5:27 p.m., the administrator revealed that she worked as the administrator at this facility for 1 year and had ANE training in October 2025 including ANE definitions, types, and who to report and conduct investigations. If suspected ANE, it should be reported to her within 2 hrs. Examples of verbal abuse would be calling names, yelling, perception of tone of voice, how they were spoken to. She stated that she considered CNA D one of her best CNAs and intended to promote her to staffing coordinator. She stated that she suspended CNA D immediately after learning of allegations from the surveyor and reported those allegations to the HHSC and started investigation. The administrator stated she never had any complaints regarding CNA D before and even considered her for the staffing coordinator position. CNA D sent her an e-mail regarding an incident last night, 11/24/2025, describing the situation when she took a tray from Resident #1's room and Resident #1 got upset.The undated Policy titled Abuse Prevention and Investigation indicated verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Under #9 of this policy: All employees are required to report any observed, known, or suspected instances of resident abuse or neglect to their supervisors, the Administrator or the Director of Nursing. Any report, grievance, or complaint that indicates residents abuse or the potential for resident abuse will be reported to the Administrator and investigated as needed in order to protect all residents. The timeframe required for reporting (immediately but not later than 2 hours after forming suspicion requirements for reporting). Record Reviews of facility's grievances in last three months did not reveal any ANE grievances with CNA D.

Based on interviews and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 4 residents reviewed for physician notification, in that: The facility failed to notify Resident #1's provider of medication refusals for insulin from 06/01/2025 through 06/19/2025 and Pioglitazone (for type 2 diabetes) on 06/01/2025, 06/07/2025, 06/08/2025, 06/14/2025, and 06/15/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services. Findings include: Review of Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure), cerebral infarction (a condition where a part of the brain is damaged due to insufficient blood supply), type 2 diabetes mellitus (chronic condition where the body either doesn't produce enough insulin leading to elevated blood sugar), major depressive disorder, and muscle weakness. Review of Resident #1's care plan dated 03/04/2025 reflected Resident #1 had diabetes mellitus with goal to have no signs or symptoms of hyperglycemia (too much glucose in the blood) . Interventions reflected to administer diabetes medication as ordered by doctor and monitor/document effectiveness. Intervention also included to educate regarding medications and importance of compliance and have Resident #1 verbalize understanding. Review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident #1's physician orders reflected an order for insulin lispro injection solution before meals and at bed time with a start date of 02/26/2025 for type 2 diabetes. Further review reflected Resident #1 had an order for pioglitazone tablet one time a day for type 2 diabetes with a start date of 04/04/2025. Review of Resident #1's MAR for June 1, 2025 to June 19, 2025 reflected Resident #1 refused his pioglitazone on 06/1/2025, 06/07/2025, 06/08/2025, 06/14/2025, and 06/15/2025. Further review reflected Resident #1 refused his insulin lispro injection three times a day from 06/01/2025 to 06/19/2025. Resident #1's blood sugar was taken three times a day from 06/01/2025 to 06/19/2025 with low of 110 mg/dL and high of 307 mg/dL. Review reflected if greater than 399 mg/dL notify provider. Review of Resident #1's nursing progress notes from 06/01/2025 to 06/19/2025 reflected the NP/MD was not notified of Resident #1's medication refusals for June 2025. Further review reflected Resident #1 was not provided education regarding medication refusals for June 2025. Review of Resident #1's social services quarterly note dated 06/03/2025 reflected Resident #1 wished to return home but appeared to lack safety awareness and full insight to situation and care needs. During an interview on 06/19/2025 at 10:14 AM, Resident #1 stated that staff checked his blood sugar all the time. Resident #1 stated that he refused his insulin and told the staff that he did not want it because he does not want to become dependent on it. Resident #1 stated that he has not felt ill due to his blood sugar levels and has not had to go to the hospital since he admitted to the facility. Resident #1 stated that the staff tell him what his blood sugar is and if it was too high he would take the insulin. During an interview on 06/19/2025 at 1:07 PM, LVN A stated that residents had the right to refuse medications. LVN A stated if a resident refused medication their provider should have been notified as well as their family. LVN A stated that the resident should have been educated as to what the medication was and why it was important to take. LVN A stated if a resident refused insulin it was important to let the resident know why they were supposed to receive insulin and that their body cannot lower blood sugar on its own and the insulin was to manage and prevent blood sugar from getting too high. LVN A stated possible consequences for not taking insulin was to not have controlled blood sugar, coma or stroke. LVN A stated that notification to the provider should be documented in the resident's chart as a progress note. During an interview on 06/19/2025 at 1:19 PM, LVN B stated that if a resident refused medication it would be written in the 24 hour report and the provider would be notified to see what needed to be done. LVN B stated that a refusal should have been documented in a progress note as well as the notification to the provider. LVN B stated that education could be provided depending on the resident's cognition. LVN B stated that education to the resident could include letting the resident know that they do not want the resident's blood sugar to drop or get too high. LVN B stated that potential harm for not taking insulin was lethargy (unusual tiredness, drowsiness, or lack of energy) increased thirst, or aggression. LVN B stated education should have also been documented in a progress note. During an interview on 06/19/2025 at 1:31 PM, LVN C stated that he normally worked with Resident #1 and on Resident #1's hall. LVN C stated that the protocol for medication refusals included to figure out why the resident refused the medication, ease any concern they may have with the medication and answer any questions the resident may have had. LVN C stated that if a resident refused medication the MD/NP would be notified. LVN C stated that the refusal should be documented in a progress note and on the MAR. LVN C stated that the provider should be notified each time a resident refused. LVN C stated that the potential risk for a resident refusing insulin was worsening of the diabetic condition. LVN C stated that he did not notify the provider today (06/19/2025) of Resident #1's medication refusal. LVN C stated that he sent the NP a text yesterday regarding the refusals. LVN C did not have the text message that he notified the provider. During an interview on 06/19/2025 at 1:41 PM, the NP stated that he was familiar with Resident #1. The NP stated that he had been notified earlier today (06/19/2025) that Resident #1 refused medication. The NP stated he cannot recall being notified of Resident #1's medication refusals prior to today. NP stated that he expected the facility to notify him when a resident refused insulin. NP stated that he has not provided any education to Resident #1 regarding insulin refusals and said for Resident #1 to continue as ordered. NP stated that Resident #1's A1C (blood test for sugar levels) has been controlled and Resident #1 has not had any issues. During an interview on 06/19/2025 at 1:49 PM, the DON stated that residents have the right to refuse medications and staff should approach the resident later and try again. The DON stated that the provider should have been notified of medication refusals and the notification should be documented in a progress note. The DON stated that refusing insulin would have the potential to increase blood sugar but it was dependent on the resident on the potential outcome. The DON stated she expected staff to provide education if a resident was cognitively able to understand and expected education to be documented in the progress notes after the refusal. The DON stated Resident #1 does refuse his insulin and believe he was not on it prior to his hospitalization that occurred prior to admission to the facility and stated the hospital usually added insulin to diabetes when they went to the hospital. The DON stated Resident #1 has not returned to the hospital since admission to the facility. During an interview on 06/19/2025 at 2:02 PM, the ADM stated that she expected staff to attempt again if a resident refused medication, but if they refuse then the family should be contacted to see if the family could assist. The ADM stated the provider should be contacted to let them know the resident was not taking the medication and that education should be provided to the resident about what medications were for. The ADM stated she expected notification to the provider to be documented. The ADM stated a lot of times they talk to the provider on the phone, but it needed to be documented in the progress notes. The ADM stated education should have also been documented in the progress notes. Review of undated facility policy titled Medications - Administering reflected if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document this in the record. Review of undated facility policy titled Medication - Documentation of Administration reflected documentation must include reasons why a medication was withheld not administered or refused. Review of undated facility policy titled Change in a Resident's Condition of Status reflected charge nurse will notify the resident's provider when there has been a refusal of treatment or medications two or more consecutive times.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure [NAME] J were practicing proper hand hygiene while preparing foods. The facility failed to ensure DM were practicing proper hand hygiene as he entered and exited the kitchen. The facility failed to check produce for quality prior to delivery. The facility failed to ensure food service employees have received training related to dishwasher sanitation. The facility failed to ensure record keeping of dishwasher sanitation checks. The facility failed to keep refrigerated foods tightly wrapped or packaged. The facility failed to label and date all refrigerator and freezer items. The facility failed to provide an outline of dietary in-services and sign in attendance sheets for food service employees. These failures could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 4/15/2025 at 9:00 AM revealed the entrance to the kitchen had a marked off orange area for staff entryway that was within proximity of the ice machine for resident consumption and coffee and iced tea station with trays of washed coffee mugs and cups for resident consumption of liquids. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. Observation on 4/16/2025 at 11:22 AM revealed DM returning from the dining room area without washing or sanitizing his hands and putting ice into a pitcher and filling it with water for residents. Observation on 4/16/2025 at 11:46 AM of [NAME] J cutting vegetables revealed that she removed her gloves to go check her personal phone call in the locker room. [NAME] J was observed checking her personal cell phone and returned to her workstation without washing or sanitizing her hands, she put her gloves on, and returned to cutting vegetables. Observation on 4/17/2025 at 9:30 AM of kitchen after breakfast meal service revealed DM and DA Q were working the hot temperature dishwasher. Staff was observed testing the temperature and logging it. There was no log or records for dishwasher sanitation. In an interview on 04/15/2025 at 9:00 AM the DM stated the Dietician consults him on food storage and procurements, conducts walk through of kitchen, walk through of freezers and refrigerators and pinpoints areas to work on in the kitchen. In an interview on 4/16/2025 at 11:33 AM the Dietician stated she provides the facility 20 hours per month of clinical and kitchen consultation. She stated she performs kitchen walk throughs with DM, reviews meal tickets, provides consultation on kitchen operations, provides DM with training on hair restraints and hand washing. She stated that all dietary staff were to wash their hands every time they were soiled. She stated the orange zone near the kitchen entrance was implemented by the facility and allows for non-dietary staff to enter the kitchen up to the orange taped off area since there was no food production in that area. She stated since the ice machine and coffee station were not a food production area the facility does not require staff who stay behind the orange taped off area to wear a hairnet. In an interview on 4/17/2025 at 9:30 AM DA Q stated she had been employed with the facility for four months and had not been trained to use the dishwasher, but she had used the posters on the wall to help guide her to washing dishes. She stated she often washes the dishes, but she does not perform dishwasher temperature and sanitation checks. She stated she has not been trained on monitoring records and does not log information. She stated she would like more training to help her do her job better. DA Q stated she was under the impression the dishes were washed as long as the hot water temperature reached over 160 degrees. In an interview on 4/17/2025 at 9:30 AM the DM stated he was not familiar with checking dishwasher temperatures or sanitation. He stated his cooks usually perform this task. He stated there was a dishwasher temperature log that was up to date, but he was not aware he needed to keep sanitation logs and he was not sure how to perform sanitation testing. He stated to ensure dishes were washed the hot water temperature would have to reach above 160 degrees. He stated his cooks were not trained to check dishwasher sanitation levels as they did not have a log to document readings. They were only trained to check the sanitation levels of the 3 compartment sinks. In an interview on 4/17/2025 at 1:59 PM [NAME] J stated she had limited dietary training, but throughout her years as a cook she had been trained on infection control and proper hand washing. She stated that the policy for hand washing was staff were to wash hands every 30 minutes and each time they leave the kitchen area and return. She stated that the policy for hairnets was that all staff were to wear one when they enter the kitchen, no exceptions. She stated that if staff did not practice proper hand hygiene or use hairnets in the kitchen it could put the resident at risk of getting sick. She stated she does recall not washing her hands after returning from the locker and stated she overlooked this task as she was moving quickly. In an interview on 04/17/2025 at 2:21 PM the DM stated he had been trained on infection control and proper hand hygiene. He stated that dietary staff were all required to wash their hands after each task. He stated all staff members were required to wear hairnets and beard guards when entering the kitchen past the orange taped off area. He stated if staff did not perform proper hand hygiene it could cause the food to become contaminated and make the residents sick. He stated he was not sure why he did not wash his hands each time he entered the kitchen as he was to be modeling proper hand hygiene for his team and that he would be working on this. He stated that he was constantly reminding staff about hand hygiene and was aware that some of the dietary staff move quickly and forget to wash their hands between tasks. He stated he was responsible for monitoring to ensure that all staff were washing their hands. He stated he monitors the hand washing by reminding the staff and observation. In an interview on 4/17/2025 at 2:54 PM the ADON stated she has been trained on infection control and hand hygiene. She stated that all dietary staff were to wash their hands when entering the kitchen and all staff regardless of what department they worked in should be wearing a hairnet if entering the kitchen. She stated that the DM was responsible for providing dietary staff with in-services on dietary related topics. She stated she has conducted an in-service on hand washing for all facility staff. Record Review of Hand Washing: Dietary Policy, no date revealed Hands must be washed: 1. As soon as you report on duty. 2. Before and after handling of food. 3. Before and after personal use of toilet. Proper Hand Washing is the single most important means of preventing the spread of infections. 2. Wash hands and wrists thoroughly. Record Review of Consultant Registered Dietician: Policy Interpretation and Implementation: Dietary Policy, no date revealed The RD (Registered Dietician) will review food service operation, and provide guidance and direction for the DM. Record Review of Dietary In-Service: Dietary Policy, no date revealed Educational programs designed to develop and improve skill and knowledge of the employees with respect to the needs of the residents will be planned on a yearly basis by the Dietician and/or DM. Purpose: These programs will enable the staff to acquire skills and techniques necessary to provide quality care to the residents. 2. Content on in-services will vary but must include at least one yearly in-service on: a. Proper food handling, c. Nutrition. 3. Attendance at the above in-services will be mandatory for all food service personnel. 4. An outline of each in-service and related handout(s) will be kept on file. 5. Every person attending the in-service will be required to sign an attendance sheet that will be kept on file with the outline.

Based on observation, interview, and record review the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. The facility failed to ensure [NAME] L were preparing meals within two hours or less of meal service. The facility failed to ensure regular diet and puree test trays rendered a proper serving temperature and had flavor. These failures could compromise and destroy nutritive value of food and prevent residents who ate food from the kitchen at risk of recovery from illness or injury. Findings included: Observation on 04/15/2025 at 9:00 AM during the brief tour of kitchen revealed the following: Mealtime schedule posted in the dining room noted lunch was served at 11:30 AM. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. The walk-in refrigerator contained unlabeled and open bag of lettuce mix. Observation on 4/15/2025 at 11:30 AM first meal service revealed old menus dated 03/05/2025 were posted in the dining room. Observation of cook, [NAME] L preparing puree foods on 4/16/2025 at 10:51 AM revealed he used water as the liquid to puree cornbread muffin. He was not following a specific recipe. Observation on 4/16/2025 at 1:09 PM of the survey test tray revealed the following: Regular diet chili temperature reading was 110 degrees and taste of test tray by surveyor found it was flavorless. Regular diet corn temperature reading was 109 degrees and taste of test tray by surveyor found it was tasteless. Puree chili temperature reading was 109 degrees and taste of test tray by surveyor found it was flavorless. Puree corn temperature reading was 95 degrees and taste of test tray by surveyor found it was tasteless. In an interview on 4/15/2025 at 9:31 AM the DM stated the residents were not enjoying the facility meals because they were not feeling the Louisiana menu he was currently using to prepare foods from. He stated the company he procures product for provides a Louisiana menu and he was working on making the switch to a local, Texas procurement company. He stated there were contracts being worked on which will transition the facility over to a Texas menu beginning May 1, 2025. In an interview on 4/15/2025 at 10:48 AM Resident #67 stated he doesn't care for the meals being served from the kitchen and prefers the alternate choices of hamburgers, hotdogs, corndogs, and pizza. He stated 1-2 times per week he will choose the alternate meal because he was tired of constantly eating rice and beans and would prefer other options like chicken with mashed potatoes and carrots. In an interview on 4/15/2025 at 12:37 PM Resident #73 stated, she hates the lunch, she hasn't eaten the facility food in so long, roughly two years. She stated she used to eat the meats served for protein, but the food has become cardboard, really tough, and flavorless. She stated the alternative grilled cheese sandwiches were a joke, the food was cold, smells horrible at times and the flavor was poor. In an interview on 4/15/2025 at 12:10 PM Resident #56 stated she normally doesn't eat because she doesn't like the meals that were served. She said she was not happy with meals. She stated she doesn't like the alternatives because they were not cooked well. She stated she would rather eat cereal than to eat the food being served. She stated she likes fruit, but it doesn't look appetizing. In an interview on 4/16/2025 at 9:20 AM Resident #39 stated food was mediocre. The resident stated mashed potatoes are served practically every day , the seasoning is very poor, and boring. She can ask for alternative of some sort of sandwich if she doesn't care for the food. In an interview on 4/16/2025 at 9:57 AM Resident #64 stated his eggs were burnt, this morning and he didn't care for the breakfast. In an interview on 4/16/2025 at 9:10 AM Resident #46 stated he did not like breakfast, the food has no taste to it, meat was dry, and cold. He stated he eats in the dining room and will be provided a substitute meal when he doesn't like what was being served. He stated he will usually ask for cereal, [NAME] Krispies. In an interview on 4/17/2025 at 2:21 PM the DM stated the Dietician provides him training on preparing menus, hand sanitation, food procurement, following recipes, diets, and puree preparation and in turn he trains the dietary staff. Surveyor asked DM for in-service logs during this interview, and he stated he doesn't complete his own in-service logs and the ADM would have in-service logs. He stated he would reach out to the ADM and obtain logs for surveyor (logs not provided prior to exiting). He stated the protocol for pureeing foods was to use milk, butter, gravy, broth, and thickening powder, if necessary, but to not use water. He stated he was unsure why [NAME] L would use water when pureeing foods as he knows it has no nutritional value. He stated he has the supplies needed to puree foods. He stated he was expected to follow the menus and understands he can add to the menu just not remove items or seasonings. He stated he will typically taste the food and believes it was good quality and flavorful and would eat it himself and he doesn't have concerns serving to the residents. He stated he was aware several residents were declining the meal trays, and he has instructed aids to notify him so he may offer a substitute. He stated he does not have substitutions documented. He stated he has been informed by aids and residents the food lacks flavor and would like other foods and he stated he wants to provide the residents with flavorful, edible, and presentable food so they would want to eat it. He stated the 8 lettuce heads in the walk-in refrigerator have been in there for four weeks now pending company picking up and he would have to follow-up with the company. He stated he did not inspect the food quality at delivery, and he had some items that was returning. He wasn't aware he needed to label it. He stated the black ripe bananas were kept in the kitchen for residents who require soft foods for consumption. He stated the expectation was for cooks to begin meal prep no more than two house prior to meal service. He discussed that he was not aware that [NAME] L was preparing lunch as early as 9:00 am on 4/15/2025 and that this can cause concerns for residents. In an interview on 4/17/2025 at 2:54 PM the ADM stated the DM receives in-services directly from the Dietician. The ADM stated the expectation was for the food to be warm and appetizing, that it tastes good, right temperature, and nutritious. The ADM stated she was aware of a few residents not liking the meals and being offered alternatives, which they decline as they were provided meals by their family. Surveyor requested in-service logs for all dietary staff (not provided to surveyor prior to exiting). In an interview on 4/17/2025 at 2:54 PM the DON stated she was aware that some residents don't like the type of food that was being prepared by the kitchen and were offered alternatives. She stated some residents have notified her that the food was sometimes cold, but this wasn't often. Record Review of Storage Freezer: Dietary Policy, no date revealed 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 2. Label and date all items. Record Review of Storage: Refrigerator: Dietary Policy, no date revealed 7. Keep refrigerated foods wrapped or covered and in sanitary containers. Record Review of Dietary Daily Functions: Dish machine: Dietary Policy, no date revealed Monitor and record temperatures and sanitizer solution at each meal. Record Review of Meal Delivery: Dining Rooms: Dietary Policy, no date revealed 3. Service must be prompt and efficient so that food will remain at the appropriate temperatures for consumption. 5. If the resident refuses any food item, the kitchen will supply a substitute of similar nutritive value. Acceptance or refusal of such substitution should be documented. Record Review of Menu Planning: Dietary Policy, no date revealed Menus will be posted and clearly visible to residents. Record Review of Dietary General Policies: Organizational Goals: Dietary Policy, no date revealed Provide the best quality food and food service for the residents within the budget as predetermined by the administration and according to established guidelines of all other regulatory agencies.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 3 of 3 (Resident #22, Resident #33 and Resident #71) residents, 2 of 2 medication carts (400-hall and 500-hall), and 1 of 1 medication storage room reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #33 took their medication prior to LVN A leaving the room. 2. The facility failed to ensure expired medications and supplies were removed from the 400-hall and 500-hall medication carts and the medication storage room. These failures could place residents at risk for not receiving a therapeutic dosage or another resident taking medications that were not administered to them. Findings include: 1. Record review of Resident #22's admission record, dated 04/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: diabetes mellitus type II (a condition that affects how the body uses sugar as a fuel), cerebral infarction (a condition when the blood flow to the brain is impaired), hypertension (high blood pressure), and atrial fibrillation (an irregular and often rapid heart rhythm). Record review of Resident #22's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated mild cognitive impairment. Section N: Medication reflected resident received insulin 1 day out of the previous 7 days to the assessment. Record review of Resident #22's order summary, dated 04/17/2025, reflected Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale. If 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 399 = 5 Greater than 399 = 6 units and notify provider, Okay to administer if patient is NPO, subcutaneously (under the skin) before meals and at bedtime, related to type 2 diabetes mellitus with unspecified complications. Record review of Resident #22's care plan, dated 03/04/2025, reflected Focus: The resident has Diabetes Mellitus with Interventions that included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. 2. Record review of Resident #33's admission record, dated 04/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: pain, dysphagia (difficulty swallowing), apraxia (difficulty with coordination), chronic kidney disease (a condition in which the kidneys could not adequately filter waste), dysarthria (difficulty with speaking), diabetes mellitus type 2 (a condition that affects how the body uses sugar as a fuel), vascular dementia (difficulty with thought processes and memory due to an injury to the brain affecting blood flow), hypertension (high blood pressure), cerebral infarction (a condition when the blood flow to the brain is impaired), and hypertensive heart failure (damage to the heart due to prolonged high blood pressure). Record review of Resident #33's annual comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated mild cognitive impairment. Record review of Resident #33's medical chart, on 04/17/2025, reflected Resident #33 did not have a self-administer medication evaluation. Record review of Resident #33's care plan, dated 03/24/2025, reflected there was not a care plan for Resident #33 to self-administer his own medications. 3. Record review of Resident #71's admission record, dated 04/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: diabetes mellitus type 2 (a condition that affects how the body uses sugar as a fuel), unspecified dementia (difficulty with thought processes, memory and social functioning), hyperlipidemia (high cholesterol), anxiety (a feeling characterized by fear, tension or worry in response to real or perceived threats), transient ischemic attack (a brief blockage of blood flow to the brain), and hypertensive heart failure (damage to the heart due to prolonged high blood pressure). Record review of Resident #71's quarterly MDS, dated [DATE], reflected a BIMS score of 04, which indicated severe cognitive impairment. Section N: Medications reflected Resident #71 received insulin for 7 of the 7 days prior to the assessment. Record review of Resident #71's care plan, dated 02/27/2025, reflected Focus: The resident has Diabetes Mellitus with Interventions that included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Humalog with sliding scale. Lantus. Sitagliptin. Record review of Resident #71's order summary, dated 04/17/2025, reflected Insulin Glargine Soln Pen-Injector 100 Unit/ml Inject 35 unit subcutaneously one time a day related to type 2 diabetes mellitus. Observation on 04/15/2025 at 09:04 AM revealed Resident #33 in his room with a medication cup with nine unidentified pills in it. There were not any staff members in sight at that time. Observation on 04/16/2025 at 04:27 PM of the 400-hall medication cart revealed: One Humalog (Insulin Lispro) pen that belonged to Resident #22 with an opened date of 03/05/2025 written on a sticker under Discard after 28 days One Lantus (Insulin Glargine) pen that belonged to Resident #71 with an opened date of 03/18/2025 written on a sticker under Discard after 28 days One box of bisacodyl 10mg suppositories with an expiration date of 01/2025 Three single use packets of lubricating jelly with an expiration date of 11/30/2024 Observation on 04/16/2025 at 05:30 PM of the medication storage room revealed: One bottle of melatonin 3mg with an expiration date of 11/30/2024 One CVC dressing change tray with an expiration date of 01/31/2025 One box of glucose control solution with an expiration date of 08/15/2024 One bag of 0.9% Sodium Chloride Intravenous Solution 1000mL with an expiration date of 08/2024 Six packages of albuterol sulfate inhalation solution 2.5mg/3ml packaged with a prescription label for someone that was not a resident at the time of the survey. The expiration date was 11/2024. Observation on 04/17/2025 at 01:35 PM of the 500-hall medication cart revealed: Five 27g x 1.5 hypodermic needles with an expiration date of 03/31/2025 Five 23g x 1 hypodermic needles with an expiration date of 08/2021 One bottle of Zinc 50mg with an expiration date of 03/2025 Twenty-one peri-stoma (the skin around a surgical opening created to allow waste to exit the body) cleaner and adhesive remover wipes individually wrapped with an expiration date of 11/10/2024. During an interview on 04/15/2025 at 09:04 AM with Resident #33, he stated staff usually left medication in a cup with him for him to take without watching him take the medication. During an interview and observation on 04/15/2025 at 09:06 AM with LVN A, he stated he didn't normally leave medication for the resident in a cup at the bedside, but he left the room to go get batteries for Resident #33's remote control. He stated doing so could place a resident at risk of choking, aspiration (when something that was swallowed entered the airway or lungs), or the resident could not take the medication. Observed LVN A return to Resident #33's room and picked up the cup of medication from the bedside table, LVN A told Resident #33 I have medicine for you then told the state surveyor I will be here for a while. During an interview on 04/16/2025 at 05:42 PM, LVN R stated all the nurses were responsible for checking for expired medications/supplies on their own cart every shift. She stated if a resident was to take expired medication, then the medicine may not be as effective. She stated the policy for medication administration was to ensure residents took their medication completely before leaving the room because they could choke or someone else could take the medication. During an interview on 04/16/2025 at 05:46 PM with the ADON, she stated she, the DON, and the pharmacist were responsible for checking for expired medication and supplies in the medication room weekly. She stated using expired medication or supplies could affect the resident differently depending on what it was. She stated she would have to look each individual item up to determine the potential effect to the resident. She stated each nurse was responsible for ensuring their cart was locked anytime it was left unattended. The ADON stated not securing the cart could leave it where residents could open the drawer and take anything inside. During an interview on 04/17/2025 at 01:33 PM with LVN A, he stated the nurses were responsible for checking their own cart for expired or discontinued medication. He stated medications and supplies may lose effectiveness or may cause adverse reactions if utilized after the expiration date. During an interview on 04/17/2025 at 2:18 PM with the DON, she stated she expected the nurses to check their carts for expired and discontinued medications and supplies daily. She stated all expired medications and supplies were to be removed from the carts and placed in the destruction bin. The DON stated the weekend RN was responsible for auditing the medication carts on the weekends. She stated the ADON, the pharmacist and she spot checked the carts for expired medication/supplies. She stated the ADON was responsible for ensuring all expired supplies and medications were removed from the medication storage room and the DON spot checked the medication room once a month. She stated if used after the expiration date, then medications or supplies may not be as effective. The DON stated the nurses were responsible for ensuring their medication cart was secured at all times. She stated leaving a medication cart unsecured could place residents at risk because they could get into a drawer and grab something potentially. She stated she does daily spot checks and has done in-services on securing the medication cart. The DON stated her expectations for medication administration was to ensure the resident takes their medications completely before leaving their side. She stated not doing could lead to the resident not taking their medication and getting the needed benefits. During an interview on 04/17/2025 at 02:38 PM with the ADM, she stated she expected all expired medication and supplies to be removed from the medication carts and room. She stated the nurses were responsible for ensuring this was done on their carts and the ADON was responsible for ensuring this was done in the medication storage room. She stated having expired medications available lead to a potential for the resident to take the expired medication but was unsure how that might affect the resident. She stated she relied on the DON and the pharmacist to audit the carts and medication room weekly to ensure expired medication and supplies were removed. The ADM stated the nurses were responsible for ensuring their medication carts were secured. She stated leaving a medication cart unsecured could allow a resident access to the drawers and take something not meant for them and it could be detrimental. She stated administrative staff did frequent rounding to ensure medication carts were locked. The ADM stated she expected the nurses to remain with the resident until they took all their medication. She stated if medication was left in a room, then another resident would have access to the medication and could take some medication that wasn't prescribed to them, or the resident could not take their medication and not receive the intended therapeutic benefits. Record review of the facility's, undated, policy titled Medications-Storage reflected: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the facility's, undated, policy titled Medications - Administering reflected: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required time frame . 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation and interview he facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 5 (400 and 500 halls) observed for housekeeping and maintenance services. The facility failed to ensure there were no continuous foul odor on 400 and 500 halls. This deficient practice could place residents at risk of living in an unclean and unsanitary environment and result in feelings of dissatisfaction. The findings were: Observation of 400 hall on 4/15/2025 at 8:58 AM revealed the middle of the hall to the end of the hall smelled like urine. Observation of 500 hall on 04/15/2025 at 9:10 AM revealed the hall smelled like feces. Observation of 400 hall on 04/15/25 at 03:30 PM revealed there was a strong smell of urine. Observation of 400 hall on 04/16/25 at 08:01 AM revealed a strong smell of urine. During an interview on 04/16/2025 at 11:16 AM revealed Family member of Resident #56 stated she smelled the 500 hall and it smelled like someone had an accident. She said it smelled like that a few days and she thought they were cleaning it. She also said she thought Resident #56 had gotten used to the smell . During an interview on 4/17/2025 at 9:02 AM revealed CNA S normally worked hall 100 and did not work 500 hall often. She said 500 hall was the worst hall for smelling bad. She said the carpet was old, and she believed that was where the smell was coming from . During interviews on 04/15/2025 at 10:50 am revealed Resident #69 did not smell a foul odor in the hall or in his room. During interviews on 04/15/2025 at 11:17 am revealed Resident #73 did not smell any foul odors in the building. During interviews on 04/16/2025 at 11:16 am revealed that Resident #56 did not smell any foul odor in the hall. During interviews on 04/17/2025 at 8:40 am with Resident #33 revealed that he did not smell any foul odor from the hall. Record review of the facility's, undated, Homelike Environment revealed the facility would maintain a clean environment and minimize odors.

Based on observation , interview and record review the facility failed to ensure residents were provided with a private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for residents' monthly council meetings and the confidential resident group meeting during the survey for 8 of 8 residents reviewed for confidential resident council meeting. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Include: Observation on 04/15/2025 at 10:35 AM, revealed staff walked in on the resident council meeting, and the residents told the staff they were having a meeting . Observation on 04/15/2025 at 10:41 AM, revealed staff just walked in to the resident council meeting, and the residents told the staff they were having a meeting. The meeting was held in the assisted dining room Observation on 04/15/2025 at 10:56 AM, revealed a family member interrupted the resident council meeting in the assisted dining room. Observation on 04/15/2025 at 11:13 AM revealed a staff member interrupted the meeting to bring a resident into the room for lunch in the assisted dining room . During an interview on 04/15/2025 at 9:20 AM, with the Administrator revealed a meeting was already scheduled for 10:30 AM, in the main dining room. She said they always had the meeting in the main dining room. She said they could move it to the assisted dining room to be more private . During an interview with a confidential resident revealed resident council always met in the dining room. He said staff would come in and out of the dining room while the meeting was in session. He also said even if the door was closed staff still opened it and came in. He said he would tell them they were having a meeting and for the staff not to come in, but they still came in. He said the resident council did not get the privacy they wanted. He said he talked to the ADM about staff coming in and out. He said the ADM told him there was nothing the facility could do. During an interview with the AD on 04/17/2025 at 11:14 AM revealed she had been trained on resident rights. She said the resident council was supposed to have a private meeting area. She also said they had the right to privacy and could say if staff could join or not. She said she was responsible for ensuring the resident council had a private area to meet. She said the resident council asked for a private area to meet so that was why she moved it to the small dining room. She also said this was the first time they had met in the small dining room. She said she did not consider the small dining room a private area after the meeting on 04/15/2025. She said it was not a private area due to all the interruptions that had happened. She also said that if they did not have a private area it could make the residents not want to speak freely about issues. During an interview with the ADM on 04/17/25 at 11:26 AM revealed her and staff were trained on resident rights. She said the resident council must have a private place to meet. She said She said the AD was responsible for ensuring the resident council had a private place to meet. She said she was not aware they asked for a private area. She said the resident council was supposed to be a secure environment and if not secure then the residents may not feel comfortable talking about their concerns about staff. During an interview with the DON on 04/17/2025 at 12:16 PM revealed she had been trained on resident rights. She said the resident council must have a private place to meet. She said she said the AD and administration were responsible for ensuring the resident council had a private place to meet. She said she had not heard the resident council wanted a more private place to meet. She said if the resident council did not have a private meeting space the residents may not feel they could speak freely about staff or the facility. Record review of the facility's, undated, Resident Council Meetings Policy revealed the facility will provide the Resident Council with a private space to meet and take reasonable steps, with the approval of the group to make residents aware of upcoming meetings in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 18 residents (Resident #23, Resident #30, Resident #33 and Resident #82) reviewed for resident rights an dignity. The facility failed to ensure that Resident #23 was assisted with feeding when her meal tray was delivered to the assisted dining room. The facility failed to ensure LVN A and MAIN knocked on Resident #30, Resident #33 and Resident #82's doors when going into the residents' rooms. These failures could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. This failure could place residents at risk of diminished dignity and affect their quality of life. Findings include: 1.Review of Resident #23's face sheet dated 4/17/2025 reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of muscle weakness, vascular dementia (describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain), nutritional deficiency (inadequate supply of essential nutrients (as vitamins and minerals) in the diet), dysphagia (difficulty swallowing), cerebrovascular disease (conditions that impact the blood vessels in your brain), muscle wasting and atrophy (reduced muscle mass), cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions), anorexia (eating disorder in which people have a low body weight). Review of Resident #23's MDS Quarterly assessment, dated 03/24/2025 reflected a BIMS score of 03 indicating severe cognitive impairment. The MDS further reflected Resident #23 was on a mechanically altered diet (texture-modified diet designed for individual who have difficulty chewing or swallowing) and required partial/moderate assistance from staff for eating. Review of Resident #23's care plan, dated 03/24/2025 reflected Resident #23 was total dependent on staff for eating. 2. Record review of Resident #30's face sheet, dated 04/16/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included heart failure, muscle weakness, anemia (not enough healthy red blood cells), lack of coordination, abnormality of gait and mobility, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), type 2 diabetes mellitus with hyperglycemia (high blood sugar), cognitive communication deficit (problems with communication), repeated falls, pain in right shoulder, pain in left shoulder, nausea with vomiting, and dementia (memory, thinking, difficulty). Record review of Resident #30's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #30 had a BIMS score of 03, which indicated severe cognitive impairment. 3. Record review of Resident #33's face sheet, dated 04/16/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included insomnia (difficulty sleeping), nausea, history of falling, acute pain, dysphagia (difficulty swallowing), COVID 19 , difficulty walking, attention and concentration deficit, kidney disease, muscle wasting, abnormality of gait and mobility, obesity, unsteadiness on feet, pain in right shoulder, major depressive disorder , and vitamin D deficiency. Record review of Resident #33's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #33 had a BIMS score of 12, which indicated moderate impairment. 4. Record review of Resident #82's face sheet, dated 04/16/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #82 had diagnoses which included insomnia (difficulty sleeping), burn of third degree of shoulder and upper limb, nausea, constipation, heart failure, vitamin deficiency, Severe Sepsis without septic shock (life threating condition where the bodies overwhelming response to an infection leads to organ damage), hyperlipidemia (high cholesterol), acquired absence of right leg below the knee, and pain. Record review of Resident #82's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #82 had a BIMS score of 11, which indicated moderate impairment. Observation on 04/15/2025 at 11:10 a.m., revealed the MAIN walked into Resident #30's room without knocking to check the bathroom. Resident #30 was in the bathroom when the MAIN walked in her room and opened the bathroom door. Observation on 04/15/2025 at 9:05 a.m., revealed LVN A walked into Resident #33 and Resident #82's room without knocking. Observation on 04/15/2025 at 10:02 a.m., revealed LVN A walked into Resident #33 and Resident #82's room without knocking. Observation on 4/16/2025 at 5:30 p.m. revealed CNA T feeding Resident #23 in the assisted dining room. CNA T was observed sitting beside Resident #23 feeding her. When she received a text message, she put down the utensils she was using to feed Resident #23 and pulled out her cell phone and began reading a message and laughing. She was observed on her personal phone for 3 minutes. Once CNA T observed Surveyor in the doorway, she put her cell phone away and returned to feeding Resident #23. During an interview with Resident #33 on 04/17/2025 at 8:40 a.m., revealed staff did not always knock on his door. He said staff did not knock on his door a lot. He said he would like for them to knock all the time. He said it did not upset him when staff did not knock . An interview with Resident #83 on 04/17/2025 at 8:42 a.m., revealed staff did not always knock. He said he would like for staff to knock all the time. He said he did not know how he felt about staff not knocking on his door. He said he did not know how often the staff did not knock on his door. During an attempted interview with Resident #30 on 04/17/2025 8:33 a.m., she said she did not know if staff always knocked before entering her room. She said she did not care if the staff knocked or not. She also said she did not know if she got upset when staff did not knock. She said she was not sure how often staff did not knock. An interview with LVN A on 04/17/2025 at 8:34 a.m., revealed he was trained on resident rights. He said the policy was staff were to knock on the door and wait for the resident to respond. He said staff were to knock except if it was an emergency such as the resident not breathing. He said if a resident did not want someone in their room they could get upset. He said everyone was responsible for monitoring to ensure staff were knocking. He said knocking on the door was monitored by doing observations. He said he was just in a hurry and did not think about knocking on the resident's door. An interview with the MAIN on 04/17/2025 at 9:15 a.m., revealed he was trained on resident rights. He said the policy was staff were to knock on the door and wait for the resident to say it was okay to come in. He said he was not sure of anytime the staff did not have to knock. He said every resident had a room and that was their private space. He said it was a violation of the resident's right and it was not nice to be obnoxious by not knocking. He said everyone should monitor to ensure staff were knocking. He also said staff monitored each other by observation. He said he did not recall going into Resident #30's room without knocking and opening the bathroom door while she was in the bathroom. An interview with the ADM on 04/17/2025 at 11:38 a.m., revealed she and staff were trained on resident rights. She said the policy was to knock on the door and inform the resident what they were there to do. She said all staff were supposed to knock before entering the residents' room. She said some residents did not care if staff knocked. She said regardless of if the resident did not care staff should be knocking. She said management monitored knocking by observation of the halls. She said she thought the staff got complacent and did not knock. An interview with the DON on 04/17/2025 at 12:19 p.m., revealed she and staff were trained on resident rights. She said she was not sure what the policy was that staff were to knock on the door. She said staff were expected to knock whenever they wanted to go into the room. She said if staff did not knock the resident may feel as if the facility was not his/her home. She said all staff were supposed to knock anytime they wanted to enter the resident's rooms. She said everyone was responsible for monitoring to ensure staff were knocking. She said knocking on the door was monitored by doing observations. She said she did not know why the staff did not knock. In an attempted interview on 04/17/2025 at 1:20 p.m. Resident #23 was nonverbal. Resident would not say anything she would just look at surveyor. In an interview on 04/17/2025 at 1:26 p.m. CNA H stated that she had been trained on resident rights. She stated not treating a resident with respect and providing privacy would affect them negatively and make them feel worthless or unimportant. She stated the facility's cell phone policy was to not have cell phones out on the floor, near personal information, around resident or in their room, it must be put away. She stated cell phones were not allowed to be used if tasked with feeding a resident. She stated if phones were out when assisting a resident with feeding this can cause them to feel unimportant and they were being paid to pay attention to the resident to avoid them from choking. In an interview on 04/17/2025 at 1:43 p.m. RN D stated that she had been trained on resident rights and privacy and dignity was important to residents as they can be affected negatively if not treated with respect and dignity. She stated the cell policy was to not have them out unless on break or work related. She stated the facility allows for the use of personal cell phones. She stated she does assist with feeding residents as there were many feeders, and as a wound care nurse nutrition was a big part of wound care, and everybody shares this responsibility. She stated it would not be appropriate to feed a resident and use cell phone. She stated she has personally witnessed staff using their personal cell phones while assisting a resident with feeding. She stated that residents could choke if they were not being supervised or assisted correctly. She stated CNAs were less likely to communicate work items on cell phones and sees no need for them to be out. She stated she was unsure how staff communicate between each other and may require their personal cell phones. In an interview on 4/17/2025 at 2:54 p.m. the DON stated the facility's cell phone policy was that staff can have it on their person. She stated with patient care staff should not be on their phones especially when assisting a resident with feeding. She stated cell phones were allowed and if an emergency staff can step away and go and use in the breakroom. In an interview on 4/17/2025 at 2:54 p.m. RN E stated managers have a cell phone, communication between staff was allowed on phone. She stated she does text staff members and states phones were becoming more common in the facility. She stated nurses can communicate with practitioners at the desk and phone was allowed if it was work related. She stated no staff should be using their cell phone when providing direct services in person. RN E stated the cell phone policy was provided to each new hire during onboarding as it can affect HIPAA, resident's privacy. She stated if a severe problem with cell phones he would put a stop to it immediately and provide all staff in-service on cell phones. In an interview on 4/17/2025 at 2:54 p.m. RN E stated the assisted dining was for the residents that require assistance with feeding. She stated feeding a resident while on a personal cell phone could impact a resident's dignity as they were not receiving the attention they need to be fed. RN E stated being focused on their task at hand was necessary whenever working on direct services with any resident. Record review of the Resident Rights: 5. Respect and dignity: Resident Rights Policy, not dated, reflected The resident has a right to be treated with respect and dignity. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to property care for its residents. Record review of the Dining Rooms: Dietary Policy, not dated, reflected 2. Nursing assistance will assist the resident as needed, i.e., cutting meat, buttering bread, unwrapping food items, etc. Record review of the Resident Rights, not dated, revealed residents have the right to be treated with respect and dignity. Residents have the right to personal privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 3 of 8 residents (Resident #75, Resident #39, and Resident #26) reviewed for resident rights. The facility failed to ensure Resident #75, Resident #39, and Resident #26 were provided privacy and confidentiality when personal care and treatment signs were hung up in their rooms. The failure could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Resident #75 Review of Resident #75's face sheet dated 4/17/2025 reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Hemiplegia (severe paralysis on one side of the body), Hemiparesis (weakness on one side of the body), Cerebrovascular disease (affect blood flow to the brain), muscle weakness, repeated falls, and Type 2 diabetes (insulin resistance and high blood sugar levels). Review of Resident #75's MDS quarterly assessment dated [DATE] reflected a BIMS score of 08 indicating moderate impairment. MDS further reflected Resident #75 has symptoms presence of feeling down, depressed, or hopeless. Review of Resident #75's care plan, dated 03/24/2025 reflected Resident #75 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Observation of Resident #75's room on 4/16/2025 at 8:48 AM revealed personal care and medical treatment signage, PLEASE APPLY BARRIER CREAM IN BETWEEN BRIEF CHANGES AND PRN and Reminder to all Staff! When in bed. Kindly position the cushion provided under right leg to prevent pressure sore and further contracture. It stated she declines the cushion under her right leg hanging on the wall behind Resident #75's bed. In an interview on 4/17/2025 at 8:57 AM Resident #75 stated the personal care and medical treatment signage hanging directly behind her was meant for staff providing her daily personal care. She stated the signage was uncomfortable, but she was used to them being there. She stated she has discussed concern with staff, but they stated it was meant to help them and in return helps her. Resident #39 Review of Resident #39's face sheet dated 04/17/2027 reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Venous insufficiency (flow of blood through the veins is impaired), muscle weakness, Muscle atrophy (wasting or thinning of muscle mass), Unspecified lack of coordination (poor muscle control), and cognitive communication deficit (communication difficulties). Review of Resident #39's MDS quarterly assessment dated [DATE] reflected a BIMS score of 11 indicating moderate impairment. Review of Resident #39's care plan, dated 3/25/2025 reflected Resident #39 was confirmed to bed. Observation of Resident #39's room on 4/16/2025 at 9:20 AM revealed personal care and medical treatment signage, please apply barrier cream in between brief changes hanging on the wall behind Resident #39's bed. In an interview on 4/17/2025 at 8:57 AM Resident #39 stated she would prefer if the personal care signage was not up and for staff to know what to do with her daily personal care. She stated she doesn't stay anything about the signage as staff have stated it helps them. Resident #26 Review of Resident #26's face sheet dated 4/17/2025 reflected [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Non-ST-Elevation Myocardial (heart attack that usually happens when your heart's need for oxygen can't be met), acute kidney failure (sudden loss of kidney function), muscle weakness, lack of coordination, repeated falls, Dysphagia (difficulty in swallowing food or liquid), and cognitive communication deficit (communication difficulties). Review of Resident #26's MDS quarterly assessment dated [DATE] reflected a BIMS score of 04 indicating severe cognitive impairment. Review of Resident #26's care plan, dated 4/8/2025 reflected Resident #26 was having symptoms of depression. Observation of Resident #26's room on 4/15/2025 at 10:34 AM revealed personal care and medical treatment signage, please apply barrier cream in between brief changes hanging on the wall behind Resident #26's bed. In an interview on 4/17/2025 at 9:13 AM Resident #26 stated the personal care signage was not welcomed and she hates it. She stated she feels like she wasn't important, but it was for staff, and she can't do anything about it. She stated issue has been discussed with staff, but they reassure here it was necessary. In an interview on 4/17/2025 at 9:02 AM CNA S stated that she had been trained on resident rights and privacy and how dignity was important for residents. She stated residents could be affected negatively and feel unsafe, scared, and angry if not treated with dignity and provided privacy. She stated that all staff should be professional with all residents. She stated that the personal care and medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed along with all other residents with similar personal care and medical treatment signage was helpful to staff providing care. She stated as she and other staff do not work at the facility daily the signage helps to remind them of specific personal care and medical treatment needed for the resident. She stated she has not received complaints about the personal care and medical treatment signage from residents and doesn't believe it provides personal information. In an interview on 04/17/2025 at 1:26 PM CNA stated that he had been trained on resident rights. He stated not treating a resident with respect and dignity and providing them privacy would affect them negatively and make them feel worthless or unimportant. He stated the personal care and medical treatment signage hanging behind their bed was to remind facility staff of what to do daily for the resident. He stated that he was not familiar with specific personal care or medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed along with all other residents with similar signage and stated that he was aware that some residents do not like the signs up. He stated he understands the signage could cause the resident embarrassment and, in his opinion, he doesn't believe they feel comfortable and if he were the resident he wouldn't want them up either. In an interview on 04/17/2025 at 1:43 PM RN D stated that she had been trained on resident rights and privacy and dignity was important to residents as they can be affected. She stated privacy in a single room was provided by shutting the door and if there were roommates the resident can pull curtain shut for privacy. She stated another option for privacy was to ask the roommate to step out. She stated the signage listing daily care for residents was for communication for all staff members. She stated she was familiar with a few residents having personal care and medical treatment signage up for daily care, but was not familiar with signage behind Resident #26, Resident #39, and Resident #75's beds specifically. RN D stated that she can see how personal care and medical treatment signage technically would cross the boundaries of privacy. She stated privacy and dignity was affected, but has not heard complaints, that would oversee any privacy concerns. In an interview on 4/17/2025 at 2:54 PM RN E stated that she had been trained on resident rights and privacy and understands the negative effects that can be imposed on a resident if not provided these rights. She stated she provides facility staff with regular in-services on HIPAA and resident privacy. RN E stated that the residents need to communicate with facility staff as to what they need or what they don't like. She stated that personal care and medical treatment signage for residents was to provide personal care information to staff and doors were usually closed when staff were assisting a resident. She stated that the personal care and medical treatment signage listing resident's care hanging in the rooms could be seen as a privacy issue, but stated she was familiar with a few residents having signage up for daily care directions for staff but was not familiar with personal care and medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed specifically. She stated she has not received or heard complaints regarding privacy concerns. Record review of Resident Rights Policy: Explanation and Compliance Guidelines, not dated, reflected 1. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities. 2. Information about resident rights and responsibilities will be given to the resident both orally and in writing. Record review of Resident Rights Policy, not dated, reflected, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of Resident Rights: 5. Respect and dignity: Resident Rights Policy, not dated, reflected The resident has a right to be treated with respect and dignity. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Record review of Resident Rights: 6. Self-Determination: Resident Rights Policy, not dated, reflected b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 8. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on observation, interview, and record review the facility failed to properly store, label, and/or secure medications and biologicals for 2 of 2 medication carts and 1 of 1 medication storage room reviewed for drug storage. 1. The facility failed to ensure the medication cart for 500 hall was locked when unattended by LVN A on [DATE] at 9:04 AM. 2. The facility failed to ensure glucose control solution was dated with an opened-on date for the 500-hall medication cart. 3. The facility failed to ensure medication were secured in their original packaging. The medication cart for 400-hall had three and a half loose pills. The medication cart for 500-hall had one loose pill. 4. The facility failed to ensure medications that required a prescription were labeled with the appropriate information including the resident's name in the medication storage room and the 500-hall medication cart. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medication, needles, and other biologicals. These failures could also place residents at risk of not receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions. Findings included: Observation on [DATE] at 09:04 AM revealed a medication cart unlocked and unattended at the nurses' station at the end of 500-hall. RN A was at the other end of 500-hall in a room. Observation on [DATE] at 04:25 PM of the medication cart for 400-hall revealed two beige oval pills with UL125 on one side and blank on the other side, one yellow oval pill with HH on one side and 343 on the other side, and one-half white pill with unidentifiable markings. Observation on [DATE] at 05:39 PM in the medication storage room revealed a large clear baggie with 100 individually wrapped ondansetron orally disintegrating tablets (a prescription medication used to treat nausea). No resident or prescription label was observed on the bag. Observation on [DATE] at 01:35 PM revealed two bottles of glucose control solution with the plastic seal removed and two unopened unlabeled packages of Budesonide 0.5mg/2mL (a prescription medication used to treat inflammation), one oval blue pill with H on one side and 87 on the other side in the medication cart for 500-hall. No handwritten dates observed on either bottle or box of the glucose control solution. The side of the box containing both bottles of glucose control solution stated, Discard after 3 months from opening date. The packages of Budesonide stated Rx only, but no prescription label was on the packaging. During an interview on [DATE] at 09:06 AM with LVN A, he stated he was responsible for locking the medication cart anytime he walked away from it. He stated he thought he had locked the medication cart for 500-hall before he walked away. He stated if the cart was left unlocked then residents could get into the cart and take the medications inside. During an interview on [DATE] at 05:42 PM with LVN R, she stated she had worked at the facility since [DATE]. She stated that she has not ever noticed pills in the bottom of the drawer. She stated all nurses were responsible for checking their cart for loose pills. She stated all prescribed medications were required to have a prescription label on it unless it was removed from the emergency medication supply and given immediately to the resident. She stated if a prescribed medication was not labeled properly then it could possibly be administered to a resident with whom it wasn't intended for, or a resident could miss a dose of scheduled medication. During an interview on [DATE] at 05:46 PM with the ADON, she stated that ondansetron should have a prescription label with a resident's name on it. She stated she, the DON and the pharmacist check the medication room weekly to ensure all expired and invalid medications are removed. She stated she didn't know what the effect to the resident might be for a prescribed medication that wasn't labeled properly. During an interview on [DATE] at 01:33 PM with LVN A, he stated he had worked at the facility for about the last two and a half years. He stated that budesonide should have had a prescription label on it because it was a prescribed medication. He stated the glucose control solution should have been labeled with an opened-on date by the nurse who opened it. He stated not having a date on the glucose control solution could lead to altered results on the blood glucose monitor due to invalid calibration. During an interview on [DATE] at 2:18 PM with the DON, she stated that all medications that required a prescription needed a label on it from the pharmacy. She stated the nurses were responsible for keeping their cart clean. She stated loose pills in the medication cart could mean a resident might have missed a dose of medication. She stated the ADON was responsible for checking the medications in the medication room. The DON stated the glucose control solution should be dated by the nurse who opened the box. She stated not doing so could potentially affect the accuracy of blood glucose monitoring. She stated the nurses were responsible for locking their medication cart when they walk away from it. The DON stated if a cart was left unlocked, then residents could get in the drawer and potentially grab something and take it. She stated she did daily spot checks and monthly in servicing on securing medications properly. During an interview on [DATE] at 02:38 PM with the ADM, she stated all medication that required a prescription should have a prescription label on it. She stated if it didn't have a label then the resident might miss getting the medication. She stated the nurses were responsible for ensuring their carts were clean and locked when the cart was unattended. She stated the pharmacist, DON and ADON were responsible for auditing the cart to ensure no loose medications. She stated if the carts were left unlocked then a resident could have access to medication that is not for them, and it could be detrimental. The ADM stated she did frequent rounding and in-services to ensure the carts remained secured. Review of undated facility policy title Medications-Storage reflected: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to serve a menu to the meet the nutritional needs of residents in accordance with established national guidelines including a subsitution for the main entree for one of one menu reviewed. The facility failed to document resident acceptance or refusal of meal substitutions as per the facility policy. These failures could decrease intake and cause weight loss and functional decline. Findings included: Observation on 04/15/2025 at 9:00 AM during the brief tour of kitchen revealed the following: Mealtime schedule posted in the dining room noted lunch was served at 11:30 AM. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. The walk-in refrigerator contained unlabeled and open bag of lettuce mix. Observation on 4/15/2025 at 11:30 AM first meal service revealed old menus dated 03/05/2025 were posted in the dining room. Observation of cook, [NAME] L preparing puree foods on 4/16/2025 at 10:51 AM revealed he used water as the liquid to puree cornbread muffin. He was not following a specific recipe. Observation on 4/16/2025 at 1:09 PM of the survey test tray revealed the following: Regular diet chili temperature reading was 110 degrees and taste of test tray by surveyor found it was flavorless. Regular diet corn temperature reading was 109 degrees and taste of test tray by surveyor found it was tasteless. Puree chili temperature reading was 109 degrees and taste of test tray by surveyor found it was flavorless. Puree corn temperature reading was 95 degrees and taste of test tray by surveyor found it was tasteless. In an interview on 4/15/2025 at 9:31 AM the DM stated the residents were not enjoying the facility meals because they were not feeling the Louisiana menu he was currently using to prepare foods from. He stated the company he procures product for provides a Louisiana menu and he was working on making the switch to a local, Texas procurement company. He stated there were contracts being worked on which will transition the facility over to a Texas menu beginning May 1, 2025. In an interview on 4/15/2025 at 10:48 AM Resident #67 stated he doesn't care for the meals being served from the kitchen and prefers the alternate choices of hamburgers, hotdogs, corndogs, and pizza. He stated 1-2 times per week he will choose the alternate meal because he was tired of constantly eating rice and beans and would prefer other options like chicken with mashed potatoes and carrots. In an interview on 4/15/2025 at 12:37 PM Resident #73 stated, she hates the lunch, she hasn't eaten the facility food in so long, roughly two years. She stated she used to eat the meats served for protein, but the food has become cardboard, really tough, and flavorless. She stated the alternative grilled cheese sandwiches were a joke, the food was cold, smells horrible at times and the flavor was poor. In an interview on 4/15/2025 at 12:10 PM Resident #56 stated she normally doesn't eat because she doesn't like the meals that were served. She said she was not happy with meals. She stated she doesn't like the alternatives because they were not cooked well. She stated she would rather eat cereal than to eat the food being served. She stated she likes fruit, but it doesn't look appetizing. In an interview on 4/16/2025 at 9:20 AM Resident #39 stated food was mediocre. The resident stated mashed potatoes are served practically every day , the seasoning is very poor, and boring. She can ask for alternative of some sort of sandwich if she doesn't care for the food. In an interview on 4/16/2025 at 9:57 AM Resident #64 stated his eggs were burnt, this morning and he didn't care for the breakfast. In an interview on 4/16/2025 at 9:10 AM Resident #46 stated he did not like breakfast, the food has no taste to it, meat was dry, and cold. He stated he eats in the dining room and will be provided a substitute meal when he doesn't like what was being served. He stated he will usually ask for cereal, [NAME] Krispies. In an interview on 4/17/2025 at 2:21 PM the DM stated the Dietician provides him training on preparing menus, hand sanitation, food procurement, following recipes, diets, and puree preparation and in turn he trains the dietary staff. Surveyor asked DM for in-service logs during this interview, and he stated he doesn't complete his own in-service logs and the ADM would have in-service logs. He stated he would reach out to the ADM and obtain logs for surveyor (logs not provided prior to exiting). He stated the protocol for pureeing foods was to use milk, butter, gravy, broth, and thickening powder, if necessary, but to not use water. He stated he was unsure why [NAME] L would use water when pureeing foods as he knows it has no nutritional value. He stated he has the supplies needed to puree foods. He stated he was expected to follow the menus and understands he can add to the menu just not remove items or seasonings. He stated he will typically taste the food and believes it was good quality and flavorful and would eat it himself and he doesn't have concerns serving to the residents. He stated he was aware several residents were declining the meal trays, and he has instructed aids to notify him so he may offer a substitute. He stated he does not have substitutions documented. He stated he has been informed by aids and residents the food lacks flavor and would like other foods and he stated he wants to provide the residents with flavorful, edible, and presentable food so they would want to eat it. He stated the 8 lettuce heads in the walk-in refrigerator have been in there for four weeks now pending company picking up and he would have to follow-up with the company. He stated he did not inspect the food quality at delivery, and he had some items that was returning. He wasn't aware he needed to label it. He stated the black ripe bananas were kept in the kitchen for residents who require soft foods for consumption. He stated the expectation was for cooks to begin meal prep no more than two house prior to meal service. He discussed that he was not aware that [NAME] L was preparing lunch as early as 9:00 am on 4/15/2025 and that this can cause concerns for residents. In an interview on 4/17/2025 at 2:54 PM the ADM stated the DM receives in-services directly from the Dietician. The ADM stated the expectation was for the food to be warm and appetizing, that it tastes good, right temperature, and nutritious. The ADM stated she was aware of a few residents not liking the meals and being offered alternatives, which they decline as they were provided meals by their family. Surveyor requested in-service logs for all dietary staff (not provided to surveyor prior to exiting). In an interview on 4/17/2025 at 2:54 PM the DON stated she was aware that some residents don't like the type of food that was being prepared by the kitchen and were offered alternatives. She stated some residents have notified her that the food was sometimes cold, but this wasn't often. Record Review of Storage Freezer: Dietary Policy, no date revealed 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 2. Label and date all items. Record Review of Storage: Refrigerator: Dietary Policy, no date revealed 7. Keep refrigerated foods wrapped or covered and in sanitary containers. Record Review of Dietary Daily Functions: Dish machine: Dietary Policy, no date revealed Monitor and record temperatures and sanitizer solution at each meal. Record Review of Meal Delivery: Dining Rooms: Dietary Policy, no date revealed 3. Service must be prompt and efficient so that food will remain at the appropriate temperatures for consumption. 5. If the resident refuses any food item, the kitchen will supply a substitute of similar nutritive value. Acceptance or refusal of such substitution should be documented. Record Review of Menu Planning: Dietary Policy, no date revealed Menus will be posted and clearly visible to residents. Record Review of Dietary General Policies: Organizational Goals: Dietary Policy, no date revealed Provide the best quality food and food service for the residents within the budget as predetermined by the administration and according to established guidelines of all other regulatory agencies.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #18) reviewed for ADL care. The facility failed to ensure Resident #18 was provided fingernail care. This failure could place residents at risk for not receiving adequate care and services to prevent infection, injury, and a diminished quality of life. Findings include: Record review of Resident #18's face sheet, dated 04/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 had diagnoses which included: Cerebral Infarction (a stroke occurs when blood flow to the brain is cut off), speech impairment related to stroke, Parkinson's disease (a chronic and progressive movement disorder that causes tremors, stiffness, or slowing of movement) with dyskinesia (uncontrolled, involuntary movements), hemiplegia (paralysis) and hemiparesis (weakness) affecting left side, and diabetes mellitus (a disease that affects how the body uses blood sugar). Record review of Resident #18's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #18 had impaired vision. Section E-Behavior reflected Resident #18 did not resist ADL care that was necessary to achieve the resident's goals for health and wellbeing. Section GG-Functional Abilities and Goals reflected Resident #18 needed substantial/maximal assistance with bathing and toileting hygiene, Resident #18 required partial/moderate assistance for personal hygiene. Record review of Resident #18's Comprehension Care Plan, revised on 04/16/2025, reflected she had limited physical mobility due to hemiplegia on left dominant side due to stroke. Interventions included, passive range of motion during ADL care daily, hand roll in left hand as tolerated, provide supportive care and assistance with mobility as needed. The care plan did not address nail care. Care plan reflected Resident #18 was resistant to nail care. Record review of Resident #18's task list for in PCC reflected nail care was scheduled to be provided by licensed nurse twice a week. Between 03/18/2025 through 04/15/2025, one refusal was documented on 04/01/2025. Record review of Resident #18's order summary did not reflect any order for nail care. Observation and interview on 04/15/2025 at 10:43 AM revealed Resident #18 was sitting in a wheelchair in her room watching television. Her left hand was closed in a fist, contracted, and she could not open it. Her left thumb nail was long and had rough edges. The resident stated she would like someone to trim her nails. In an interview on 04/15/2025 at 10:55 AM, CNA G stated Resident #18's nails on her left hand were really long. CNA G stated she could feel the long nails on the left hand when she gave Resident #18 showers and put soap into resident's left hand. CNA G stated Resident #18 could not open her left hand due to the contracture and moving it caused the resident pain. She was not aware of anyone trimming the resident's nails. CNA G stated she could not trim Resident #18 nails because the resident was diabetic and nail care was provided by the nurse. Observation and interview on 04/15/2025 at 03:16 PM revealed Resident #18's left thumb nail was long and had rough edges. Resident #18 stated she would like someone to trim her nails and she had not refused nail care, and no one provided nail care on 04/15/2025. Interview on 04/16/2025 at 03:57 PM, LVN B stated he was familiar with Resident #18 and her left hand was contracted. LVN B stated fingernails needed to be trimmed to avoid self-injury, skin issue and infection. LVN B stated he, the treatment nurse, or ADON could provide nail care. LVN B stated he had not provided nail care for Resident #18 because the resident was not his resident, and he was not aware Resident #18 needed nail care. LVN B stated he checked the residents' nails about once a week, but he didn't know how often he should be checking the residents' nails. He was not familiar with the policy or schedule of required nail care. Interview on 04/17/2025 at 10:07 AM, CNA F stated she was familiar with Resident #18 and she gave Resident #18 a shower this morning and noticed the resident's nails were long. Resident #18 left hand was contracted, and she required assistance with showers. CNA F stated CNAs could not provide nail care to Resident #18 because the resident was diabetic. She stated she would report her concern to the nurse on shift and ask them to cut the nails because the resident could hurt herself, cut her skin, or cause an injury to herself due to the long nails. Observation and interview on 04/17/2025 at 10:13 AM revealed Resident #18's left thumb nail was long and had rough edges. Resident #18 stated she would like someone to trim her nails and she had not refused nail care, and no one provided nail care on 04/17/2025. Interview on 04/17/2025 at 10:26 AM and 11:27 AM, RN E stated nail care was performed by any licensed nurse according to the tasks in the resident's chart. Normally, LVN C provided nail care to Resident #18, but she was unavailable to interview as she was in clinicals. RN E stated LVN C told her she trimmed Resident #18's nails a few weeks ago and forgot to sign off as task completed in PCC. RN E stated there was an error in the task function in PCC, which had been corrected. The check marks the state surveyor had observed were made by CNAs and they could not perform nail care on Resident #18 because she was diabetic. She stated Resident #18 was scheduled for nail care on 04/18/2025. RN E stated residents fingernails needed to be trimmed for the comfort, dignity, appearance and cleanliness. Also to avoid the risk of scratching self, skin wounds or digging into the palm of the hand due to the contracture on the left hand. RN E stated there was a policy that provided guidance on the frequency of nail care, but she did not know the details. All nursing staff were responsible for checking residents' nails, especially the CNAs. RN E stated CNAs needed to check nails to ensure they were clean and report to nurses any concerns with nails if they needed to be trimmed. Her expectation would be the nurse would provide nail care same shift/same day as nurse was notified nail care was needed. RN E viewed the photo of Resident #18's nails and that resident needed nail care and this would not meet her expectations. Interview on 04/17/2025 at 11:47 AM, RN D stated she was a wound care nurse and provided nail care to residents on Sundays but did not document nail care anywhere in PCC because she did not know where to document. RN D stated nurses and CNAs were supposed to be checking residents' nails once a week or every other week but did not know what the schedule for nail care was. RN D stated it was important to check residents' nails to avoid residents causing skin tears, self-injury, or infection concerns due to touching feces. RN D stated there was a policy about nail care, but she did not know the details. RN D stated she would provide nail care same day/as soon as possible if a staff member informed her of a concern with a resident's nails. RN D viewed a photo of Resident #18's nails and RN D stated residents needed nail care to avoid injury to self. Interview on 04/17/2025 at 12:02 PM the DON stated it was important for residents to receive nail care on Tuesdays and Fridays to keep nails short, clean, and avoid a skin issue. If a resident was diabetic, then any nurse or treatment nurse could provide nail care, otherwise, CNAs could trim nails, which was documented in the tasks in PCC. The DON stated CNAs and nurses were responsible for checking residents' nails and her expectation would be that nail care occurred the same day the nurse was notified or became aware that nail care was needed. The DON viewed a photo of Resident #18's nails and stated resident's nails needed to be trimmed immediately and this would not meet her expectation. Interview on 04/17/2025 at 12:06 PM the ADON stated that any nurse could provide nail care to residents with diabetes. The ADON stated nurses were responsible for checking residents' nails once a week and they should be documenting nail care in PCC under tasks. Nurses get alerts for residents scheduled for nail care in PCC and nurses should be checking those residents twice a week. The ADON would expect nurses' to trim nails if they were long, even if it was not the resident's scheduled day for nail trimming to avoid infection control issues. The ADON viewed a photo of Resident #18's nails and stated residents nails needed to be trimmed immediately and this would not meet her expectation. Interview on 04/17/2025 at 02:01 PM, the ADM stated she just became aware of the nail care concern when the state surveyor started asking questions. Before this, she thought Sunday was reserved for nail care for all residents. The ADM sated CNAs were responsible for checking residents' nails to ensure they were clean and to trim as needed or let the charge nurse know if they could not trim the nails. The ADM stated she just learned today once the state surveyor started asking questions that diabetic residents were different, and those residents needed to be handled by the nurses, not the CNAs. The ADM stated she knew diabetic residents had to have a podiatrist trim their toenails, but she never thought about residents' fingernails. The ADM stated the treatment nurse should be checking for nail care when doing skin rounds weekly. The ADM didn't know if their nail care policy required nail checking at a certain frequency, but she thought it should be done twice a week. The ADM stated it was important to check and trim nails as needed so the residents didn't get infections or scratch themselves. The ADM stated her expectation was the charge nurse would complete nail care the same day they become aware the resident needed nail care. The ADM stated long nails could dig into the palm of a resident who had contractures and could cause a wound or pain. Record review of the facility's, undated, policy titled Nail Care reflected: Policy: The purpose of this policy is to provide guidelines for the provision of care lo a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail care will be provided between scheduled occasions as the need arises. 3. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes Record review of the facility's, undated, policy titled Activities of Daily Living reflected the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to notify their Abuse and Neglect Coordinator (The ADM) within 2 hours when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing . He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . . 2. The facility has designated the Administrator as the Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F609 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F609 ' The facility must ensure all allegations of abuse are reported immediately but no more than two hours after the allegation is made. The facility failed to ensure the safety of Resident #1 during and after she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. The facility did not self-report this allegation the Administrator. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP , report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN /new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: K. Responding immediately to protect the alleged victim and integrity of the investigation; L. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; M. Increased supervision of the alleged victim and residents; N. Providing emotional support and counseling to the resident during and after the investigation, as needed; O. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: K. Responding immediately to protect the alleged victim and integrity of the investigation; L. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; M. Increased supervision of the alleged victim and residents; N. Providing emotional support and counseling to the resident during and after the investigation, as needed; O. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/02/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice, dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW had a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of four residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement the facility abuse policy when they failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis. Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared. She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing. He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. . 3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . 6. Providing complete and thorough documentation of the investigation. VI. Protection of the Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F607 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F607 - The facility must develop and implement written policies and procedures that prohibit and prevent abuse. The facility failed to follow their policies and procedures related to abuse. The facility failed to ensure CNA A was suspended/terminated or removed from working with Resident #1 after the incident, causing more emotional distress. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through (reporting system), report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN/new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: F. Responding immediately to protect the alleged victim and integrity of the investigation; G. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; H. Increased supervision of the alleged victim and residents; I. Providing emotional support and counseling to the resident during and after the investigation, as needed; J. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: F. Responding immediately to protect the alleged victim and integrity of the investigation; G. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; H. Increased supervision of the alleged victim and residents; I. Providing emotional support and counseling to the resident during and after the investigation, as needed; J. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/02/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice, dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHSC as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to investigate an allegation of abuse when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage . She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing. He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened . He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have been able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. . 3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . 6. Providing complete and thorough documentation of the investigation. VI. Protection of the Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F610 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. The facility failed to thoroughly investigate an allegation of abuse after the DON was notified of an incident with CNA A and Resident #1 when she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP , report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN/new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: P. Responding immediately to protect the alleged victim and integrity of the investigation; Q. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; R. Increased supervision of the alleged victim and residents; S. Providing emotional support and counseling to the resident during and after the investigation, as needed; T. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: P. Responding immediately to protect the alleged victim and integrity of the investigation; Q. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; R. Increased supervision of the alleged victim and residents; S. Providing emotional support and counseling to the resident during and after the investigation, as needed; T. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/03/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice , dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A ) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] then comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing . He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee been able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse . 'Willful' means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. 'Physical Abuse' includes, but is not limited to, hitting, slapping, punching, biting, and kicking. 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F600 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F600 ' The facility failed to keep the residents free from abuse. The facility failed to ensure the safety of Resident #1 during and after she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. The facility failed to ensure CNA A was suspended/terminated or removed from working with Resident #1 after the incident, causing more emotional distress. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP (reporting system), report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN /new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Providing emotional support and counseling to the resident during and after the investigation, as needed; E. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Providing emotional support and counseling to the resident during and after the investigation, as needed; E. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/023/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice , dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW had a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations interview, and record review, the facility failed to provide adequate supervision and assistive devices and ensure the resident environment remained as free of accident and hazards as possible for one (Resident #1) of four residents reviewed for accidents and hazards, in that: The facility failed to ensure transportation was available for Resident #1's dialysis appointment on 01/10/24. While being pushed to the center, her wheelchair fell over causing her to fall out of the wheelchair resulting in a tibia fracture to her right leg. The noncompliance began on 01/10/2024 and ended on 01/11/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing pain, injuries, a decreased quality of life, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, muscle wasting and atrophy (wasting away), end-stage renal disease, osteoporosis (a condition when bone strength weakens and is susceptible to fracture), type II diabetes, and dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum). Review of Resident #1's quarterly MDS assessment, dated 12/12/23, reflected a BIMS of 15, indicating no cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected she received dialysis treatments. Review of Resident #1's quarterly care plan, revised 01/22/24, reflected she was at risk for falls with an intervention of monitoring for changes in condition that may warrant increased supervision/assistance and notify the physician. She required dialysis with an intervention of providing/coordinating transportation to the dialysis center. She required two-person assistance with ADLs. Review of Resident #1's hospital discharge paperwork, dated 01/10/24, reflected the reason for the visit was because of a fall. She was diagnosed with a closed fracture of the proximal end of her right tibia . Review of Resident #1's progress notes in her EMR, dated 01/10/24 and documented by LVN A, reflected the following: Approx. 9:40 am, [LVN A] was pushing [Resident #1] in wc to dialysis appt. on way there, [LVN A] rolled over uneven sidewalk causing [Resident #1] to topple over with wc and [LVN A]. [LVN A] was able to hold [Resident #1] arm to keep her from hitting her head. [Resident #1] fall was broken by her Lbka stump and rt leg/knee. Bystanders stopped to help [LVN A] get [Resident #1] into her chair using hoyer sling. Arrived to dialysis appt and called 911. [Resident #1] had rapid swelling to rt shin. [Resident #1] was transported by EMS to ER for evaluation and assessment and will complete dialysis at hospital after ER assessment . During an interview on 01/23/24 at 9:48 AM, the ADM stated he had only been at the facility for a little more than a month. He stated they have three residents that go to dialysis for treatment. He stated they have a full-time Transportation Director (TD) that utilized their facility van for resident appointments. He stated he had heard of the staff in the past occasionally taking residents to dialysis themselves as the dialysis center was .4 miles away from the facility. He stated after the incident with Resident #1 on 01/10/24, there would be no more instances of staff taking residents to dialysis without transportation. He stated on 01/10/24, there had been an accidental double-booking and the van had not been available. He stated for the future, all residents will be transported by their facility van or a third-party transportation service and staff had been in-serviced on that. During an interview on 01/23/24 at 10:16 AM, Resident #1 stated the incident on 01/10/24 was scary. She stated she was normally transported to her dialysis appointments by the facility van, but for some reason it was not available that day. She stated she was told that morning by the DON that she was going to be pushed there by LVN A and she told the DON she did not want her (LVN A) to take her as she was too small. She stated they were crossing the street to get to the sidewalk when the wheelchair started gaining momentum and it got caught on the lip of the wheelchair ramp and she flipped over and out of the chair onto her left side. She stated she and LVN A were both panicking but they were blessed when a truck of construction workers stopped and helped put her back in her wheelchair. She stated they did not call 911 but the dialysis center did once they made it there. She stated she did not believe LVN A had her phone with her. She stated she had been in so much pain to her left arm and her right leg. She stated her left side was bruised and her right leg had a broken tibia. She stated she continued to be in a lot of pain every day since then and it hurt every time the aides tried to roll her over to change her brief. Resident #1 became extremely tearful and raised her voice stating, I do not know why they did not have a backup (vehicle)! It really irks me. She stated she would never let someone push her to dialysis again. During an interview on 01/23/24 at 11:18 AM, the DON stated she had not been informed transportation for Resident #1 was not available on 01/10/24. She stated their TD scheduled resident appointments and tried to ensure he was not double-booked. She stated if he did notice a double-booking, he normally notified her before the day arrived and it was unusual she did not find out until the morning of 01/10/24. She stated LVN A made the right call by taking her to dialysis herself. The DON stated after Resident #1 fell , it would be her expectation that she was assessed - head-to-toe, assessed for pain, if she could move her limbs, and look for any deformities. She stated she does believe LVN A assessed her. She stated she was not okay with the construction men assisting with Resident #1's transfer from the ground to the wheelchair because they did not know the resident and the facility did not know them. She stated that could have caused harm or injury to the resident. She stated if it were her and she did not have her phone, she would have asked the strangers to call 911. She stated all nurses have different levels of experience but believed LVN A did the right thing. During an interview on 01/23/24 at 11:37 AM, RN B stated no residents should be transported to any appointments unless they were in the facility van or by a third-party transportation company. During an interview on 01/23/24 at 11:42 AM, the TD stated he did not believe LVN A should have taken the resident to the clinic as the walk was uphill. He stated he had worked there a few months and was not aware if this had happened ever before. He stated he notified LVN A and the DON on 01/07/24 that there was a double-booking and LVN A stated that it was okay and she would just walk her. He stated he had been in-serviced that no residents were to be sent to appointments unless they were being transported by their van or a third-party transportation company. During an interview on 01/23/24 at 2:18 PM, Resident #1's MD was asked what kind of assessments should have been completed by LVN A before Resident #1 was transferred. He stated, When you take your car to the shop, some will have master Mechanics and 'everyone had their own protocols.' At the end of the day, it would depend on the expertise of that person (LVN A). He stated on that particular day (01/10/24), LVN A did good. He stated she was put in a difficult situation and she tried to do a good action. He stated an assessment would be expected to be done but would depend on the complaint and what symptoms of trauma the resident was displaying. During an interview on 01/23/24 at 2:36 PM, LVN C stated if their van was unavailable for a resident appointment, the procedure was to contact a third-party company or anyone the facility contracted with. He stated he was taught that after a resident had fallen, he would assess them immediately. He stated he would check for injury and check vital signs before moving them. During an interview on 01/23/24 at 2:41 PM, LVN D stated a resident should never be transferred to dialysis by a staff member. He stated all residents should be transported to appointments by the facility van, or if unavailable, out-source to ambulance services or another third-party company. During a telephone interview on 01/24/24 at 4:50 PM, LVN A stated she had never walked a resident over for dialysis treatment. She stated when she realized the van would not be accessible on 01/10/24, she thought it would have been easy to just take Resident #1 to dialysis as it was not that far down the road. She stated the trek was more difficult than she thought. She stated part of her wheelchair got stuck on the curb and Resident #1 went flying out and onto her left side. She stated she (LVN A) and the wheelchair fell on top of Resident #1. She stated she was able to ensure Resident #1 did not hit her head. She stated she had assessed her, asked her if she was in pain, but she did not have any instruments with her to take her vitals. She stated she had left her phone at the facility and was unable to contact 911. She stated a truck drove by with several men and they stopped to help. She stated each person picked up one corner of Resident #1's hoyer sling while she held her legs straight. She stated by the time she got Resident #1 to the dialysis clinic her pain was escalated. She stated she rolled up her right pant leg and her leg was extremely swollen. She stated 911 was called and she was taken to the hospital. She stated she would never do something like that again, as she felt so bad that she broke the resident's leg. She stated they were in-serviced on utilizing a third-party company if the facility van was unavailable. Review of the facility's van appointment book, from 01/01/24 - 01/31/24, reflected there were no two resident appointments scheduled around the same time of each other. Review of the facility's in-service, dated 01/11/24 and conducted by the ADM, reflected the following: Do not double book unless you have alternative transportation set-up. Notify the ADM of any conflicts. All dialysis residents to be taken by w/c van or (third-party transportation company). A request for a facility policy on Transporting Residents to Appointments was made but was informed they did not have a related policy.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one of ten residents (Resident #1) reviewed for notification of change. The facility failed to ensure Resident #1's physician was consulted when she slept for 25 hours after an unwitnessed fall resulting in required intubation (a medical procedure that involves passing a tube into a person ' s airway to help with airway management and breathing) and two craniotomies (a brain surgery that involves cutting a piece of the skull to reach the brain and then putting it back) because of injuries sustained. This failure resulted in the identification of an IJ on 09/06/23 at 05:20 PM. IJ template was provided to the facility on [DATE] at 05:26 PM. While the immediacy was removed on 09/09/23 at 09:45 AM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments and notification to the physician. This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls . Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism , gastroesophageal reflux disease, mild protein-calorie malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #1 dated 07/12/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident #1 dated 07/05/23 reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation. Review of a care plan item for Resident #1 dated 07/05/22 reflected the following: Care Plan Description- Code status: Full Code Care Plan Goal- Resident's advance directive will be followed as specified Directive: full code Care Plan Interventions- Allow family to expressed feelings and concerns regarding their family member. Give emotional support. Allow family to discuss concerns and allow them privacy when visiting. Notify MD/RP of changes in resident's condition. Respect and give support for resident and family regarding code status. Review of a nurse practitioner exam note dated 08/15/23 reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated 09/02/23 reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident beside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated 09/03/23 reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: 09/02/23 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Neuros within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified (FM). On-call admin apprised on-call for (PCP). 09/03/23 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and, then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. 09/03/23 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. 09/03/23 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. 09/03/23 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fell ow patients and upon group disbursing. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. 09/03/23 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. 09/03/23 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. 09/03/23 09:30 PM by LVN F Right hip x-ray negative for fracture. 09/04/23 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. 09/04/23 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Neuros within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. 09/04/23 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. 09/04/23 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. 09/04/23 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. 09/04/23 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. 09/04/23 09:30 PM by RN C No change in condition. Pulse 90 BP 156/78, respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: 09/02/23 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep 09/03/23 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep 09/04/23 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep 09/05/23 12:15 AM Hospital Review of Emergency Documentation for Resident #1 dated 09/05/23 at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated 09/05/23 at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum 09/05/23 (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on 08/06/23 at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on 08/06/23 at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two burr holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on 08/06/23 at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on 09/04/23, the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on 09/02/23 and 09/03/23, but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on 09/02/23. LVN D stated when he came onto shift at 06:00 AM on 09/04/23, the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on 09/04/23 at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on 09/04/23, the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. An attempt was made by telephone on 09/09/23 at 02:32 PM to interview NP A and voicemail left but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:34 PM to interview the PCP for Resident #1 and voicemail left but no return contact was received. During an interview on 09/06/23 at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident to be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had, to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. An attempt was made by telephone on 09/09/23 at 03:12 PM to interview LVN E but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:13 PM to interview LVN F and voicemail left but no return contact was received. During an interview on 09/06/23 at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on 09/03/23 after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The ADON stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on 09/06/23 at 3:32 PM, the DON stated she had worked the floor on 09/03/23, and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell , she was upset. The DON stated that all unwitnessed falls resulted in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on 09/04/23 and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they were checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The DON stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility a short time and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on 09/06/23 at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that, to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day 09/03/23, and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they initiated the neurological checks . The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened 09/04/23 where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. Review of undated facility policy titled Acute Condition Changes- Clinical Protocol reflected the following: Assessment and recognition 1. During the initial assessment, the nurse shall assess and document/report the following baseline information: vital signs; a. Neurological status; b. Current level of pain; c. Level of consciousness d. Cognitive and emotional status e. Residence, age and sex; f. History of psychiatric disturbances, mental illness, depression, etc. g. All active diagnoses; and h. All current medications. 4. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; a. Phone calls to attending or on-call physician should be made by an adequately prepared nurse, who has collected and organized, pertinent information, including the residents current symptoms, and status. 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately 1/2 hour or less). 6. The Attending Physician, or a practitioner, providing back up coverage, will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The Nurse and Physician will discuss and evaluate the situation. a. The physician should ask questions to clarify the situation; for example, vital signs, physical findings, and a description of symptoms. Treatment/Management 1. The physician will help identify and authorize appropriate treatments. 2. If it is decided, after sufficient review, the care or observation cannot reasonably prove be provided in the facility, the attending physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. On 09/09/23 at 05:26 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided and POR requested. The facility's POR was accepted on 09/08/23 at 05:08 PM and included: 580 Plan of Removal Introduction: On September 6, 2023, an immediate Jeopardy was identified because of resident falls. Resident 1 sustained two falls within 13 hours, was hospitalized after sleeping for a period of 25 hours. Resident was diagnosed with two brain bleeds, underwent surgery for repair. Resident 1 remains on a ventilator and may not recover. All current residents at (facility) center are at risk of falling and have the potential to be impacted by this deficient practice. 1. As a result of the IJ, the facility has implemented the following. Administrator, DON, were in serviced by chief nursing officer, as well as regional nurse: healthcare, regarding resident changes in condition, follow up, incident and accident, monitoring staff, staff, reporting of incidents and changes in condition/neurochecks. Admin and DON in serviced on the need for increased staff education and monitoring new hires and agency staff. Both verbalized understanding. 2. ADON was in serviced by corporate/regional nurse: regarding Resident changes in condition, follow up, incidents and accidents, monitoring staff, staff reporting of incidents and changes in condition/neurochecks. Admin and DON in-serviced on the need for increased staff education and monitoring, including new hires and agency staff. Both verbalized understanding. 3.As a result of the two falls Resident 1 sustained the facility, DON & ADON on 9/6/23 at 6 PM implemented the following: a. all on duty nursing staff were in serviced on the following by DON and a DOM. i. MD notification of change in condition, including change in mental status/alertness ii. Notification of DON/administrator of any change in condition iii. Resident and Falls, and follow up monitoring iv. Completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma v. Monitoring residents for change in condition, including sleeping for abnormal periods of time. b. Signs/symptoms of resident change of condition to include, but not limited to: i. Mental status ii. Unarousable while sleeping iii. Changes to pupils iv. Changes to normal behavior patterns v. Inability to/or refusing to eat, drink, or take medications c. These in-services were completed on 9/7/23 4. All other nurses will be in service prior to starting their next scheduled shift. The DON, or designee will train the nurses. 5. All nurses will be tested for understanding in these areas and re-educated if they do not score 100% on the test. 6. The facility will add additional falls and neurological check training for the nurses. DON, ADON, will provide training and in-service training to nurses upon higher, and then semiannually and staff in-services. 7. Additionally, DON/ADON have in-serviced nurses by phone prior to the start of their next shift. 8. A reference binder has been set up for nursing staff to quickly access policy on incidents and accidents and neurological checks. New hires, agency, staff, and existing stuff will be oriented to the location of the information. And will complete the in-service and related test 9. Completion date, 9/7/2023 at 7 AM 10. The facility completed an internal review and audit of falls for the past 90 days. The review was completed by administrator, corporate/regional nurse, and DON/ADON. All resident falls were reviewed for the potential of head injury. Files that were identified a sustaining a head injury were audited for compliance with the fall policy. a. The facility identified 101 total incidents in the review. Period 86 of which were false. b. Facility reviewed all 86 falls and identified 15 initially identified as head injuries or potential head injuries. A review of the other 71 Falls was conducted. The review found 63 where neurological checks were performed. Instances of incomplete documentation were noted. No adverse were identified during the review. c. Additional in servicing was initiated, to reinforce earlier and service on documentation, and the requirement on documentation completion and follow up. d. This review was completed on 9/7/23. The review identified additional in-services completed regarding incident reporting a neurological checks. 11. The facility completed an ad hoc QAPI, regarding the incident resulting in the IJ. QAPI committee will add Resident Falls with, and without head injuries to the agenda, and will review data for eight weeks. Additionally falls will be reviewed in the morning QA, a specific file review has been added to the daily QA meeting. The POR was monitored in the following ways: Observation on 09/09/23 at 08:30 AM revealed the DON in-servicing two agency medication aides. The DON went over the detailed information in the in-service including protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. During interviews on 09/07/23 between 04:30 PM and 05:15 PM, one RN, three LVNs, and two CNAs stated they had be in-serviced on protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. The RN and LVNs stated they had also been in-serviced on the signs and symptoms that should be reported dur [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care including but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident needs for one of ten residents (Resident #1) reviewed for assessment of change in condition. The facility failed to ensure Resident #1 received timely intervention following assessment when she slept for 25 hours after an unwitnessed fall, and she required intubation and two craniotomies (a surgical procedure that involves the removal of a part of the bone from the skull or cranium to expose the brain) because of injuries sustained. This failure resulted in the identification of an IJ on 09/06/23 at 05:20 PM. IJ template was provided to the facility on [DATE] at 05:26 PM. While the immediacy was removed on 09/09/23 at 09:45 AM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments. This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls. Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism, gastroesophageal reflux disease, mild protein-calorie, malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS for Resident #1 dated 07/12/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident # dated 07/05/23 reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation. Review of a nurse practitioner exam note dated 08/15/23 reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated 09/02/23 reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident bedside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated 09/03/23 reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: 09/02/23 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Narrows within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified ((FM)). On-call admin apprised on-call for (PCP). 09/03/23 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. 09/03/23 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. 09/03/23 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. 09/03/23 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fell ow patients and upon group disbursement. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. 09/03/23 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. 09/03/23 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. 09/03/23 09:30 PM by LVN F Right hip x-ray negative for fracture. 09/04/23 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. 09/04/23 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Narrows within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. 09/04/23 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. 09/04/23 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. 09/04/23 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. 09/04/23 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. 09/04/23 09:30 PM by RN C No change in condition. Pulse 90 BP 156/78, respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: 09/02/23 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep 09/03/23 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep 09/04/23 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep 09/05/23 12:15 AM Hospital Review of Emergency Documentation for Resident #1 dated 09/05/23 at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated 09/05/23 at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum 09/05/23 (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on 08/06/23 at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on 08/06/23 at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two burr holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on 08/06/23 at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on 09/04/23, the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on 09/02/23 and 09/03/23, but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on 09/02/23. LVN D stated when he came onto shift at 06:00 AM on 09/04/23, the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on 09/04/23 at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on 09/04/23, the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. She stated the outcome for the resident was very sad. An attempt was made by telephone on 09/09/23 at 02:32 PM to interview NP A and voicemail left but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:34 PM to interview the PCP for Resident #1 and voicemail left but no return contact was received. During an interview on 09/06/23 at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. He stated what had occurred with Resident #1 was very unfortunate. An attempt was made by telephone on 09/09/23 at 03:12 PM to interview LVN E but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:13 PM to interview LVN F and voicemail left but no return contact was received. During an interview on 09/06/23 at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on 09/03/23 after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations, but she did not have any of this training documented. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The AODN stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on 09/06/23 at 3:32 PM, the DON stated she had worked the floor on 09/03/23, and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell , she was upset. The DON stated that all unwitnessed falls result in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on 09/04/23 and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they are checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The Don stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on 09/06/23 at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day 09/03/23, and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they put the neurological checks. The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened 09/04/23 where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. Review of undated facility policy titled Acute Condition Changes- Clinical Protocol reflected the following: Assessment and recognition 1.During the initial assessment, the nurse shall assess and document/report the following baseline information: vital signs; i. Neurological status; j. Current level of pain; k. Level of consciousness l. Cognitive and emotional status m. Residence, age and six; n. History of psychiatric disturbances, mental illness, depression, etc. o. All active diagnoses; and p. All current medications. 4. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; a. Phone calls to attending or on-call physician should be made by an adequately prepared nurse, who has collected and organized, pertinent information, including the residence current symptoms, symptoms, and status. 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately 1/2 hour or less). 6. The Attending Physician, or a practitioner, providing back up coverage, will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The Nurse and Physician will discuss and evaluate the situation. a. The physician should ask questions to clarify the situation; for example, vital signs, physical findings, and a description of symptoms. Treatment/Management 3. The physician will help identify and authorize appropriate treatments. 4. If it is decided, after sufficient review, the care or observation cannot reasonably prove be provided in the facility, the attending physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. On 09/06/23 at 05:20 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided. The facility's POR was accepted on 09/08/23 at 05:08 PM and included: 726 Plan of Removal Introduction: On September 6, 2023, an immediate Jeopardy was identified because of resident falls. Resident 1 sustained two falls within 13 hours, was hospitalized after sleeping for a period of 25 hours. Resident was diagnosed with two brain bleeds, underwent surgery for repair. Resident 1 remains on a ventilator and may not recover. All current residents at Cypress Healthcare and Rehabilitation center are at risk of falling and have the potential to be impacted by this deficient practice. 12. As a result of the IJ, the facility has implemented the following. Administrator, DON, were in serviced by chief nursing officer, as well as regional nurse: healthcare, regarding resident changes in condition, follow up, incident and accident, monitoring staff, staff, reporting of incidents and changes in condition/neurochecks. Admin and DON in serviced on the need for increased staff education and monitoring new hires and agency staff. Both verbalized understanding. 13. ADON was in serviced by corporate/regional nurse: regarding Resident changes in condition, follow up, incidents and accidents, monitoring staff, staff reporting of incidents and changes in condition/neurochecks. Admin and DON in-serviced on the need for increased staff education and monitoring, including new hires and agency staff. Both verbalized understanding. 14. As a result of the two falls Resident 1 sustained the facility, DON & ADON on 9/6/23 at 6 PM implemented the following: d. all on duty nursing staff were in serviced on the following by DON and a DOM. vi. MD notification of change in condition, including change in mental status/alertness vii. Notification of DON/administrator of any change in condition viii. Resident and Falls, and follow up monitoring ix. Completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma x. Monitoring residents for change in condition, including sleeping for abnormal periods of time. e. Signs/symptoms of resident change of condition to include, but not limited to: vi. Mental status vii. Unarousable while sleeping viii. Changes to pupils ix. Changes to normal behavior patterns x. Inability to/or refusing to eat, drink, or take medications f. These in-services were completed on 9/7/23 15. All other nurses will be in service prior to starting their next scheduled shift. The DON, or designee will train the nurses. 16. All nurses will be tested for understanding in these areas and re-educated if they do not score 100% on the test. 17. The facility will add additional falls and neurological check training for the nurses. DON, ADON, will provide training and in-service training to nurses upon higher, and then semiannually and staff in-services. 18. Additionally, DON/ADON have in-serviced nurses by phone prior to the start of their next shift. 19. A reference binder has been set up for nursing staff to quickly access policy on incidents and accidents and neurological checks. New hires, agency, staff, and existing stuff will be oriented to the location of the information. And will complete the in-service and related test 20. Completion date, 9/7/2023 at 7 AM 21. The facility completed an internal review and audit of falls for the past 90 days. The review was completed by administrator, corporate/regional nurse, and DON/ADON. All resident falls were reviewed for the potential of head injury. Files that were identified a sustaining a head injury were audited for compliance with the fall policy. e. The facility identified 101 total incidents in the review. Period 86 of which were false. f. Facility reviewed all 86 falls and identified 15 initially identified as head injuries or potential head injuries. A review of the other 71 Falls was conducted. The review found 63 where neurological checks were performed. Instances of incomplete documentation were noted. No adverse were identified during the review. g. Additional in servicing was initiated, to reinforce earlier and service on documentation, and the requirement on documentation completion and follow up. h. This review was completed on 9/7/23. The review identified additional in-services completed regarding incident reporting a neurological checks. 22. The facility completed an ad hoc QAPI, regarding the incident resulting in the IJ. QAPI committee will add Resident Falls with, and without head injuries to the agenda, and will review data for eight weeks. Additionally falls will be reviewed in the morning QA, a specific file review has been added to the daily QA meeting. The POR was monitored in the following ways: Observation on 09/09/23 at 08:30 AM revealed the DON in-servicing two agency medication aides. The DON went over the detailed information in the in-service including protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. During interviews on 09/07/23 between 04:30 PM and 05:15 PM, one RN, three LVNs, and two CNAs stated they had be in-serviced on protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. The RN and LVNs stated they had also been in-serviced on the signs and symptoms that should be reported during neurological checks: mental status, unarousable while sleeping, changes to pupils, changes to normal behavior patterns, and inability to/or refusing to eat, drink, or take medications. During an interview on 09/08/23 at 07:55 AM, an overnight LVN stated she had been in-serviced on protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion o [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of fourteen residents (Resident #1) reviewed for falls and supervision. The facility failed to prevent Resident #1 from falling again on [DATE] after an initial fall on [DATE]. She sustained two subdural hematomas, required intubation (mechanical breathing), and underwent two craniotomies (surgical operation on skull) and died on [DATE]. This failure resulted in the identification of an IJ on [DATE] at 02:05 PM. IJ template was provided to the facility on [DATE] at 02:07 PM. While the immediacy was removed on [DATE] at 04:50 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments and notification to the physician . This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls. Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism, gastroesophageal reflux disease, mild protein-calorie malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #1 dated [DATE] reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers as well as toileting and other ADLs. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident #1 dated [DATE] reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation . Review of a nurse practitioner exam note dated [DATE] reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated [DATE] reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident beside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated [DATE] reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: [DATE] 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Neuros within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified (FM). On-call admin apprised on-call for (PCP ). [DATE] 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and, then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. [DATE] 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. [DATE] 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. [DATE] 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fell ow patients and upon group dispersing. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. [DATE] 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. [DATE] 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. [DATE] 09:30 PM by LVN F Right hip x-ray negative for fracture. [DATE] 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. [DATE] 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Neuros within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. [DATE] 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. [DATE] 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. [DATE] 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. [DATE] 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. [DATE] 09:30 PM by RN C No change in condition. Pulse 90 BP ,d+[DATE], respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: [DATE] 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep [DATE] 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep [DATE] 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep [DATE] 12:15 AM Hospital Review of hospital Emergency Documentation for Resident #1 dated [DATE] at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated [DATE] at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum [DATE] (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on [DATE] at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on [DATE] at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two burr holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on [DATE] at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on [DATE], the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on [DATE] and [DATE], but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on [DATE]. LVN D stated when he came onto shift at 06:00 AM on [DATE], the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on [DATE] at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on [DATE], the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. She stated the outcome for the resident was very sad. An attempt was made by telephone on [DATE] at 02:32 PM to interview NP A and voicemail left but no return contact was received. During an interview on [DATE] at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident to be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had, to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. He stated what had occurred with Resident #1 was very unfortunate. An attempt was made by telephone on [DATE] at 03:12 PM to interview LVN E but no return contact was received. During an interview on [DATE] at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on [DATE] after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The ADON stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on [DATE] at 3:32 PM, the DON stated she had worked the floor on [DATE], and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell , she was upset. The DON stated that all unwitnessed falls resulted in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on [DATE] and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they were checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The DON stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on [DATE] at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that, to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day [DATE], and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they initiated the neurological checks. The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened [DATE] where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. During a text interview on [DATE] at 11:22 AM, a FM of Resident #1 stated the following: Just wanted to inform you that my MIL passed away the night of [DATE] @ 10:15pm she had been transferred to (another local nursing facility) to live out her final days . she went 10 days without being able to eat or drink because she the trauma to her brain contributed to failing her barium swallow X-ray test a few days after we first met you at the hospital. Observation on [DATE] of an automated electronic monitoring video dated [DATE] at 10:37 AM revealed the door to Resident #1's bathroom opened, and LVN F stopped at the bedroom door for Resident #1, looked in, and then kept walking by. Resident #1 became visible from the other side of the bathroom door with her walker, the door was pushed out, and then the door began to fall closed again and pushed the walker over. Resident #1 fell to the right with the walker, and the right side of her head made contact with the floor. During an interview on [DATE] at 11:09 AM, LVN F stated she was the charge nurse for Resident #1 on the weekends, and she had worked with Resident #1 for a long time. She stated Resident #1 had lots of falls, so she did not remember all the falls perfectly. After being reminded that the fall in question was the one on [DATE] after which Resident #1 was sent to the hospital, LVN F stated she remembered the fall. LVN F stated just before the fall that morning, she had peeked in on Resident #1 because LVN F was getting ready to go to lunchbreak and wanted to check on Resident #1 for safety reasons. LVN F stated they were keeping a closer eye on her after the fall on [DATE] and subsequent agitation and fidgeting, and they were trying to get a urine specimen for some changes. LVN F stated during the fall on [DATE], Resident #1 had rolled out of bed because she was fidgety and restless. LVN F stated they had realized Resident #1 was restless having more anxiety than usual, so they were trying to keep her where she could see someone. LVN F stated Resident #1 was not in direct line of sight, but they kept her where there would be more instances of seeing people, so she would be calmer. LVN F stated Resident #1 had breakfast near her doorway that morning. LVN F stated Resident #1 was more anxious in the dining room, so she usually ate in her room, but the morning of [DATE], they put in place breakfast in her doorway to keep her closer to staff. LVN F stated the whole morning with Resident #1 was like that, so on her way out to lunchbreak, LVN F stopped to check, saw Resident #1 coming out of the bathroom, and Resident #1 was fine. LVN F stated she kept walking for a couple of seconds before the CNA called her back and said Resident #1 was on the floor. LVN F stated Resident #1 frequently toileted herself, and when LVN F saw Resident #1, she was not agitated, so LVN F let the resident do her thing. When asked how they do standby assist for residents who require standby assist for all ambulation, she stated they did not stay with those residents at all moments while the residents were ambulating. LVN F stated they could manage to do one-to-one supervision, as they basically initiated that after the fall the morning of [DATE]. LVN F stated if there was an extenuating circumstance, one-to-one could be provided. LVN F stated, as far as every day, they offered toileting on a frequent basis and tried to anticipate needs when they were in there serving meals. When asked if Resident #1 required constant supervision and standby assistance during ambulation, LVN F stated it depended on the day. LVN F stated Resident #1 was very different that day, which was why LVN F was checking on Resident #1 so often. During an interview on [DATE] at 11:31 AM, Resident #1's PCP stated he had a chance to review the hospital records for Resident #1. He stated the records reflected an acute-on-chronic subdural, which meant she may have had the injuries prior to the fall on [DATE], and there was no way to tell how or when they might have been sustained. The PCP stated he would be visiting the facility on Monday [DATE] and would look closely into the records and call back with a bigger picture. A return phone call was not received as of [DATE]. Review of facility's undated policy titled Fall Prevention, undated reflected the following: 'Environmental Hazards/Facility Staff Involvement & Training. All facility employees will be involved with the prevention of falls including providing assistance to any resident who appears to be at risk for an immediate fall and by immediately reporting or resolving environmental hazards. Facility staff will be trained during orientation and as needed thereafter.' On [DATE] at 02:05 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided and POR requested. The facility's POR was accepted on [DATE] at 12:35 PM and included: 689 Plan of Removal Introduction: On [DATE], an Immediate Jeopardy was identified because of resident falls. Resident 1 sustained 2 falls within 13 hours, on [DATE] and on [DATE]. The Resident was hospitalized after ER sleeping for a period of 25 hours. Resident was diagnosed with 2 brain bleeds, underwent surgery for repair. On [DATE] HHS re-entered on the original complaint from [DATE]. Resident 1 was discharged from the hospital, admitted to another care center, and passed away on [DATE]. Residents care plan indicated a required intervention of Assist with one staff member for all ambulation and assist with stand-by-assist for all ambulation. An additional Immediate Jeopardy was identified regarding accidents and hazards. All current residents at (facility name) are at risk of falling and have the potential to be impacted by this deficient practice. As a result of the IJ the facility has implemented the following: 1. On [DATE] at 1430 hrs. The Administrator and DON were in-serviced by Chief Nursing Officer. The in-service covered: a. Ensure that all residents have an accurate plan of care, including fall interventions and assistance required for ambulation. b. All residents must be reviewed to ensure accurate and appropriate interventions are care-planned and in place. c. Ensure that staff follows each resident's plan of care including fall prevention measures d. Ensure that staff assess and monitor residents for any status change and report change immediately. e. Each resident's plan of care to be reviewed by interdisciplinary team for accuracy and appropriate interventions. 2. On [DATE] at 1500 hrs. The Administrator in-serviced ADON regarding following resident care plans. MDS Nurses were in-serviced by Administrator and DON. ADON in-serviced staff on duty on following resident care plans, specifically for ambulation interventions for the 7 residents who were identified as having the following interventions listed: Assist with 1 staff member for all ambulation. Assist with stand-by-assist for ambulation. All nursing staff will be in-serviced by the DON or Designee prior to the start of their next shift. Training will be conducted face to face, telephone, and by facility nurses trained to deliver the in-service to agency staff. Nursing staff must verbalize understanding and be able to identify residents who require additional assistance for ambulation. An informational binder has been created to complete the in-service. A list of residents who have been identified as needing interventions with ambulation has been placed in the binder. Care plan training will be provided to new hires during floor orientation. 3. Completion date for care plan in-services [DATE] 10am. 4. Resident Care plans were reviewed by members of the IDT Team on [DATE]. A comparison was made to the MDS. The cross comparison identified 7 residents who could require stand-by-assist for ambulation or assist with 1 staff member for all ambulation. Reassessments by rehab and nursing were conducted on these 7 residents and completed on [DATE] 5. Facility Census was reviewed by Director of Rehab for other potential residents to be reassessed. Rehab Director identified 4 additional residents for consideration of additional supervision. These residents require assistance with set up of assistive devices. Including but not limited to ensuring wheelchairs and/or walkers are positioned close to the resident for transfer. These residents do not require stand by or 1:1 assistance with ambulation. 6. Facility reviewed resident care plans who have been care planned to have the following interventions: Assist with 1 staff member for all ambulation. Assist with stand-by-assist for ambulation. Residents were reviewed and in some cases a reassessment as completed to ensure proper fall interventions were implemented. A review of the individual residents fall history determined residents who received an updated fall assessment. Criteria included resident gait, resident changes of condition in the past 90 days, related to mobility. 7. Residents were reviewed by nursing and PT/OT staff. Upon completing of the review, Resident care plans were updated to reflect current interventions for residents who require assistance with ambulation. Care plans for the residents identified were updated by MDS Coordinators 1 and 2 on [DATE]. 8. Administrator in-serviced ADON regarding following resident care plans. ADON in-serviced [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards, in that: The facility failed on 08/09/23 to identify Resident #1 as a missing resident until they were notified that he had arrived at the hospital with facial abrasions, fractured teeth, and an inter-cranial hemorrhage (bleeding within the skull). This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization . An Immediate Jeopardy (IJ) existed from 08/09/23 - 08/09/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. Findings included: Review of Resident #1's undated face sheet reflected a[AGE] year old male who was admitted to the facility on [DATE] with diagnoses including history of TIA (stroke), type II diabetes, anxiety disorder, and unspecified dementia. Review of Resident #1's quarterly MDS assessment, dated 05/04/23, reflected a BIMS of 3, indicating a severe cognitive impairment. Section E (Behavior) reflected he had not shown signs of wandering. Section G (Functional Status) reflected he could ambulate independently. Section J (Health Conditions) reflected he had not had any falls since admission. Review of Resident #1's quarterly care plan, dated 08/04/23, reflected he was at risk for elopement with an intervention of having secured/coded exit doors. He also had poor safety awareness with an intervention of monitoring for changes in condition that may warrant increased supervision/assistance. Review of Resident #1's admission Elopement Risk Assessment, dated 09/22/22 , reflected that he did wander aimlessly but had not attempted to leave the facility. Review of Resident #1's nursing notes in his EMR, dated 08/09/23 and documented by LVN A, reflected the following: This nurse was notified that [Resident #1] had eloped and was in the hospital around 11:00 AM. This nurse last saw [Resident #1] at 8:15 AM. A nurse from (hospital) called and reported that [Resident #1] had been brought in around 10:00 AM and was in A-FIB . [Resident #1] being assessed at this time. Review of Resident #1's hospital records, dated 08/09/23, reflected the following: This is a [AGE] year-old male with history of dementia, diabetes, who presented to the emergency room after being found down. According to the ER physician [Resident #1] eloped from his nursing home and was found lying on the ground by a fire truck passing by. There is concern for possible syncope (fainting) and [Resident #1] was found with to be in atrial fibrillation upon arriving to the emergency room . [Resident #1] is amnesic to the events and does not know any events of today or where he lives . He does have an abrasion to his left cheek. [Resident #1] is on Plavix, per emergency room physician for CAD. CT imaging was concerning for a possible IVH and neurosurgery was consulted for evaluation. Impression: 1. Findings concerning for a small amount of intraventricular hemorrhage. 2. Multiple fractured teeth. Review of Resident #1's hospital records, dated 08/10/23, reflected the following: [Resident #1] found to have facial abrasions, multiple teeth fx, and IVH. Observation made of the facility's video surveillance of the front lobby, on 08/10/23 at 8:30 AM, revealed Resident #1 standing by the front door of the facility on 08/09/23 at 8:46 AM. Shortly after, PT B was seen pushing another resident in his wheelchair, bringing him in from the outdoor patio. Resident #1 was seen leaving through the open door. PT B acknowledged the wander guard alarm, looked back towards the door, and continued pushing the resident to the nurse's station. During an interview on 08/10/23 at 8:42 AM, the ADM stated he was notified immediately of Resident #1's elopement by LVN A around 11:00 AM on 08/09/23. He stated he and the DON immediately made sure all residents at the facility were accounted for, all wander guards were tested to ensure they were working properly on residents that had them, all residents were being checked and signed off on their whereabouts every two hours, a list of residents with wander guards were placed at the nurses' station and on all medication carts, a new sign was made for the front door that was neon green and had a red STOP sign, reminding staff and visitors to not let any residents exit the facility , and an Ad Hoc QAPI meeting was held on 08/09/23 with himself, the DON, ADON, and the MD. He stated all staff that were working on 08/09/23 were in-serviced on elopements, missing residents, and wander guards. He stated the staff that were not in attendance or unable to work the floor until they were in-serviced, including PRN and agency staff. He stated after he watched the surveillance camera video footage, he recognized there were several chances for the incident to have been diverted, such as PT B checking to see if Resident #1 had a wander guard on, or LVN C looking up his physician orders. During an interview on 08/10/23 at 9:24 AM, PT B stated the wander guard alarm did sound the previous day (8/09/23). He stated the resident he was working with used to have a wander guard and figured that was what set the alarm off. He stated he immediately went to the nurse's station and asked LVN C for the code to turn off the alarm. He stated he also informed LVN C that Resident #1 had gone outside and LVN C told him he was allowed to go outside by himself, and the alarm sounded because of the wander guard his resident had on. He stated he normally identified residents with a wander guard by checking their wheelchair or ankle, but he did not yesterday. He stated Resident #1 always walked around the facility, but he had never saw him attempting to exit the facility. He stated he was in-serviced yesterday on elopement, exit-seeking, wander guard alarm, and the list of residents with wander guards that was now posted at the nurse's station and on medication carts. During an interview on 08/10/23 at 9:35 AM, LVN C stated he had never worked as Resident #1's nurse, so he was not completely familiar with him. He stated Resident #1 was always walking around the facility and had never seen him exit-seek or attempt to leave the facility, so he did not know he had a wander guard. He stated he was in-serviced yesterday on elopement, the wander guard system, and documenting residents' whereabouts every two hours. He stated there was now an accessible list with the residents that required a wander guard. During an interview on 08/10/23 at 9:43 AM, LVN A stated he worked on Resident #1's hall on 08/09/23. He stated he almost always worked that hall, so he was very familiar with Resident #1. He stated he had a wander guard because he was ambulatory and liked to walk around the facility, but he had never seen him exit-seek or try to leave the facility. He stated on 08/09/23, he administered Resident #1 his morning medications. He stated he last saw him around 8:15 AM when he was leaving the dining room after breakfast. He stated he was no agitated or anxious, he was at his baseline. He stated he received a call from the hospital around 11:00 AM and was informed he had been brought into the ER and was going to be admitted into the ICU for further evaluation because he hit his head and was on blood thinners. He stated he was in-serviced yesterday (08/09/23) on elopement, exit-seeking behaviors, missing residents, wander guard alarms, and checking on resident whereabouts every two hours. Interviews conducted on 08/10/23 from 10:02 AM - 11:08 AM, three nurses, three aides, and one med aide were able to answer questions appropriately regarding elopement, exit-seeking behaviors, missing residents, and wander guard alarms. The nurses knew where to document resident whereabouts every two hours. All were able to describe exit-seeking behaviors such as agitation or constant pushing on exit door handles. Observations were made on 08/10/23 from 10:35 AM - 10:52 AM revealing a list of residents with wander guards on the nurses' station ad on all medication carts. Review of the resident observation check-off list, on 08/10/23, reflected all residents had been monitored from 08/09/23 at 11:00 AM - 08/10/23 at 11:00 AM every two hours. Review of the facility's Ad Hoc QAPI meeting, dated 08/09/23, reflected the following: QA initiated as follows: - Census checks every two hours by charge nurse of each hall - 100, 200, 400, and 500. - Wander guard checks on every resident on and working. - Administrator made rounds throughout the day and night. - Physician orders in place for the residents with wander guards. Review of the facility's in-service, dated 08/09/23 and ongoing, reflected staff were educated on every two-hour census checks on all residents - Check mark if present, or OOP if at appointment or signed out with family. They were all also in-serviced on exit-seeking behaviors, immediately going to see which resident left the facility if the wander guard alarm sounded, and the facility policies on resident elopement risks and the procedure when a resident went missing. Review of the facility's undated Elopement Risk policy reflected the following: The facility will make every attempt to provide adequate supervision to all residents. However, even when all precautions are taken, a resident who is independently mobile may be able to leave the facility grounds without being observed by the staff. . 3. The facility may maintain a locking door system whereby an at-risk resident would wear a safety device that activates a door alarm. Review of the facility's undated Elopement/Missing Residents policy reflected the following: As soon as a resident is determined to be missing, the Charge Nurse will immediately do the following: 1. Assign all available staff to systematically search the entire premises, both inside and outside, patient rooms, bathrooms, closets, kitchen, lobby, and offices. 2. Notify the Administrator and/or Director of Nursing. 3. Assign someone to speak to all staff present to determine when the resident was last seen. . 8. The Administrator will be responsible to review the safety procedures of the facility for needed changes.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of (Resident # 1) four residents reviewed for falls, in that: CNA A failed to get assistance while providing Resident #1 with a bed bath which resulted in Resident #1 rolling out of the bed and fractured multiple ribs. This deficient practice placed residents at risk for accidents, falls, fractures, and a diminished quality of life. Findings include: Review of Resident#'1s face sheet revealed an [AGE] year-old female with an admitted [DATE]. Diagnoses include anemia (a condition in which the blood doesn't have health red blood cell), unspecified lack of coordination, chronic ischemic heart disease (inadequate blood supply to the heart muscle), aneurysm (excessive localized enlargement of an artery caused by weakening of the artery wall) of unspecified site, urinary tract infection Review of Resident #1's admissions MDS assessment dated [DATE] reflected a BIMS score of 15, indicating no cognitive impairment. MDS reflected Resident #1 required 2 persons physical assist for bed mobility. Review of Resident #1's Care Plan dated 11/24/2022 at 4:30 p.m. reflected Resident #1 required bed mobility x 2 staff assistance and transfers x2 staff assistance. Review of Resident #1's fall risk assessment dated [DATE] reflected a score of 4. (Total score of 10 or above represent high risk). Review of an incident report dated 11/28/2022 reflected CNA A reported, Resident #1 assisted with turning while receiving bed bath and Resident #1 rolled out of bed onto the floor. Resident #1 was assessed for injuries, skin tear at right elbow was cleansed and 12 steri strips applied per MD's order. It was also reflected Resident #1 was sent to the local hospital ER for further evaluation per family request. Review of Hospital ER report indicated Resident #1 was admitted [DATE] for right sided chest pain. Record review of the Hospital Radiology reports: CT chest without contrast dated 11/28/2022 reflected, acute, nondisplaced right lateral fifth through ninth rib fracture. Record review of a hospital Discharge record reflected diagnoses of Multiple rib fractures, skin tear to the right elbow without complications. During an interview on 12/12/2022 at 11:37 a. m., CNA A stated on 11/28/2022, [Resident #1] was offered a shower or bed bath and [Resident #1] preferred bed bath. CNA A stated she turned [Resident #1] on her right side, [Resident #1] was stable, and her back was clean. CNA A stated she told Resident #1 she needed to be turned on the left side and [Resident #1] stated she needed assistance. CNA A stated she turned [Resident #1] to the left side and [Resident #1] was stable, [Resident #1] kicked her right foot over the left foot and fell over from the bed to the floor. CNA A stated there was nothing for [Resident #1] to hold onto. When asked how much assistance Resident #1 needed, CNA A stated she got in report that [Resident #1] was a 1 person assistance and that was the first time she was working with [Resident #1]. When asked if there is a place to look to know the care needs for assigned residents, CNA A stated yes, in the smart chart system is where the CNAs look to know how much assistance a resident need. When asked if CNA A checked Resident #1's bed mobility status before providing care for [Resident #1}, CNA A stated she did not check because [Resident #1] offered to help turn herself. CNA A concluded by saying she should have checked for [Resident #1's] bed mobility status before providing the care. CNA A stated 2 nurses and another CNA went to the room to assess [Resident #1] and got the resident off the floor. CNA A stated the MD also assessed [Resident #1]. Resident #1 did not have a side rail to hold unto. During an interview on 12/12/2022 at 12:00 p.m., LVN A stated he was notified by CNA A that [Resident #1] had fallen from the bed to floor while providing a bed bath. LVN A stated he was the first nurse on the scene, [Resident #1] was assessed, [Resident #1] was on her right side, bleeding from the right elbow, alert and oriented, complained of pain at right elbow. LVN A stated [Resident #1's] assigned nurse stepped in the room and took over the situation. LVN A stated the CNAs are able to look in the charting system to know how much assistance residents need for ADLs. During an interview on 12/12/2022 at 12:21 p.m., LVN B stated she was the assigned nurse for [Resident #1] on 11/28/2022. LVN B stated by the time she got to the room, [Resident #1] was already assisted to the chair. LVN B stated [Resident #1] had a skin tear at her right elbow, which was cleaned and steri strips applied, pain medication given according to MD's orders. LVN B stated the MD was in the facility, the MD visited and assessed [Resident #1]. LVN B stated [Resident #1 later complained of right rib pain when the family arrived. LVN B stated [Resident #1] was sent to ER per family request due to rib pain. During an interview on 12/12/2022 at 1:04 p.m., CNA B stated when there is a new resident, the CNAs ask the nurse about the resident's ADLs and the CNA can also look in the smart chart system to find out the resident's care needs. CNA B stated she has worked with [Resident #1] and it is always 2 persons to provide care. CNA B stated, when turning [Resident #1] she always push back, that is why the second person is needed to hold [Resident #1] in place. CNA B stated for the days she worked with [Resident #1] she was not able to hold herself in a side lying position. CNA B stated, We were in-serviced after the resident fell out of bed. We were told to make sure we get help, ask if we are not sure , they also talked about falls and prevention as I listed above.' During an interview on 12/12/2022 at 1:43 p.m., the DON stated the CNAs know what care to provide to the residents by looking in the smart chart because part of the CNAs job is coding for MDS. The DON stated the CNAs are trained on smart chart documentation quarterly. The DON stated, From admission she [Resident #1] needed 2 person's physical assist. She [CNA A] asked the resident [Resident #1] if she needed 2 persons and the resident stated she [Resident #1] could help/assist in turning. I know she [CNA A] was supposed to get assistance. When asked if the fall would have been prevented if CNA A would have gotten another staff as indicated in the care plan the DON stated, yes, if the CNA had gotten another aide, the fall would have been prevented. The DON stated staff were in-serviced on getting assistance, checking the resident care needs before providing care, fall preventions. The DON stated [Resident #1's] family told her (DON), Resident #1 would not be readmitted to the facility. During an interview on 12/12/2022 at 2:02 p.m., the ADON stated if [CNA A] would have gotten the second person, [Resident #1] wouldn't have fallen. The ADON stated If she [Resident #1] is a 2-person bed mobility, most likely she [Resident #1] wouldn't have fallen. If she [Resident #1] is care planned as 2 persons, she [Resident #1] should have been 2 persons.'' During an interview on 12/12/2022 at 2:18 p.m., the MD stated he visited with [Resident #1] about 20 minutes before the fall and assessed [Resident #1] after the fall. The MD stated [Resident #1] was neurologically intact when he assessed her. The MD stated [Resident #1] did a pseudo movement of her leg that led to the accident. The MD stated, 'I really do not know if the fall would have been prevented it there were 3 persons in the room, we have had injuries with 2 therapists, and you wouldn't have thought that would happen. This surveyor attempted a telephone interview with Resident #1's family on 12/12/2022 at 1:34 p.m., no response, no call back. Review of facility's policy titled Fall Prevention, undated reflected the following: 'Environmental Hazards/Facility Staff Involvement & Training. All facility employees will be involved with the prevention of falls including providing assistance to any resident who appears to be at risk for an immediate fall and by immediately reporting or resolving environmental hazards. Facility staff will be trained during orientation and as needed thereafter.'

Based on observation, interview, and record review the facility failed to ensure that residents receive adequate supervision to prevent avoidable accidents for 2 residents (Residents # 8 and 24) of 35 residents reviewed for supervision related to falls, and 2 of 2 residents (#12 and #16) who smoke in that they: 1. Failed to implement appropriate individualized interventions after Resident # 8's 14 falls over a 9 month period. Resident #8 sustained a fall on 9/12/17. The Resident was transported to the hospital after being found on the floor, confused with a 7.1 cm laceration located on the right side of her head at the hairline. 2. Failed to implement appropriate individualized interventions after Resident # 24's 19 falls over 4 months Resident # 24 sustained a fall and was transferred to a local hospital and diagnosed with [REDACTED]. 3. Failed to implement interventions for Resident # 12 and 16, by not supervising and collecting their cigarettes and lighter as care planned, to ensure the safety of these two residents and all residents and staff in the facility. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/23/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death, and 2 residents who smoke. The findings were: 1.) Record review of Resident #8's Face Sheet not dated, revealed Resident #8 was admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital, with the [DIAGNOSES REDACTED]. Record review of Resident #8's Fall Risk Assessment (FRA) dated 9/22/17 revealed a score of 23 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #8's Quarterly-Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 10 (where 8-12 is moderately impaired). A more recent MDS was not available as it was in progress. Record review of Resident #8's Quarterly MDS scores dated 8/24/17 revealed Resident #8 requires extensive assistance/ one person physical assist for transfers, and toileting. During an interview on 9/19/17 at 10:15 a.m., with the ADON revealed Resident #8 ambulated in a wheelchair, was continent of bowel and bladder, had weight loss, a history of falls and was on fall precautions. Record review of Resident #8's Care Plan originally dated 3/22/13, updates hand-written on the following dates: 11/01/16, 11/16/16, 12/5/16, 1/26/17, 2/24/17, 3/02/17, 3/19/17 (2 entries), 3/20/17 (2 entries), 7/21/17, 7/30/17, 9/8/17, 9/12/17 and 9/19/17. Care Plan Problem: I have had a history of [REDACTED]. Care Plan Goals: I will minimize risk of injuries from falls over the next 90 days. Care Plan Interventions: Monitor changes in Resident's condition that may warrant increased supervision/assistance and notify the physician. I am non-compliant with fall interventions. I will continually be encouraged to use call light. Observation of Resident #8 on 9/19/17 at 2:00 p.m. revealed the resident was in regular bed, with a quarter-sized skin tear to left elbow. Record review of the facility's Incident/Accident Reports. The reports were inconsistent and included some of the following documents: Incident Investigation, a Skin, Bruise or other Events, Interdisciplinary Post-Fall Assessment, a Witness Statement/First Responder Statement sheet. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from the period between 11/16/16 to 9/9/17, revealed Resident #8 had fallen a total of 14 times. Record review of the Care Plan revealed Resident #8 had actually fallen a total of 17 times. The Fall Reports revealed the following: (1) On 11/01/16 Resident #8 had a fall, there was no report available, Care Plan Recommendations: Continue current interventions, I am non-compliant with fall interventions. I will continually be encouraged to use call light. Interview on 6/26/17 at 6:00 p.m., DON revealed that corrective actions were not taken and some were not fully investigated. Record Review of the Incident/Accident Reports book revealed, there was no IAR for the fall on 11/01/16. Care Plan dated 11/01/16 contained the following: I was trying to hang on to something on the wall as nurse came in I lost my balance and fell . (2) Record Review of the Resident #8's Incident/Accident Report dated 11/16/16 at 10:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor, noted to be alert and oriented. No injury noted. Record Review of the Resident #8's Incident Investigation sheet dated 11/16/16 revealed: immediate actions taken: neuro-checks. Report states the resident was found sitting in her own bathroom and was oriented, last toileting was at 9:50 am. Record Review of the Resident #8's Skin, Bruise or Other Event Investigation sheet dated 11/16/16: Resident oriented, uses wheel chair, wheel herself, and transfers independently. Resident was educated on safety and reminded to ask for assistance. Do not rush when doing ADL's, take her time. Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Recommendations: Continue current intervention. Record Review of the Resident #8's Care Plan revealed an update on 11/16/16: Continue current interventions. Record Review of the Therapy Screen dated 11/29/16 for falls that occurred on 11/01/16 and 11/16/16 had recommendations to continue physical therapy and occupational therapy. (3) Record Review of the Resident #8's Incident/Accident Report dated 1/26/17 at 12:15 p.m., Resident #8 fell unwitnessed, found sitting on the floor in the bathroom, alert and oriented. No injuries or bruises noted. Record Review of Resident #8's Therapy Screen dated 1/31/17. Recommendation: No skilled therapy at this time. Record Review of Resident #8's Care Plan dated 1/31/17. Recommendations: Continue current interventions, resident refuses any fall interventions, no new interventions documented (4) Record Review of the Resident #8's Incident/Accident Reports 2/24/17 at 6:40 p.m., Resident #8 fell , witnessed, Resident lost her balance while standing, bumped her head on the seat of the wheelchair. Resident #8 was sent to the hospital at 9:30 am. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 2/24/17 states, Resident, loses balance. Recommendations: Reinforce with resident that assistance is needed when ambulating or transferring. Record Review of Resident #8's Care Plan dated 2/24/17 revealed the following Recommendations: Continue on Therapy (Occupational Therapy initiated on 12/5/16 five times a week for 30 days), sent to hospital for evaluations and treatment. (5) Record Review of the Resident #8's Incident/Accident Report dated 3/02/17 at 7:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor. Resident stated, I lost my balance and fell on to the floor and hit my head on the bedside table. Small bruise to left elbow noted, no additional injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/02/17 states the Resident tries to ambulate without assist, loses balance independently. Recommendations: Encourage to use call light for staff assist and wait for help. Record Review of the Resident #8's Care Plan dated 3/02/17: Continue therapy. Record Review of the Therapy Screen dated 3/07/17 for falls that occurred on 2/24/17 and 3/02/17 had recommendations to continue physical therapy and occupational therapy. Physical therapy was initiated on 3/10/17 and continued to 3/24/17. (6) Record Review of the Resident #8's Care Plan revealed an update on 3/19/17 (2 entries) revealed, Resident #8 unwitnessed fall, where she was attempting to stand up in the room without assistance, lost her balance and fell at 10:40 a.m. No reports found for this incident: Recommendations: Continue physical therapy. (7) Record Review of the Resident #8's Incident/Accident Report dated 3/19/17 at 4:45 p.m., Resident #8 fell , unwitnessed, found lying on her right side, on the floor. Resident complained of back pain and was sent to the hospital. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/19/17 states the Resident, attempts to transfer by self. Recommendations: Orthostatic for 3 days. Record Review of the Resident #8's Care Plan revealed an update on 3/19/17: Recommendations: Orthostatic Blood Pressure for 3 days, Resident sent to Hospital. (8) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:00 p.m., Resident #8 fell , unwitnessed, found on the floor next to her bed. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/20/17 states the Resident, attempts to ambulate without assist from staff, Resident not asking staff for help. Attempting to ambulate unassisted. Recommendations: Encourage resident to use call-bell, started on Keflex Twice a day for prophylactic, Pacemaker implant. Record Review of the Resident #8's Care Plan revealed an update on 3/20/17. Recommendations: Encourage resident to use call-bell, on antibiotics for pacemaker implant. (9) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:20 p.m., Resident #8 fell , unwitnessed, found on the floor face down next to the toilet in the bathroom. Resident stated she hit her head on the floor. Resident #8 was sent to the Hospital. (Also noted: resident had vomited on her bed). Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the Resident, attempts ambulation without assist, Unassisted ambulation and transfers. Recommendations: Remind resident to ask for help. Record Review of the Resident #8's Care Plan revealed a second update on 3/20/17: Recommendations: Remind resident to call for help, sent to hospital for evaluation and treatment, on antibiotics four times a day for 7 days for bacterial infection (UTI), no new interventions noted. (10) Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident uses a wheelchair to ambulate and has very weak legs. She must have standby assistance when transferring to chair from bed. Sometimes needs weight bearing assistance. Resident with intermittent confusion, with 1-2 falls in the past 3 months. Patient will sometimes forget she has disabilities to her ambulation capabilities and try to transfer herself from the bed to the wheel chair, without calling for help. Resident Ambulatory and incontinent, has poor vision without glasses. Score 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Falls Investigation dated 7/25/17 at 6:30 (am/pm not specified, no nursing notes provided). Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Record Review of the Resident #8's Care Plan dated 7/21/17: Recommendations: Educate to use call light, no other/new interventions noted (11) Record Review of the Resident #8's Falls Investigation dated 7/30/17 at 2:00 (am/pm not specified, nursing note at 2:19 a.m. Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Resident alert x 3, with 1-3 falls. Resident ambulatory and continent. Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident. Resident alert, with 1-2 falls in the past 3 months, is ambulatory and continent. Fall risk score 8, previous score on 7/21/17 was 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Care Plan dated 7/30/17: Recommendations: Follow-up labs, no interventions related to fall prevention. Record Review of the Therapy Screen dated 8/03/17 for falls that occurred on 7/30/17, had recommendations to continue physical therapy and occupational therapy. (12) Record Review of the Resident #8's Incident/Accident Report dated 8/04/17 at 6:10 p.m., Resident #8 fell , witnessed. Resident observed having lost her balance and falling onto the floor on her Left hip and left elbow. Skin tear to left elbow. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/04/17 states the Resident, attempts ambulation without assist, Non-compliant with calling for help. Recommendations: CBC/CMP due 8/5/17. Record Review of the Resident #8's Care Plan dated 8/04/17: Recommendations: Labs as ordered. (13) Record Review of the Resident #8's Incident/Accident Report dated 8/05/17 at 10:45 a.m., Resident #8 fell , unwitnessed. Resident found on the floor on her right side. Skin tear to the back of her left hand. Alert and oriented to self. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/05/17 states the Resident, Non-compliant with using call-light or asking for assistance, Possible UTI due to confusion prior to fall and previous fall the evening before. Recommendations: Rocephin IV for 7 days, Azithromycin for 7 days, Complete Blood Count (CBC) in morning (AM), Tylenol as needed (PRN). Record Review of the Resident #8's Care Plan dated 8/05/17. Recommendations: Rocephin IV for 7 days, Azithromycin for 7 days, CBC in AM, Tylenol PRN. Record Review of the Therapy Screen dated 8/08/17 for falls that occurred on 8/04/17 and 8/05/17 had recommendations to continue physical therapy and occupational therapy (started on 8/4/17 and ended on 8/18/17) (14) Record Review of the Resident #8's Incident/Accident Report dated 8/25/17 at 9:20 p.m., Resident #8 fell , witnessed. Resident seen falling to floor onto her buttocks. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/25/17 states the Resident, Attempting to ambulate self, has poor safety awareness. Recommendations: Continue current interventions. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental status. General weakness for her functional status, No changes observed for her behavioral status, the rest of this form including Primary care Clinicians recommendations was not fully completed, dated or signed. Record Review of the Resident #8's Care Plan dated on 8/25/17: Recommendations: Continue current interventions. Record Review of the Therapy Screen dated 9/01/17 for falls that occurred on 8/25/17, had recommendations to continue physical therapy and occupational therapy. Record Review of the Restorative Progress Report dated 8/30/17 at 9:58 a.m. revealed Resident #8 was seen one time that week. Not seen other days due to staffing issues. (15) Record Review of the Resident #8's Incident/Accident Report dated 9/08/17 at 4:50 p.m., Resident #8 fell , unwitnessed. Resident found on the floor in her restroom. Alert and oriented to self and place. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/08/17 states the Resident, Has poor safety awareness. Recommendations: Therapy to screen. Record Review of Resident #8's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological or skin status. Resident reported to have pain in the Occipital Area. No recommendations were made by the Primary Care Clinician. Signed and dated 9/8/17 at 4:35 pm. Record Review of the Resident #8's Care Plan dated 9/08/17. Recommendations: therapy to screen. Record Review of the Therapy Screen dated 9/11/17 for falls that occurred on 9/08/17, had recommendations to continue with therapy interventions. (16) Record Review of the Resident #8's Incident/Accident Report dated 9/12/17 at 11:30 p.m., Resident #8 fell , unwitnessed. Resident found on the floor, alert and oriented to self and place, with a forehead laceration to the right side of the head at the hairline measured at 7.1 cm. at 11:34 am, resident was reported alert and oriented to self only. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/12/17 states the Resident, Attempting to ambulate, poor safety awareness. Recommendations: Sent to the hospital. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/12/17 for RN's/LPN/LVN revealed the Resident had changes in mental status and was making confusing statements. Her functional status, general weakness with decreased mobility, needs more assistance with Activities of Daily Living and falls with generalized weakness. Resident's behavioral and respiratory status was not clinically applicable to the change in condition being reported. The second page of third report was not provided by the facility. Record Review of the Resident #8's Care Plan dated 8/25/17 revealed no interventions or recommendations. Record Review of the Resident #8's Care Plan dated 9/12/17 revealed no interventions or recommendations Record Review of the Therapy Screen dated 9/13/17 for falls that occurred on 9/12/17, no skilled therapy needs at this time. (17) Record Review of the Resident #8's Incident/Accident Report dated 9/19/17 at 1:30 p.m., Resident #8 fell , witnessed. Resident was seen as she was going down onto the floor. Resident was reported to have intermittent confusion and an unsteady balance, scab from previous Skin tear to elbow fell off. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/19/17 states the Resident, Non-compliant with fall precautions. Recommendations: Continue current interventions, Therapy to screen due to weakness. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/19/17 for RN's/LPN/LVN revealed the Resident had a period of intermittent confusion, no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological, pain or skin status. No recommendations from the primary care clinician. Signed and dated on 9/19/17 at 1:40 pm. Record Review of the Resident #8's Care Plan dated 9/20/17 revealed no interventions or recommendations. Record Review of the Therapy Screen dated 9/21/17 for falls that occurred on 9/19/17, had recommendations to restart physical therapy and occupational therapy. Record Review of Restorative Progress Notes dated 09/06/17, 9/13/17 and 9/20/17 revealed Resident #8. Was not seen due to staffing issues. During an interview on 9/21/17 at 11:32 a.m., the DON stated, that Resident #8 was, very, very non-compliant and stuck in her ways. She revealed that Resident #8 had to be, redirected and that redirection was all you can do with her, She wants to be independent. She also stated that this Resident takes herself to the bathroom and is at risk for UTI's. She then revealed regarding her numerous falls, Resident #8, Will continue to do what she wants and would Continue falling., They have the right to fall. During interview on 9/21/17 at 10:30 a.m. the Administrator, revealed that he was aware that Resident #8 was a frequent faller. He revealed, more could have been done to prevent more fall. During an interview on 9/23/17 at 6:00 p.m., the DON stated, that falls were not fully investigated and that they had not implemented sufficient corrective actions to prevent further falls. During interview on 9/23/17 at 1:00 p.m. the Administrator, revealed Resident #8's, repeated falls, were part of her normal. He then went on to state, that with this resident her First fall was not normal, repeated falls are the normal for her. 2). Record review of Resident #24's Face Sheet revealed Resident # 24 was initially admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Final Report History and Physical dated 09/22/17 at 11:05 a.m. revealed the Chief complaint was: left hip fracture. Assessment/Plan: Forehead contusion with CT scan of head showed no acute findings. Fracture of femoral head with an Orthopedic consult which revealed the patient is not a good surgical candidate, due to a history of cardio embolic cerebrovascular accident (CVA)- a history of frequent falls secondary to patient being unaware of limitations due to advanced Dementia. Recommendations were: Continue with fall precautions. Record review of Hospital Discharge Summary dated 09/23/17 revealed Resident # 24 returned to nursing home on hospice. Record review of Resident #24's Fall Risk assessment dated [DATE] revealed a score of 16 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 3 (where 0-7 is severely impaired) and a Quarterly MDS dated [DATE], BIMS score of 4. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE] and Quarterly Minimum (MDS) data set [DATE] revealed Resident # 24 requires extensive assistance/ one person physical assist for bed-mobility, transfers, and toileting. During initial tour on 09/19/17 with ADON she revealed Resident #24 was not Interviewable, used a wheelchair for mobility, continent of bowel and bladder, and had a history of [REDACTED]. Record review of Resident #24's Care Plan originally dated 05/01/17 handwritten updates were completed on the following dates: 05/30/17, 05/31/17, 06/09/17, 06/17/17, 07/15/17, 07/27/17 (2 entries), 07/31/17, 08/06/17, 08/14/17 (4 entries) 08/16/17, 08/17/17. Care Plan Problem: I have the potential risk of further falls and injury from falls due to recent history of falls. Care Plan Goals: Will minimize risk for injury or falls daily and ongoing by next care plan review. Care Plan Interventions: Monitor my environment for wet spots or items placed below field of vision on floor, Call light close, Instruct and remind me to call for assistance Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from 05/26/17 to 09/22/17 revealed Resident #24 had fallen a total of 16 times. Record review of the Care Plans revealed Resident #24 had actually fallen 19 times. The Fall Reports revealed the following: (1) Record review of Resident's # 24's Incident/Accident Report 05/26/17 at 1:00 p.m., revealed Resident #24 had a witnessed fall. Resident # 24 fell to his knees while making his bed. Record Review of the Interdisciplinary Post-Fall Evaluation dated 05/26/17 revealed recommendation: Moved to A Bed and probable cause of fall: Residents knee gave out. (2) Record review of Resident's # 24's Incident/Accident Report 06/09/17 at 8:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 slid out of bed onto the floor. Resident stated blanket was slippery. Small abrasion right thumb. Physician and family notified at 9:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/09/17 revealed recommendation: Use linens that are not slippery. Probable cause of fall: Slid out of bed. Record Review of the Care Plan dated 06/09/17 revealed, educate to use call bell for assistance. Record review of Restorative progress notes dated 06/14/17 revealed Resident # 24 was started on Restorative Nursing Program on 06/07/17. Record review of Resident # 24's restorative progress note dated 06/16/17 revealed resident's back pain was worse today and he was only able to take a couple of steps, nurse notified. (3) Record review of Resident's # 24's Incident/Accident Report 06/17/17 at 3:00 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found siting on floor with back against the bed, No apparent injuries. Physician notified at 5:10 p.m. family notified at 6:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/17/17 revealed recommendation: Continue Interventions Probable cause of fall: Up without assistance Resident stated he was trying to lower bed rail, poor safety awareness. Impulsive. Record Review of the Care Plan dated 06/17/17 revealed, continue interventions. Incident/Accident report requested none provided. No new interventions related to falls noted. Record review of Resident # 24's restorative progress note dated 06/19/17 revealed resident only took a couple of steps and sat back down stating he couldn't ambulate. Record review of Resident #24's restorative nursing progress note dated 06/21/17 reveals, Resident # 24 is unable to ambulate due to pain in lower back and left knee. Record review of Resident #24's restorative progress note dated 06/28/17, 06/29/17, 06/30/17, and 07/05/17 revealed Resident #24 unable to ambulate due to left knee pain. Record review of Resident#24's restorative progress note dated 07/12/17 revealed resident does not tolerate ambulation due to knee pain and his left knee is bending outwards making it unsafe for him to ambulate. Record review of Resident #24's restorative progress note dated 07/14/17 revealed resident did not ambulate today due to extreme discomfort and pain to left knee. (4) Record review of statement by CNA dated 07/15/17 and signed by LVN on 08/12/17 (no time) revealed Resident # 24 was found sitting on the floor with back against the bed frame. No injuries found upon assessment. Record Review of the Care Plan dated 07/15/17 revealed, Doctor HH to evaluate and continue antibiotics. Record review of Resident #24's restorative progress note dated 07/19/17, 07/21/17, 07/26/17, resident did not want to participate due to knee pain. (5) Record Review of the Care Plan dated 07/27/17 revealed, Resident # 24 fell on his back in the bathroom (2-10 shift). Record Review of the Care Plan dated 07/27/17 revealed Namenda was discontinued, CBC, BMP, UA, x-ray as ordered orthostatic blood pressure x 3. No Incident/Accident Report requested none provided. (6) Record review of original care plan dated 05/01/17 updated on 07/27/17 revealed Resident # 24 slipped off edge of wheelchair in room. Educate to use call bell. Incident/Accident report requested none provided. Record Review of the Care Plan dated 07/27/17 revealed, educate to use call lights, no other/new interventions noted. (7) Record review of statement by CNA dated 07/31/17 and signed by LVN (no date, no time) revealed Resident # 24 was found sitting on the floor close to his bed on the side by the door. He stated he slipped forward trying to put on his shoes. Record Review of the Care Plan dated 07/31/17 UA/C&S (negative). Neuro-checks completed x 3 days. Record review of Resident #24's restorative progress note dated 7/31/17, 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (8) Record review of Resident's # 24's Incident/Accident Report 08/06/17 at 1:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in the 100 Hall hoper room. Physician notified at 3:22 p.m. Family notified at 3:20 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/06/17 revealed recommendation: Staff to at least check Resident every 2 hours. Resident refuses assistance from staff. Probable cause of fall: Attempting to toilet self. Record Review of the Care Plan dated 08/06/17 revealed, the staff was to check on resident at least every 2 hours. No new interventions related to falls noted for 08/07/17. Record review of Resident #24's restorative progress note dated 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (9) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 6:15 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found at 11:00 p.m. to be sitting up at the right side of his bed on the floor. Physician and family notified at 6:15 a.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care. Probable cause of fall: His wheelchair was outside his room and he does not want his side rails up on his bed. Side rails are up now. Wheelchair is in his room and he agreed to use call button. Record Review revealed there was no care plan for fall precautions or prevention noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/13/17 revealed recommendation of primary clinicians section left blank. (10) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 7:00 a.m , revealed Resident #24 had a witnessed fall. Resident # 24 was seen by nurse struggling to pull up his pants, lost his footing and fell on to his buttocks. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care document refusal. Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed there was no care plan interventions noted for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. Interview with DON on 09/26/17 at 10:15 AM revealed it was an unwitnessed fall LVN documented what Resident stated. (11) Record Review of Resident's # 24's Incident/Accident Report 08/12/17 at 5:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in restroom with pants and brief down. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed, there was no care plan interventions for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. (12) Record review of Resident's # 24 Incident/Accident Report 08/14/17 at 4:30 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on his bathroom floor beside the toilet and his wheelchair. Physician notified and family notified at 6:00 a.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/14/17 revealed recommendation: Continue current plan of care Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/14/17 revealed recommendation of primary clinicians section left blank. Record Review of the facility's Care Plan dated 08/14/17 revealed continue to check on resident every 2 hours, offer toileting e(TRUNCATED)

Based on observations, interviews, and record reviews the facility Administrator failed to provide oversight in a manner that enabled the use of the facility's resources effectively and efficiently to attain or maintain the highest practicable physical well-being for 2 of 35 residents (Resident # 8 and #24) identified with falls with injuries. A. The Director of Nurses (DON) failed to prevent facility policies and procedures regarding falls with injuries. B. The Administrator failed to supervise the Director of Nurses (DON) to ensure she was monitoring tracking, trending and identifying and providing modified, effective interventions better suited to meet these Resident's (# 8, and #24) increasing needs including declining cognition to prevent any further falls and serious injuries. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/23/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The facility failed to provide services to prevent harm when they: 1.) Failed to implement appropriate individualized interventions after Resident # 8's 14 falls over a 9 month period (11/16/16 to 9/9/17). Resident #4 sustained a fall on 9/12/17. The Resident was transported to the hospital after being found on the floor, confused with a 7.1 cm laceration located on the right side of her head at the hairline. 2. Failed to implement appropriate individualized interventions after Resident # 24's 19 falls over 4 months (5/26/17 to 9/22/17). Resident # 24 sustained a fall on 9/22/17 and was transferred to a local hospital on [DATE] and were diagnosed with [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/23/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The findings were: 1.) Record review of Resident #8's Face Sheet not dated, revealed Resident #8 was admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital, with the [DIAGNOSES REDACTED]. Record review of Resident #8's Fall Risk Assessment (FRA) dated 9/22/17 revealed a score of 23 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #8's Quarterly-Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 10 (where 8-12 is moderately impaired), and Quarterly-MDS dated [DATE], BIMS score 9, Comprehensive, Annual MDS dated [DATE], BIMS score of 9 and a Comprehensive, Annual MDS dated [DATE], with a BIMS score of 9. Record review of Resident #8's Quarterly MDS scores dated 8/24/17 revealed Resident #8 requires extensive assistance/ one person physical assist for transfers, and toileting. Comprehensive, Annual MDS dated [DATE], revealed Resident #8 requires extensive assistance/ one person physical assist, Comprehensive, Annual MDS dated [DATE], revealed Resident #8 requires limited assistance/ one person physical assist. During an interview on 9/19/17 at 10:15 a.m., with the ADON revealed Resident #8 ambulated in a wheelchair, was continent of bowel and bladder, had weight loss, a history of falls and was on fall precautions. Record review of Resident #8's Care Plan originally dated 3/22/13, updated (updates hand-written) on 11/01/16, 12/5/16, 1/26/17, 2/24/17, 3/02/17, 3/19/17 (2 entries), 3/20/17 (2 entries), 7/21/17, 7/30/17, 9/8/17, 9/12/17, 9/12/17 and 9/19/17. (Italicized dates do not coincide with care plan updates for falls). Care Plan Problem: I have had a history of [REDACTED]. Care Plan Goals: I will minimize risk of injuries from falls over the next 90 days. Care Plan Interventions: Monitor changes in Resident's condition that may warrant increased supervision/assistance and notify the physician. I am non-compliant with fall interventions. I will continually be encouraged to use call light. Observation of Resident #8 on 9/19/17 at 2:00 p.m. revealed the resident was in bed, with a quarter-sized skin tear to left elbow. Record review of the facility's Incident/Accident Reports. The reports were inconsistent and included some of the following documents: Incident Investigation, a Skin, Bruise or other Events, Interdisciplinary Post-Fall Assessment, a Witness Statement/First Responder Statement sheet. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from the period between 11/16/16 to 9/9/17, revealed Resident #8 had fallen a total of 14 times. Record review of the Care Plan revealed Resident #8 had actually fallen a total of 17 times. The Fall Reports revealed the following: (1) On 11/01/16 Resident #8 had a fall, No reports were provided from the facility, care plan was updated. Recommendations: Continue current interventions, I am non-compliant with fall interventions. I will continually be encouraged to use call light. Record Review of the Incident/Accident Reports book revealed, there was no IAR for the fall on 11/01/16. Care Plan dated 11/01/16 contained the following: I was trying to hang on to something on the wall as nurse came in I lost my balance and fell . (2) Record Review of the Resident #8's Incident/Accident Report dated 11/16/16 at 10:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor, noted to be alert and oriented. No injury noted. Record Review of the Resident #8's Incident Investigation sheet dated 11/16/16 revealed: immediate actions taken: neuro-checks. Report states the resident was found sitting in her own bathroom and was oriented, last toileting was at 9:50 am. Record Review of the Resident #8's Skin, Bruise or Other Event Investigation sheet dated 11/16/16: Resident oriented, uses wheel chair, wheel herself, and transfers independently. Resident was educated on safety and reminded to ask for assistance. Do not rush when doing ADL's, take her time. Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Recommendations: Continue current intervention. Record Review of the Resident #8's Care Plan revealed an update on 11/16/16: Continue current interventions. Record Review of the Therapy Screen dated 11/29/17 for falls that occurred on 11/01/16 and 11/16/16 had recommendations to continue physical therapy and occupational therapy. (3) Record Review of the Resident #8's Incident/Accident Report dated 1/26/17 at 12:15 p.m., Resident #8 fell unwitnessed, found siting on the floor in the bathroom, alert and oriented. No injuries or bruises noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 11/16/16 states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Care plan revision dated 1/31/17 (No update to Care Plan found). Recommendations: Continue current intervention. Record Review of Resident #8's Therapy Screen dated 1/31/17. Recommendation: No skilled therapy at this time. Record Review of Resident #8's Care Plan revealed no plan revisions dated 1/31/17. Update was dated 1/26/17. Recommendations: Continue current interventions, resident refuses any fall interventions. (4) Record Review of the Resident #8's Incident/Accident Reports 2/24/17 at 6:40 p.m., Resident #8 fell , witnessed, Resident lost her balance while standing, bumped her head on the seat of the wheelchair. Resident #8 was sent to the hospital at 9:30 am. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 2/24/17 states, Resident, loses balance. Care plan revision dated 2/27/17. (No update to Care Plan found on that date). Recommendations: Reinforce with resident that assistance is needed when ambulating or transferring. Record Review of Resident #8's Care Plan dated 2/24/17 revealed the following Recommendations: Continue on Therapy (Occupational Therapy initiated on 12/5/16 five times a week for 30 days), sent to hospital for evaluations and treatment. (5) Record Review of the Resident #8's Incident/Accident Report dated 3/02/17 at 7:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor. Resident stated, I lost my balance and fell on to the floor and hit my head on the bedside table. Small bruise to left elbow noted, no additional injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/02/17 states the Resident tries to ambulate without assist, loses balance independently. Recommendations: Encourage to use call light for staff assist and wait for help. Record Review of the Resident #8's Care Plan revealed an update on 3/02/17: Continue therapy. Record Review of the Therapy Screen dated 3/07/17 for falls that occurred on 2/24/17 and 3/02/17 had recommendations to continue physical therapy and occupational therapy. (6) Record Review of the Resident #8's Care Plan revealed an update on 3/19/17 (2 entries) revealed, Resident #8 unwitnessed fall, where she was attempting to stand up in the room without assistance, lost her balance and fell at 10:40 a.m. No reports found for this incident: Recommendations: Continue physical therapy. (7) Record Review of the Resident #8's Incident/Accident Report dated 3/19/17 at 4:45 p.m., Resident #8 fell , unwitnessed, found lying on her right side, on the floor. Resident complained of back pain and was sent to the hospital. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/19/17 states the Resident, attempts to transfer by self. Recommendations: Orthostatic for 3 days. Care plan updated on 3/19/17. Record Review of the Resident #8's Care Plan revealed an update on 3/19/17: Recommendations: Orthostatic Blood Pressure for 3 days, Resident sent to Hospital. (8) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:00 p.m., Resident #8 fell , unwitnessed, found on the floor next to her bed. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/20/17 states the Resident, attempts to ambulate without assist from staff, Resident not asking staff for help. Attempting to ambulate unassisted. Recommendations: Encourage resident to use call-bell, started on Keflex Twice a day for [MEDICATION NAME], Pacemaker implant. Care plan updated on 3/20/17 (2 entries). Record Review of the Resident #8's Care Plan revealed an update on 3/20/17. Recommendations: Encourage resident to use call-bell, on antibiotics for pacemaker implant. (9) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:20 p.m., Resident #8 fell , unwitnessed, found on the floor face down next to the toilet in the bathroom. Resident stated she hit her head on the floor. Resident #8 was sent to the Hospital. (Also noted: resident had vomited on her bed). Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the Resident, attempts ambulation without assist, Unassisted ambulation and transfers. Recommendations: Remind resident to ask for help. Care plan updated again on 3/20/17 Record Review of the Resident #8's Care Plan revealed a second update on 3/20/17: Recommendations: Remind resident to call for help, sent to hospital for evaluation and treatment, on antibiotics four times a day for 7 days for bacterial infection [MEDICAL CONDITION]. (10) Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident uses a wheelchair to ambulate and has very weak legs. She must have standby assistance when transferring to chair from bed. Sometimes needs weight bearing assistance. Resident with intermittent confusion, with 1-2 falls in the past 3 months. Patient will sometimes forget she has disabilities to her ambulation capabilities and try to transfer herself from the bed to the wheel chair, without calling for help. Resident Ambulatory and incontinent, has poor vision without glasses. Score 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Falls Investigation dated 7/25/17 at 6:30 (am/pm not specified, no nursing notes provided). Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Record Review of the Resident #8's Care Plan revealed update on 7/21/17: Recommendations: Educate to use call light. (11) Record Review of the Resident #8's Falls Investigation dated 7/30/17 at 2:00 (am/pm not specified, nursing note at 2:19 a.m. Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Resident alert x 3, with 1-3 falls. Resident ambulatory and continent. Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident. Resident alert, with 1-2 falls in the past 3 months, is ambulatory and continent. Fall risk score 8. Record Review of the Resident #8's Care Plan revealed update on 7/30/17: Recommendations: Follow-up labs. Record Review of the Therapy Screen dated 8/03/17 for falls that occurred on 7/30/17, had recommendations to continue physical therapy and occupational therapy. (12) Record Review of the Resident #8's Incident/Accident Report dated 8/04/17 at 6:10 p.m., Resident #8 fell , witnessed. Resident observed having lost her balance and falling onto the floor on her Left hip and left elbow. Skin tear to left elbow. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/04/17 states the Resident, attempts ambulation without assist, Non-compliant with calling for help. Recommendations: CBC/CMP due 8/5/17. Record Review of the Resident #8's Care Plan revealed an update on 8/04/17: Recommendations: Labs as ordered. (13) Record Review of the Resident #8's Incident/Accident Report dated 8/05/17 at 10:45 a.m., Resident #8 fell , unwitnessed. Resident found on the floor on her right side. Skin tear to the back of her left hand. Alert and oriented to self. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/05/17 states the Resident, Non-compliant with using call-light or asking for assistance, Possible UTI due to confusion prior to fall and previous fall the evening before. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, Complete Blood Count (CBC) in morning (AM), Tylenol as needed (PRN). Record Review of the Resident #8's Care Plan revealed an update on 8/05/17. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, CBC in AM, Tylenol PRN. Record Review of the Therapy Screen dated 8/08/17 for falls that occurred on 8/04/17 and 8/05/17 had recommendations to continue physical therapy and occupational therapy (14) Record Review of the Resident #8's Incident/Accident Report dated 8/25/17 at 9:20 p.m., Resident #8 fell , witnessed. Resident seen falling to floor onto her buttocks. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/25/17 states the Resident, Attempting to ambulate self, has poor safety awareness. Recommendations: Continue current interventions. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental status. General weakness for her functional status, No changes observed for her behavioral status, the rest of this form including Primary care Clinicians recommendations was not fully completed, dated or signed. Record Review of the Resident #8's Care Plan revealed an update on 8/25/17: Recommendations: Continue current intentions. Record Review of the Therapy Screen dated 9/01/17 for falls that occurred on 8/25/17, had recommendations to continue physical therapy and occupational therapy. (15) Record Review of the Resident #8's Incident/Accident Report dated 9/08/17 at 4:50 p.m., Resident #8 fell , unwitnessed. Resident found on the floor in her restroom. Alert and oriented to self and place. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/08/17 states the Resident, Has poor safety awareness. Recommendations: Therapy to screen. Care Plan updated on 9/12/17. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological or skin status. Resident reported to have pain in the Occipital Area. No recommendations were made by the Primary Care Clinician. Signed and dated 9/8/17 at 4:35 pm. Record Review of the Resident #8's Care Plan revealed no update on 9/08/17 or recommendations. Record Review of the Therapy Screen dated 9/11/17 for falls that occurred on 9/08/17, had recommendations to continue with therapy interventions. (16) Record Review of the Resident #8's Incident/Accident Report dated 9/12/17 at 11:30 p.m., Resident #8 fell , unwitnessed. Resident found on the floor, alert and oriented to self and place, with a [MEDICAL CONDITION] to the right side of the head at the hairline measured at 7.1 cm. at 11:34 am, resident was reported alert and oriented to self only. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/12/17 states the Resident, Attempting to ambulate, poor safety awareness. Recommendations: Sent to the hospital. Care plan revised on 9/12/17. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/12/17 for RN's/LPN/LVN revealed the Resident had changes in mental status and was making confusing statements. Her functional status, general weakness with decreased mobility, needs more assistance with Activities of Daily Living and falls with generalized weakness. Resident's behavioral and respiratory status was not clinically applicable to the change in condition being reported. The second page of third report was not provided by the facility. Record Review of the Resident #8's Care Plan revealed no update on 8/25/17 or recommendations. Record Review of the Resident #8's Care Plan revealed no update on 9/12/17 or recommendations. Record Review of the Therapy Screen dated 9/13/17 for falls that occurred on 9/12/17, no skilled therapy needs at this time. (17) Record Review of the Resident #8's Incident/Accident Report dated 9/19/17 at 1:30 p.m., Resident #8 fell , witnessed. Resident was seen as she was going down onto the floor. Resident was reported to have intermittent confusion and an unsteady balance, scab from previous Skin tear to elbow fell off. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/19/17 states the Resident, Non-compliant with fall precautions. Recommendations: Continue current interventions, Therapy to screen due to weakness. Care plan revised on 9/20/17. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/19/17 for RN's/LPN/LVN revealed the Resident had a period of intermittent confusion, no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological, pain or skin status. No recommendations from the primary care clinician. Signed and dated on 9/19/17 at 1:40 pm. Record Review of the Resident #8's Care Plan revealed no update on 9/20/17 or recommendations. Record Review of the Therapy Screen dated 9/21/17 for falls that occurred on 9/19/17, had recommendations to restart physical therapy and occupational therapy. Record Review of the Resident #8's Care Plan revealed an updated version of the care plan revised on 9/22/17 after an Immediate Jeopardy was called on 9/22/17 at 6:23 pm. Problem: I have the potential risk of further falls and injury from falls due to recent history for falls and [DIAGNOSES REDACTED]. I like to be independent and I do not like to ask for assistance. Goals & Targets: I will have my risk for falls and or injuries minimized daily and ongoing by the next care plan review (no date provided). Recommendations: Monitor my environment for wet spots or items placed below field of vision on the floor. Call light will be placed closely. Reeducate me on the importance of calling for assistance. I will be moved to a A to be closer to the bathroom (Resident #8 was moved from room [ROOM NUMBER] B to #402 A). Pharmacy review completed on 9/22/17 with med adjustments made. Fall assessments updated. Therapy screened post fall. UA C and S to be obtained-CBC to be drawn. I will be placed on a bowel and bladder program and I will be offered to be taken to the toilet every hour. I will not be left unattended while staff is assisting me to the bathroom. Record Review of the Resident #8's Care Plan revealed a hand written note on the care plan dated 9/25/17 which read: Spoke with resident regarding episodes of refusal during the night to participate in the bowel and bladder program. She reports she wanted the staff to continue current program. She will continue to refuse if she does not want to go. (Initialed by the DON) Record Review of Restorative Progress Notes dated 09/06/17, 9/13/17 and 9/20/17 revealed Resident #8. Was not seen due to staffing issues. During an interview on 9/21/17 at 11:32 a.m., the DON stated, that Resident #8 was, very, very non-compliant and stuck in her ways. She revealed that Resident #8 had to be, redirected and that redirection was all you can do with her, She wants to be independent. She also stated that this Resident takes herself to the bathroom and is at risk for UTI's. She then revealed regarding her numerous falls, Resident #8, Will continue to do what she wants and would Continue falling., They have the right to fall. During interview on 9/23/17 at 1:00 p.m. the Administrator, revealed Resident #8's, repeated falls, were part of her normal. He then went on to state, that with this resident her First fall was not normal, repeated falls are the normal for her. 2). Record review of Resident #24's Face Sheet revealed Resident # 24 was initially admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Final Report History and Physical dated 09/22/17 at 11:05 a.m. revealed the Chief complaint was: left [MEDICAL CONDITION]. Assessment/Plan: Forehead contusion with CT scan of head showed no acute findings. Fracture of femoral head with an Orthopedic consult which revealed the patient is not a good surgical candidate, due to a history of cardio embolic [MEDICAL CONDITIONS]- a history of frequent falls secondary to patient being unaware of limitations due to advanced Dementia. Recommendations were: Continue with fall precautions. Record review of Hospital Discharge Summary dated 09/23/17 revealed Resident # 24 returned to nursing home on hospice. Record review of Resident #24's Fall Risk assessment dated [DATE] revealed a score of 16 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 3 (where 0-7 is severely impaired) and a Quarterly MDS dated [DATE], BIMS score of 4. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE] and Quarterly Minimum (MDS) data set [DATE] revealed Resident # 24 requires extensive assistance/ one person physical assist for bed-mobility, transfers, and toileting. During initial tour on 09/19/17 with ADON she revealed Resident #24 was not Interviewable, used a wheelchair for mobility, continent of bowel and bladder, and had a history of [REDACTED]. Record review of Resident #24's Care Plan originally dated 05/01/17 handwritten updates were completed on the following dates: 05/30/17, 05/31/17, 06/09/17, 06/17/17, 07/15/17, 07/27/17 (2 entries), 07/31/17, 08/06/17, 08/14/17 (4 entries) 08/16/17, 08/17/17. Care Plan Problem: I have the potential risk of further falls and injury from falls due to recent history of falls. Care Plan Goals: Will minimize risk for injury or falls daily and ongoing by next care plan review. Care Plan Interventions: Monitor my environment for wet spots or items placed below field of vision on floor, Call light close, Instruct and remind me to call for assistance Observation of Resident #24 on 09/26/17 at 10:40 a.m. revealed the resident was up in wheelchair in patio in front of facility. Resident does not recall fall or going to hospital. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from 05/26/17 to 09/22/17 revealed Resident #24 had fallen a total of 16 times. Record review of the Care Plans revealed Resident #24 had actually fallen 19 times. The Fall Reports revealed the following: (1) Record review of Resident's # 24's Incident/Accident Report 05/26/17 at 1:00 p.m., revealed Resident #24 had a witnessed fall. Resident # 24 fell to his knees while making his bed. Record Review of the Interdisciplinary Post-Fall Evaluation dated 05/26/17 revealed recommendation: Moved to A Bed and probable cause of fall: Residents knee gave out. Record Review of the Care Plan dated on 05/30/17 revealed the Resident fell attempting to make bed wheelchair caught on bed. Care plan updated 05/31/17 revealed the Resident moved to room with A bed for better mobility. (2) Record review of Resident's # 24's Incident/Accident Report 06/09/17 at 8:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 slid out of bed onto the floor. Resident stated blanket was slippery. Small abrasion right thumb. Physician and family notified at 9:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/09/17 revealed recommendation: Use linens that are not slippery. Probable cause of fall: Slid out of bed. Care Plan Revision 06/12/17 Record Review of the Care Plan dated 06/09/17 revealed, educate to use call bell for assistance. No care plan revision noted for 06/12/17. (3) Record review of Resident's # 24's Incident/Accident Report 06/17/17 at 3:00 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found siting on floor with back against the bed No apparent injuries. Physician notified at 5:10 p.m. family notified at 6:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/17/17 revealed recommendation: Continue Interventions Probable cause of fall: Up without assistance Resident stated he was trying to lower bed rail, poor safety awareness. Impulsive. Care plan revised 06/19/17. Record Review of the Care Plan dated 06/17/17 revealed, continue interventions. Incident/Accident report requested none provided. No care plan revision noted for 06/19/17. (4) Record review of statement by CNA dated 07/15/17 and signed by LVN on 08/12/17 (no time) revealed Resident # 24 was found sitting on the floor with back against the bed frame. No injuries found upon assessment. Record Review of the Care Plan dated 07/15/17 revealed, Doctor HH to evaluate and continue antibiotics. (5) Record Review of the Care Plan dated 07/27/17 revealed, Resident # 24 fell on his back in the bathroom (2-10 shift). Record Review of the Care Plan dated 07/27/17 revealed [MEDICATION NAME] was discontinued, CBC, BMP, UA, x-ray as ordered orthostatic blood pressure x 3. No Incident/Accident Report requested none provided. (6) Record review of original care plan dated 05/01/17 updated on 07/27/17 revealed Resident # 24 slipped off edge of wheelchair in room. Educate to use call bell. Incident/Accident report requested none provided. Record Review of the Care Plan dated 07/27/17 revealed educate to use call lights. (7) Record review of statement by CNA dated 07/31/17 and signed by LVN (no date, no time) revealed Resident # 24 was found sitting on the floor close to his bed on the side by the door. He stated he slipped forward trying to put on his shoes. Record Review of the Care Plan dated 07/31/17 UA/C&S (negative). Neuro-checks completed x 3 days. (8) Record review of Resident's # 24's Incident/Accident Report 08/06/17 at 1:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in the 100 Hall hoper room. Physician notified at 3:22 p.m. Family notified at 3:20 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/06/17 revealed recommendation: Staff to at least check Resident every 2 hours. Resident refuses assistance from staff. Probable cause of fall: Attempting to toilet self. Care Plan revised 08/07/17. Record Review of the Care Plan dated 08/06/17 revealed, the staff was to check on resident at least every 2 hours. No care plan revision noted for 08/07/17. (9) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 6:15 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found at 11:00 p.m. to be sitting up at the right side of his bed on the floor. Physician and family notified at 6:15 a.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care. Probable cause of fall: His wheelchair was outside his room and he does not want his side rails up on his bed. Side rails are up now. Wheelchair is in his room and he agreed to use call button. Care plan revision 08/14/17. Record Review revealed there was no care plan revision noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/13/17 revealed recommendation of primary clinicians section left blank. (10) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 7:00 a.m , revealed Resident #24 had a witnessed fall. Resident # 24 was seen by nurse struggling to pull up his pants, lost his footing and fell on to his buttocks. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care document refusal. Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Care plan revised 08/14/17. Record Review revealed there was no care plan revision noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. Interview with DON on 09/26/17 at 10:15 AM revealed it was an unwitnessed fall LVN documented what Resident stated. (11) Record Review of Resident's # 24's Incident/Accident Report 08/12/17 at 5:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in restroom with pants and brief down. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation da(TRUNCATED)

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 6 residents (Residents # 8, 24, 1, 5, 12 and 16) of 28 residents reviewed for care plan development and implementation in that they: 1. Failed to implement appropriate individualized interventions after Resident # 8's 14 falls over a 9 month period. Resident #8 sustained a fall on 9/12/17. The Resident was transported to the hospital after being found on the floor, confused with a 7.1 cm laceration located on the right side of her head at the hairline. 2. Failed to implement appropriate individualized interventions after Resident # 24's 19 falls over 4 months Resident # 24 sustained a fall and was transferred to a local hospital and diagnosed with [REDACTED]. 3.) Failed to implement interventions for Resident #1 who developed a Stage II Pressure Ulcer to the Sacrum, after the facility failed to turn and reposition the resident every 2 hours as stated in the care plan. 4.) Failed to implement interventions for Resident # 5 who was unable to drink liquids independently by not providing the resident with an assistive device of a sippy cup at three of three meals observed. 5.) Failed to implement interventions for Resident # 12 and 16 by not supervising and collecting their cigarettes and lighter as care planned, to ensure the safety of these two residents and all residents and staff in the facility. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/22/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death, 7 residents who are reposistioned every 2 hours and 2 residents who smoke. The findings were: 1.) Record review of Resident #8's Face Sheet not dated, revealed Resident #8 was admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital, with the [DIAGNOSES REDACTED]. Record review of Resident #8's Fall Risk Assessment (FRA) dated 9/22/17 revealed a score of 23 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #8's Quarterly-Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 10 (where 8-12 is moderately impaired). A more recent MDS was not available as it was in progress. Record review of Resident #8's Quarterly MDS scores dated 8/24/17 revealed Resident #8 requires extensive assistance/ one person physical assist for transfers, and toileting. During an interview on 9/19/17 at 10:15 a.m., with the ADON revealed Resident #8 ambulated in a wheelchair, was continent of bowel and bladder, had weight loss, a history of falls and was on fall precautions. Record review of Resident #8's Care Plan originally dated 3/22/13, updates hand-written on the following dates: 11/01/16, 11/16/16, 12/5/16, 1/26/17, 2/24/17, 3/02/17, 3/19/17 (2 entries), 3/20/17 (2 entries), 7/21/17, 7/30/17, 9/8/17, 9/12/17 and 9/19/17. Care Plan Problem: I have had a history of [REDACTED]. Care Plan Goals: I will minimize risk of injuries from falls over the next 90 days. Care Plan Interventions: Monitor changes in Resident's condition that may warrant increased supervision/assistance and notify the physician. I am non-compliant with fall interventions. I will continually be encouraged to use call light. Observation of Resident #8 on 9/19/17 at 2:00 p.m. revealed the resident was in regular bed, with a quarter-sized skin tear to left elbow. Record review of the facility's Incident/Accident Reports. The reports were inconsistent and included some of the following documents: Incident Investigation, a Skin, Bruise or other Events, Interdisciplinary Post-Fall Assessment, a Witness Statement/First Responder Statement sheet. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from the period between 11/16/16 to 9/9/17, revealed Resident #8 had fallen a total of 14 times. Record review of the Care Plan revealed Resident #8 had actually fallen a total of 17 times. The Fall Reports revealed the following: (1) On 11/01/16 Resident #8 had a fall, there was no report available, Care Plan Recommendations: Continue current interventions, I am non-compliant with fall interventions. I will continually be encouraged to use call light. Interview on 6/26/17 at 6:00 p.m., DON revealed that corrective actions were not taken and some were not fully investigated. Record Review of the Incident/Accident Reports book revealed, there was no IAR for the fall on 11/01/16. Care Plan dated 11/01/16 contained the following: I was trying to hang on to something on the wall as nurse came in I lost my balance and fell . (2) Record Review of the Resident #8's Incident/Accident Report dated 11/16/16 at 10:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor, noted to be alert and oriented. No injury noted. Record Review of the Resident #8's Incident Investigation sheet dated 11/16/16 revealed: immediate actions taken: neuro-checks. Report states the resident was found sitting in her own bathroom and was oriented, last toileting was at 9:50 am. Record Review of the Resident #8's Skin, Bruise or Other Event Investigation sheet dated 11/16/16: Resident oriented, uses wheel chair, wheel herself, and transfers independently. Resident was educated on safety and reminded to ask for assistance. Do not rush when doing ADL's, take her time. Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Recommendations: Continue current intervention. Record Review of the Resident #8's Care Plan revealed an update on 11/16/16: Continue current interventions. Record Review of the Therapy Screen dated 11/29/16 for falls that occurred on 11/01/16 and 11/16/16 had recommendations to continue physical therapy and occupational therapy. (3) Record Review of the Resident #8's Incident/Accident Report dated 1/26/17 at 12:15 p.m., Resident #8 fell unwitnessed, found sitting on the floor in the bathroom, alert and oriented. No injuries or bruises noted. Record Review of Resident #8's Therapy Screen dated 1/31/17. Recommendation: No skilled therapy at this time. Record Review of Resident #8's Care Plan dated 1/31/17. Recommendations: Continue current interventions, resident refuses any fall interventions, no new interventions documented (4) Record Review of the Resident #8's Incident/Accident Reports 2/24/17 at 6:40 p.m., Resident #8 fell , witnessed, Resident lost her balance while standing, bumped her head on the seat of the wheelchair. Resident #8 was sent to the hospital at 9:30 am. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 2/24/17 states, Resident, loses balance. Recommendations: Reinforce with resident that assistance is needed when ambulating or transferring. Record Review of Resident #8's Care Plan dated 2/24/17 revealed the following Recommendations: Continue on Therapy (Occupational Therapy initiated on 12/5/16 five times a week for 30 days), sent to hospital for evaluations and treatment. (5) Record Review of the Resident #8's Incident/Accident Report dated 3/02/17 at 7:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor. Resident stated, I lost my balance and fell on to the floor and hit my head on the bedside table. Small bruise to left elbow noted, no additional injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/02/17 states the Resident tries to ambulate without assist, loses balance independently. Recommendations: Encourage to use call light for staff assist and wait for help. Record Review of the Resident #8's Care Plan dated 3/02/17: Continue therapy. Record Review of the Therapy Screen dated 3/07/17 for falls that occurred on 2/24/17 and 3/02/17 had recommendations to continue physical therapy and occupational therapy. Physical therapy was initiated on 3/10/17 and continued to 3/24/17. (6) Record Review of the Resident #8's Care Plan revealed an update on 3/19/17 (2 entries) revealed, Resident #8 unwitnessed fall, where she was attempting to stand up in the room without assistance, lost her balance and fell at 10:40 a.m. No reports found for this incident: Recommendations: Continue physical therapy. (7) Record Review of the Resident #8's Incident/Accident Report dated 3/19/17 at 4:45 p.m., Resident #8 fell , unwitnessed, found lying on her right side, on the floor. Resident complained of back pain and was sent to the hospital. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/19/17 states the Resident, attempts to transfer by self. Recommendations: Orthostatic for 3 days. Record Review of the Resident #8's Care Plan revealed an update on 3/19/17: Recommendations: Orthostatic Blood Pressure for 3 days, Resident sent to Hospital. (8) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:00 p.m., Resident #8 fell , unwitnessed, found on the floor next to her bed. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/20/17 states the Resident, attempts to ambulate without assist from staff, Resident not asking staff for help. Attempting to ambulate unassisted. Recommendations: Encourage resident to use call-bell, started on Keflex Twice a day for [MEDICATION NAME], Pacemaker implant. Record Review of the Resident #8's Care Plan revealed an update on 3/20/17. Recommendations: Encourage resident to use call-bell, on antibiotics for pacemaker implant. (9) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:20 p.m., Resident #8 fell , unwitnessed, found on the floor face down next to the toilet in the bathroom. Resident stated she hit her head on the floor. Resident #8 was sent to the Hospital. (Also noted: resident had vomited on her bed). Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the Resident, attempts ambulation without assist, Unassisted ambulation and transfers. Recommendations: Remind resident to ask for help. Record Review of the Resident #8's Care Plan revealed a second update on 3/20/17: Recommendations: Remind resident to call for help, sent to hospital for evaluation and treatment, on antibiotics four times a day for 7 days for bacterial infection [MEDICAL CONDITION], no new interventions noted. (10) Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident uses a wheelchair to ambulate and has very weak legs. She must have standby assistance when transferring to chair from bed. Sometimes needs weight bearing assistance. Resident with intermittent confusion, with 1-2 falls in the past 3 months. Patient will sometimes forget she has disabilities to her ambulation capabilities and try to transfer herself from the bed to the wheel chair, without calling for help. Resident Ambulatory and incontinent, has poor vision without glasses. Score 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Falls Investigation dated 7/25/17 at 6:30 (am/pm not specified, no nursing notes provided). Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Record Review of the Resident #8's Care Plan dated 7/21/17: Recommendations: Educate to use call light, no other/new interventions noted (11) Record Review of the Resident #8's Falls Investigation dated 7/30/17 at 2:00 (am/pm not specified, nursing note at 2:19 a.m. Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Resident alert x 3, with 1-3 falls. Resident ambulatory and continent. Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident. Resident alert, with 1-2 falls in the past 3 months, is ambulatory and continent. Fall risk score 8, previous score on 7/21/17 was 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Care Plan dated 7/30/17: Recommendations: Follow-up labs, no interventions related to fall prevention. Record Review of the Therapy Screen dated 8/03/17 for falls that occurred on 7/30/17, had recommendations to continue physical therapy and occupational therapy. (12) Record Review of the Resident #8's Incident/Accident Report dated 8/04/17 at 6:10 p.m., Resident #8 fell , witnessed. Resident observed having lost her balance and falling onto the floor on her Left hip and left elbow. Skin tear to left elbow. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/04/17 states the Resident, attempts ambulation without assist, Non-compliant with calling for help. Recommendations: CBC/CMP due 8/5/17. Record Review of the Resident #8's Care Plan dated 8/04/17: Recommendations: Labs as ordered. (13) Record Review of the Resident #8's Incident/Accident Report dated 8/05/17 at 10:45 a.m., Resident #8 fell , unwitnessed. Resident found on the floor on her right side. Skin tear to the back of her left hand. Alert and oriented to self. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/05/17 states the Resident, Non-compliant with using call-light or asking for assistance, Possible UTI due to confusion prior to fall and previous fall the evening before. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, Complete Blood Count (CBC) in morning (AM), Tylenol as needed (PRN). Record Review of the Resident #8's Care Plan dated 8/05/17. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, CBC in AM, Tylenol PRN. Record Review of the Therapy Screen dated 8/08/17 for falls that occurred on 8/04/17 and 8/05/17 had recommendations to continue physical therapy and occupational therapy (started on 8/4/17 and ended on 8/18/17) (14) Record Review of the Resident #8's Incident/Accident Report dated 8/25/17 at 9:20 p.m., Resident #8 fell , witnessed. Resident seen falling to floor onto her buttocks. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/25/17 states the Resident, Attempting to ambulate self, has poor safety awareness. Recommendations: Continue current interventions. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental status. General weakness for her functional status, No changes observed for her behavioral status, the rest of this form including Primary care Clinicians recommendations was not fully completed, dated or signed. Record Review of the Resident #8's Care Plan dated on 8/25/17: Recommendations: Continue current interventions. Record Review of the Therapy Screen dated 9/01/17 for falls that occurred on 8/25/17, had recommendations to continue physical therapy and occupational therapy. Record Review of the Restorative Progress Report dated 8/30/17 at 9:58 a.m. revealed Resident #8 was seen one time that week. Not seen other days due to staffing issues. (15) Record Review of the Resident #8's Incident/Accident Report dated 9/08/17 at 4:50 p.m., Resident #8 fell , unwitnessed. Resident found on the floor in her restroom. Alert and oriented to self and place. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/08/17 states the Resident, Has poor safety awareness. Recommendations: Therapy to screen. Record Review of Resident #8's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological or skin status. Resident reported to have pain in the Occipital Area. No recommendations were made by the Primary Care Clinician. Signed and dated 9/8/17 at 4:35 pm. Record Review of the Resident #8's Care Plan dated 9/08/17. Recommendations: therapy to screen. Record Review of the Therapy Screen dated 9/11/17 for falls that occurred on 9/08/17, had recommendations to continue with therapy interventions. (16) Record Review of the Resident #8's Incident/Accident Report dated 9/12/17 at 11:30 p.m., Resident #8 fell , unwitnessed. Resident found on the floor, alert and oriented to self and place, with a [MEDICAL CONDITION] to the right side of the head at the hairline measured at 7.1 cm. at 11:34 am, resident was reported alert and oriented to self only. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/12/17 states the Resident, Attempting to ambulate, poor safety awareness. Recommendations: Sent to the hospital. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/12/17 for RN's/LPN/LVN revealed the Resident had changes in mental status and was making confusing statements. Her functional status, general weakness with decreased mobility, needs more assistance with Activities of Daily Living and falls with generalized weakness. Resident's behavioral and respiratory status was not clinically applicable to the change in condition being reported. The second page of third report was not provided by the facility. Record Review of the Resident #8's Care Plan dated 8/25/17 revealed no interventions or recommendations. Record Review of the Resident #8's Care Plan dated 9/12/17 revealed no interventions or recommendations. Record Review of the Therapy Screen dated 9/13/17 for falls that occurred on 9/12/17, no skilled therapy needs at this time. (17) Record Review of the Resident #8's Incident/Accident Report dated 9/19/17 at 1:30 p.m., Resident #8 fell , witnessed. Resident was seen as she was going down onto the floor. Resident was reported to have intermittent confusion and an unsteady balance, scab from previous Skin tear to elbow fell off. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/19/17 states the Resident, Non-compliant with fall precautions. Recommendations: Continue current interventions, Therapy to screen due to weakness. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/19/17 for RN's/LPN/LVN revealed the Resident had a period of intermittent confusion, no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological, pain or skin status. No recommendations from the primary care clinician. Signed and dated on 9/19/17 at 1:40 pm. Record Review of the Resident #8's Care Plan dated 9/20/17 revealed no interventions or recommendations. Record Review of the Therapy Screen dated 9/21/17 for falls that occurred on 9/19/17, had recommendations to restart physical therapy and occupational therapy. Record Review of Restorative Progress Notes dated 09/06/17, 9/13/17 and 9/20/17 revealed Resident #8. Was not seen due to staffing issues. During an interview on 9/21/17 at 11:32 a.m., the DON stated, that Resident #8 was, very, very non-compliant and stuck in her ways. She revealed that Resident #8 had to be, redirected and that redirection was all you can do with her, She wants to be independent. She also stated that this Resident takes herself to the bathroom and is at risk for UTI's. She then revealed regarding her numerous falls, Resident #8, Will continue to do what she wants and would Continue falling., They have the right to fall. During interview on 9/21/17 at 10:30 a.m. the Administrator, revealed that he was aware that Resident #8 was a frequent faller. He revealed, more could have been done to prevent more fall. During an interview on 9/23/17 at 6:00 p.m., the DON stated, that falls were not fully investigated and that they had not implemented sufficient corrective actions to prevent further falls. During interview on 9/23/17 at 1:00 p.m. the Administrator, revealed Resident #8's, repeated falls, were part of her normal. He then went on to state, that with this resident her First fall was not normal, repeated falls are the normal for her. 2). Record review of Resident #24's Face Sheet revealed Resident # 24 was initially admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Final Report History and Physical dated 09/22/17 at 11:05 a.m. revealed the Chief complaint was: left [MEDICAL CONDITION]. Assessment/Plan: Forehead contusion with CT scan of head showed no acute findings. Fracture of femoral head with an Orthopedic consult which revealed the patient is not a good surgical candidate, due to a history of cardio embolic [MEDICAL CONDITIONS]- a history of frequent falls secondary to patient being unaware of limitations due to advanced Dementia. Recommendations were: Continue with fall precautions. Record review of Hospital Discharge Summary dated 09/23/17 revealed Resident # 24 returned to nursing home on hospice. Record review of Resident #24's Fall Risk assessment dated [DATE] revealed a score of 16 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 3 (where 0-7 is severely impaired) and a Quarterly MDS dated [DATE], BIMS score of 4. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE] and Quarterly Minimum (MDS) data set [DATE] revealed Resident # 24 requires extensive assistance/ one person physical assist for bed-mobility, transfers, and toileting. During initial tour on 09/19/17 with ADON she revealed Resident #24 was not Interviewable, used a wheelchair for mobility, continent of bowel and bladder, and had a history of [REDACTED]. Record review of Resident #24's Care Plan originally dated 05/01/17 handwritten updates were completed on the following dates: 05/30/17, 05/31/17, 06/09/17, 06/17/17, 07/15/17, 07/27/17 (2 entries), 07/31/17, 08/06/17, 08/14/17 (4 entries) 08/16/17, 08/17/17. Care Plan Problem: I have the potential risk of further falls and injury from falls due to recent history of falls. Care Plan Goals: Will minimize risk for injury or falls daily and ongoing by next care plan review. Care Plan Interventions: Monitor my environment for wet spots or items placed below field of vision on floor, Call light close, Instruct and remind me to call for assistance Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from 05/26/17 to 09/22/17 revealed Resident #24 had fallen a total of 16 times. Record review of the Care Plans revealed Resident #24 had actually fallen 19 times. The Fall Reports revealed the following: (1) Record review of Resident's # 24's Incident/Accident Report 05/26/17 at 1:00 p.m., revealed Resident #24 had a witnessed fall. Resident # 24 fell to his knees while making his bed. Record Review of the Interdisciplinary Post-Fall Evaluation dated 05/26/17 revealed recommendation: Moved to A Bed and probable cause of fall: Residents knee gave out. (2) Record review of Resident's # 24's Incident/Accident Report 06/09/17 at 8:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 slid out of bed onto the floor. Resident stated blanket was slippery. Small abrasion right thumb. Physician and family notified at 9:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/09/17 revealed recommendation: Use linens that are not slippery. Probable cause of fall: Slid out of bed. Record Review of the Care Plan dated 06/09/17 revealed, educate to use call bell for assistance. Record review of Restorative progress notes dated 06/14/17 revealed Resident # 24 was started on Restorative Nursing Program on 06/07/17. Record review of Resident # 24's restorative progress note dated 06/16/17 revealed resident's back pain was worse today and he was only able to take a couple of steps, nurse notified. (3) Record review of Resident's # 24's Incident/Accident Report 06/17/17 at 3:00 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found siting on floor with back against the bed, No apparent injuries. Physician notified at 5:10 p.m. family notified at 6:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/17/17 revealed recommendation: Continue Interventions Probable cause of fall: Up without assistance Resident stated he was trying to lower bed rail, poor safety awareness. Impulsive. Record Review of the Care Plan dated 06/17/17 revealed, continue interventions. Incident/Accident report requested none provided. No new interventions related to falls noted. Record review of Resident # 24's restorative progress note dated 06/19/17 revealed resident only took a couple of steps and sat back down stating he couldn't ambulate. Record review of Resident #24's restorative nursing progress note dated 06/21/17 reveals, Resident # 24 is unable to ambulate due to pain in lower back and left knee. Record review of Resident #24's restorative progress note dated 06/28/17, 06/29/17, 06/30/17, and 07/05/17 revealed Resident #24 unable to ambulate due to left knee pain. Record review of Resident#24's restorative progress note dated 07/12/17 revealed resident does not tolerate ambulation due to knee pain and his left knee is bending outwards making it unsafe for him to ambulate. Record review of Resident #24's restorative progress note dated 07/14/17 revealed resident did not ambulate today due to extreme discomfort and pain to left knee. (4) Record review of statement by CNA dated 07/15/17 and signed by LVN on 08/12/17 (no time) revealed Resident # 24 was found sitting on the floor with back against the bed frame. No injuries found upon assessment. Record Review of the Care Plan dated 07/15/17 revealed, Doctor HH to evaluate and continue antibiotics. Record review of Resident #24's restorative progress note dated 07/19/17, 07/21/17, 07/26/17, resident did not want to participate due to knee pain. (5) Record Review of the Care Plan dated 07/27/17 revealed, Resident # 24 fell on his back in the bathroom (2-10 shift). Record Review of the Care Plan dated 07/27/17 revealed [MEDICATION NAME] was discontinued, CBC, BMP, UA, X-Ray as ordered orthostatic blood pressure x 3. No Incident/Accident Report requested none provided. (6) Record review of original care plan dated 05/01/17 updated on 07/27/17 revealed Resident # 24 slipped off edge of wheelchair in room. Educate to use call bell. Incident/Accident report requested none provided. Record Review of the Care Plan dated 07/27/17 revealed, educate to use call lights, no other/new interventions noted. (7) Record review of statement by CNA dated 07/31/17 and signed by LVN (no date, no time) revealed Resident # 24 was found sitting on the floor close to his bed on the side by the door. He stated he slipped forward trying to put on his shoes. Record Review of the Care Plan dated 07/31/17 UA/C&S (negative). Neuro-checks completed x 3 days. Record review of Resident #24's restorative progress note dated 7/31/17, 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (8) Record review of Resident's # 24's Incident/Accident Report 08/06/17 at 1:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in the 100 Hall hoper room. Physician notified at 3:22 p.m. Family notified at 3:20 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/06/17 revealed recommendation: Staff to at least check Resident every 2 hours. Resident refuses assistance from staff. Probable cause of fall: Attempting to toilet self. Record Review of the Care Plan dated 08/06/17 revealed, the staff was to check on resident at least every 2 hours. No new interventions related to falls noted for 08/07/17. Record review of Resident #24's restorative progress note dated 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (9) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 6:15 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found at 11:00 p.m. to be sitting up at the right side of his bed on the floor. Physician and family notified at 6:15 a.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care. Probable cause of fall: His wheelchair was outside his room and he does not want his side rails up on his bed. Side rails are up now. Wheelchair is in his room and he agreed to use call button. Record Review revealed there was no care plan for fall precautions or prevention noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/13/17 revealed recommendation of primary clinicians section left blank. (10) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 7:00 a.m , revealed Resident #24 had a witnessed fall. Resident # 24 was seen by nurse struggling to pull up his pants, lost his footing and fell on to his buttocks. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care document refusal. Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed there was no care plan interventions noted for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. Interview with DON on 09/26/17 at 10:15 AM revealed it was an unwitnessed fall LVN documented what Resident stated. (11) Record Review of Resident's # 24's Incident/Accident Report 08/12/17 at 5:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in restroom with pants and brief down. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed, there was no care plan interventions for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. (12) Record review of Resident's # 24 Incident/Accident Report 08/14/17 at 4:30 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on his bathroom floor beside the toilet and his wheelchair. Physician notified and family notified at 6:00 a.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/14/17 revealed(TRUNCATED)

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 3 residents (Residents # 8, 24 and 18) of 35 residents reviewed for neglect related to falls and procedures for reporting incidents of abuse and neglect for 1 of 1 resident reviewed for reporting falls in that they: 1. Failed to implement appropriate individualized interventions after Resident # 8's 14 falls over a 9 month period (11/16/16 to 9/9/17). Resident #4 sustained a fall on 9/12/17. The Resident was transported to the hospital after being found on the floor, confused with a 7.1 cm laceration located on the right side of her head at the hairline. 2. Failed to implement appropriate individualized interventions after Resident # 24's 19 falls over 4 months (5/26/17 to 9/22/17). Resident # 24 sustained a fall on 9/22/17 and was transferred to a local hospital on [DATE] and were diagnosed with [REDACTED]. 3. Resident #18 had an unwitnessed fall and presented with bruising and a fracture. The fracture was discovered four days after the fall and had not been thoroughly investigated or reported to the state. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/22/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls, and could result in injury or death and could affect 1 residents who had a reported fracture within the past 27 days and resulted in resident injuries not being investigated and reported. The findings were: Record review of facility's policy on Abuse Investigation and Reporting Policy Statement (no date) revealed All reports of resident abuse, neglect, exploitation, misappropriation, of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported. 1.) Record review of Resident #8's Face Sheet not dated, revealed Resident #8 was admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital, with the [DIAGNOSES REDACTED]. Record review of Resident #8's Fall Risk Assessment (FRA) dated 9/22/17 revealed a score of 23 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #8's Quarterly-Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 10 (where 8-12 is moderately impaired), and Quarterly-MDS dated [DATE], BIMS score 9, Comprehensive, Annual MDS dated [DATE], BIMS score of 9 and a Comprehensive, Annual MDS dated [DATE], with a BIMS score of 9. Record review of Resident #8's Quarterly MDS scores dated 8/24/17 revealed Resident #8 requires extensive assistance/ one person physical assist for transfers, and toileting. Comprehensive, Annual MDS dated [DATE], revealed Resident #8 requires extensive assistance/ one person physical assist, Comprehensive, Annual MDS dated [DATE], revealed Resident #8 requires limited assistance/ one person physical assist. During an interview on 9/19/17 at 10:15 a.m., with the ADON revealed Resident #8 ambulated in a wheelchair, was continent of bowel and bladder, had weight loss, a history of falls and was on fall precautions. Record review of Resident #8's Care Plan originally dated 3/22/13, updated (updates hand-written) on 11/01/16, 12/5/16, 1/26/17, 2/24/17, 3/02/17, 3/19/17 (2 entries), 3/20/17 (2 entries), 7/21/17, 7/30/17, 9/8/17, 9/12/17, 9/12/17 and 9/19/17. (Italicized dates do not coincide with care plan updates for falls). Care Plan Problem: I have had a history of [REDACTED]. Care Plan Goals: I will minimize risk of injuries from falls over the next 90 days. Care Plan Interventions: Monitor changes in Resident's condition that may warrant increased supervision/assistance and notify the physician. I am non-compliant with fall interventions. I will continually be encouraged to use call light. Observation of Resident #8 on 9/19/17 at 2:00 p.m. revealed the resident was in bed, with a quarter-sized skin tear to left elbow. Record review of the facility's Incident/Accident Reports. The reports were inconsistent and included some of the following documents: Incident Investigation, a Skin, Bruise or other Events, Interdisciplinary Post-Fall Assessment, a Witness Statement/First Responder Statement sheet. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from the period between 11/16/16 to 9/9/17, revealed Resident #8 had fallen a total of 14 times. Record review of the Care Plan revealed Resident #8 had actually fallen a total of 17 times. The Fall Reports revealed the following: (1) On 11/01/16 Resident #8 had a fall, No reports were provided from the facility, care plan was updated. Recommendations: Continue current interventions, I am non-compliant with fall interventions. I will continually be encouraged to use call light. Record Review of the Incident/Accident Reports book revealed, there was no IAR for the fall on 11/01/16. Care Plan dated 11/01/16 contained the following: I was trying to hang on to something on the wall as nurse came in I lost my balance and fell . (2) Record Review of the Resident #8's Incident/Accident Report dated 11/16/16 at 10:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor, noted to be alert and oriented. No injury noted. Record Review of the Resident #8's Incident Investigation sheet dated 11/16/16 revealed: immediate actions taken: neuro-checks. Report states the resident was found sitting in her own bathroom and was oriented, last toileting was at 9:50 am. Record Review of the Resident #8's Skin, Bruise or Other Event Investigation sheet dated 11/16/16: Resident oriented, uses wheel chair, wheel herself, and transfers independently. Resident was educated on safety and reminded to ask for assistance. Do not rush when doing ADL's, take her time. Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Recommendations: Continue current intervention. Record Review of the Resident #8's Care Plan revealed an update on 11/16/16: Continue current interventions. Record Review of the Therapy Screen dated 11/29/17 for falls that occurred on 11/01/16 and 11/16/16 had recommendations to continue physical therapy and occupational therapy. (3) Record Review of the Resident #8's Incident/Accident Report dated 1/26/17 at 12:15 p.m., Resident #8 fell unwitnessed, found siting on the floor in the bathroom, alert and oriented. No injuries or bruises noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 11/16/16 states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Care plan revision dated 1/31/17 (No update to Care Plan found). Recommendations: Continue current intervention. Record Review of Resident #8's Therapy Screen dated 1/31/17. Recommendation: No skilled therapy at this time. Record Review of Resident #8's Care Plan revealed no plan revisions dated 1/31/17. Update was dated 1/26/17. Recommendations: Continue current interventions, resident refuses any fall interventions. (4) Record Review of the Resident #8's Incident/Accident Reports 2/24/17 at 6:40 p.m., Resident #8 fell , witnessed, Resident lost her balance while standing, bumped her head on the seat of the wheelchair. Resident #8 was sent to the hospital at 9:30 am. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 2/24/17 states, Resident, loses balance. Care plan revision dated 2/27/17. (No update to Care Plan found on that date). Recommendations: Reinforce with resident that assistance is needed when ambulating or transferring. Record Review of Resident #8's Care Plan dated 2/24/17 revealed the following Recommendations: Continue on Therapy (Occupational Therapy initiated on 12/5/16 five times a week for 30 days), sent to hospital for evaluations and treatment. (5) Record Review of the Resident #8's Incident/Accident Report dated 3/02/17 at 7:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor. Resident stated, I lost my balance and fell on to the floor and hit my head on the bedside table. Small bruise to left elbow noted, no additional injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/02/17 states the Resident tries to ambulate without assist, loses balance independently. Recommendations: Encourage to use call light for staff assist and wait for help. Record Review of the Resident #8's Care Plan revealed an update on 3/02/17: Continue therapy. Record Review of the Therapy Screen dated 3/07/17 for falls that occurred on 2/24/17 and 3/02/17 had recommendations to continue physical therapy and occupational therapy. (6) Record Review of the Resident #8's Care Plan revealed an update on 3/19/17 (2 entries) revealed, Resident #8 unwitnessed fall, where she was attempting to stand up in the room without assistance, lost her balance and fell at 10:40 a.m. No reports found for this incident: Recommendations: Continue physical therapy. (7) Record Review of the Resident #8's Incident/Accident Report dated 3/19/17 at 4:45 p.m., Resident #8 fell , unwitnessed, found lying on her right side, on the floor. Resident complained of back pain and was sent to the hospital. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/19/17 states the Resident, attempts to transfer by self. Recommendations: Orthostatic for 3 days. Care plan updated on 3/19/17. Record Review of the Resident #8's Care Plan revealed an update on 3/19/17: Recommendations: Orthostatic Blood Pressure for 3 days, Resident sent to Hospital. (8) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:00 p.m., Resident #8 fell , unwitnessed, found on the floor next to her bed. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/20/17 states the Resident, attempts to ambulate without assist from staff, Resident not asking staff for help. Attempting to ambulate unassisted. Recommendations: Encourage resident to use call-bell, started on Keflex Twice a day for [MEDICATION NAME], Pacemaker implant. Care plan updated on 3/20/17 (2 entries). Record Review of the Resident #8's Care Plan revealed an update on 3/20/17. Recommendations: Encourage resident to use call-bell, on antibiotics for pacemaker implant. (9) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:20 p.m., Resident #8 fell , unwitnessed, found on the floor face down next to the toilet in the bathroom. Resident stated she hit her head on the floor. Resident #8 was sent to the Hospital. (Also noted: resident had vomited on her bed). Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the Resident, attempts ambulation without assist, Unassisted ambulation and transfers. Recommendations: Remind resident to ask for help. Care plan updated again on 3/20/17 Record Review of the Resident #8's Care Plan revealed a second update on 3/20/17: Recommendations: Remind resident to call for help, sent to hospital for evaluation and treatment, on antibiotics four times a day for 7 days for bacterial infection [MEDICAL CONDITION]. (10) Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident uses a wheelchair to ambulate and has very weak legs. She must have standby assistance when transferring to chair from bed. Sometimes needs weight bearing assistance. Resident with intermittent confusion, with 1-2 falls in the past 3 months. Patient will sometimes forget she has disabilities to her ambulation capabilities and try to transfer herself from the bed to the wheel chair, without calling for help. Resident Ambulatory and incontinent, has poor vision without glasses. Score 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Falls Investigation dated 7/25/17 at 6:30 (am/pm not specified, no nursing notes provided). Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Record Review of the Resident #8's Care Plan revealed update on 7/21/17: Recommendations: Educate to use call light. (11) Record Review of the Resident #8's Falls Investigation dated 7/30/17 at 2:00 (am/pm not specified, nursing note at 2:19 a.m. Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Resident alert x 3, with 1-3 falls. Resident ambulatory and continent. Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident. Resident alert, with 1-2 falls in the past 3 months, is ambulatory and continent. Fall risk score 8. Record Review of the Resident #8's Care Plan revealed update on 7/30/17: Recommendations: Follow-up labs. Record Review of the Therapy Screen dated 8/03/17 for falls that occurred on 7/30/17, had recommendations to continue physical therapy and occupational therapy. (12) Record Review of the Resident #8's Incident/Accident Report dated 8/04/17 at 6:10 p.m., Resident #8 fell , witnessed. Resident observed having lost her balance and falling onto the floor on her Left hip and left elbow. Skin tear to left elbow. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/04/17 states the Resident, attempts ambulation without assist, Non-compliant with calling for help. Recommendations: CBC/CMP due 8/5/17. Record Review of the Resident #8's Care Plan revealed an update on 8/04/17: Recommendations: Labs as ordered. (13) Record Review of the Resident #8's Incident/Accident Report dated 8/05/17 at 10:45 a.m., Resident #8 fell , unwitnessed. Resident found on the floor on her right side. Skin tear to the back of her left hand. Alert and oriented to self. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/05/17 states the Resident, Non-compliant with using call-light or asking for assistance, Possible UTI due to confusion prior to fall and previous fall the evening before. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, Complete Blood Count (CBC) in morning (AM), Tylenol as needed (PRN). Record Review of the Resident #8's Care Plan revealed an update on 8/05/17. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, CBC in AM, Tylenol PRN. Record Review of the Therapy Screen dated 8/08/17 for falls that occurred on 8/04/17 and 8/05/17 had recommendations to continue physical therapy and occupational therapy (14) Record Review of the Resident #8's Incident/Accident Report dated 8/25/17 at 9:20 p.m., Resident #8 fell , witnessed. Resident seen falling to floor onto her buttocks. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/25/17 states the Resident, Attempting to ambulate self, has poor safety awareness. Recommendations: Continue current interventions. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental status. General weakness for her functional status, No changes observed for her behavioral status, the rest of this form including Primary care Clinicians recommendations was not fully completed, dated or signed. Record Review of the Resident #8's Care Plan revealed an update on 8/25/17: Recommendations: Continue current intentions. Record Review of the Therapy Screen dated 9/01/17 for falls that occurred on 8/25/17, had recommendations to continue physical therapy and occupational therapy. (15) Record Review of the Resident #8's Incident/Accident Report dated 9/08/17 at 4:50 p.m., Resident #8 fell , unwitnessed. Resident found on the floor in her restroom. Alert and oriented to self and place. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/08/17 states the Resident, Has poor safety awareness. Recommendations: Therapy to screen. Care Plan updated on 9/12/17. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological or skin status. Resident reported to have pain in the Occipital Area. No recommendations were made by the Primary Care Clinician. Signed and dated 9/8/17 at 4:35 pm. Record Review of the Resident #8's Care Plan revealed no update on 9/08/17 or recommendations. Record Review of the Therapy Screen dated 9/11/17 for falls that occurred on 9/08/17, had recommendations to continue with therapy interventions. (16) Record Review of the Resident #8's Incident/Accident Report dated 9/12/17 at 11:30 p.m., Resident #8 fell , unwitnessed. Resident found on the floor, alert and oriented to self and place, with a [MEDICAL CONDITION] to the right side of the head at the hairline measured at 7.1 cm. at 11:34 am, resident was reported alert and oriented to self only. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/12/17 states the Resident, Attempting to ambulate, poor safety awareness. Recommendations: Sent to the hospital. Care plan revised on 9/12/17. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/12/17 for RN's/LPN/LVN revealed the Resident had changes in mental status and was making confusing statements. Her functional status, general weakness with decreased mobility, needs more assistance with Activities of Daily Living and falls with generalized weakness. Resident's behavioral and respiratory status was not clinically applicable to the change in condition being reported. The second page of third report was not provided by the facility. Record Review of the Resident #8's Care Plan revealed no update on 8/25/17 or recommendations. Record Review of the Resident #8's Care Plan revealed no update on 9/12/17 or recommendations. Record Review of the Therapy Screen dated 9/13/17 for falls that occurred on 9/12/17, no skilled therapy needs at this time. (17) Record Review of the Resident #8's Incident/Accident Report dated 9/19/17 at 1:30 p.m., Resident #8 fell , witnessed. Resident was seen as she was going down onto the floor. Resident was reported to have intermittent confusion and an unsteady balance, scab from previous Skin tear to elbow fell off. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/19/17 states the Resident, Non-compliant with fall precautions. Recommendations: Continue current interventions, Therapy to screen due to weakness. Care plan revised on 9/20/17. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/19/17 for RN's/LPN/LVN revealed the Resident had a period of intermittent confusion, no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological, pain or skin status. No recommendations from the primary care clinician. Signed and dated on 9/19/17 at 1:40 pm. Record Review of the Resident #8's Care Plan revealed no update on 9/20/17 or recommendations. Record Review of the Therapy Screen dated 9/21/17 for falls that occurred on 9/19/17, had recommendations to restart physical therapy and occupational therapy. Record Review of the Resident #8's Care Plan revealed an updated version of the care plan revised on 9/22/17 after an Immediate Jeopardy was called on 9/22/17 at 6:23 pm. Problem: I have the potential risk of further falls and injury from falls due to recent history for falls and [DIAGNOSES REDACTED]. I like to be independent and I do not like to ask for assistance. Goals & Targets: I will have my risk for falls and or injuries minimized daily and ongoing by the next cate plan review (no date provided). Recommendations: Monitor my environment for wet spots or items placed below field of vision on the floor. Call light will be placed closely. Reeducate me on the importance of calling for assistance. I will be moved to a A to be closer to the bathroom (Resident #8 was moved from room [ROOM NUMBER] B to #402 A). Pharmacy review completed on 9/22/17 with med adjustments made. Fall assessments updated. Therapy screened post fall. UA C and S to be obtained-CBC to be drawn. I will be placed on a bowel and bladder program and I will be offered to be taken to the toilet every hour. I will not be left unattended while staff is assisting me to the bathroom. Record Review of the Resident #8's Care Plan revealed a hand written note on the care plan dated 9/25/17 which read: Spoke with resident regarding episodes of refusal during the night to participate in the bowel and bladder program. She reports she wanted the staff to continue current program. She will continue to refuse if she does not want to go. (Initialed by the DON) Record Review of Restorative Progress Notes dated 09/06/17, 9/13/17 and 9/20/17 revealed Resident #8. Was not seen due to staffing issues. During an interview on 9/21/17 at 11:32 a.m., the DON stated, that Resident #8 was, very, very non-compliant and stuck in her ways. She revealed that Resident #8 had to be, redirected and that redirection was all you can do with her, She wants to be independent. She also stated that this Resident takes herself to the bathroom and is at risk for UTI's. She then revealed regarding her numerous falls, Resident #8, Will continue to do what she wants and would Continue falling., They have the right to fall. During interview on 9/23/17 at 1:00 p.m. the Administrator, revealed Resident #8's, repeated falls, were part of her normal. He then went on to state, that with this resident her First fall was not normal, repeated falls are the normal for her. 2). Record review of Resident #24's Face Sheet revealed Resident # 24 was initially admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Final Report History and Physical dated 09/22/17 at 11:05 a.m. revealed the Chief complaint was: left [MEDICAL CONDITION]. Assessment/Plan: Forehead contusion with CT scan of head showed no acute findings. Fracture of femoral head with an Orthopedic consult which revealed the patient is not a good surgical candidate, due to a history of cardio embolic [MEDICAL CONDITIONS]- a history of frequent falls secondary to patient being unaware of limitations due to advanced Dementia. Recommendations were: Continue with fall precautions. Record review of Hospital Discharge Summary dated 09/23/17 revealed Resident # 24 returned to nursing home on hospice. Record review of Resident #24's Fall Risk assessment dated [DATE] revealed a score of 16 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 3 (where 0-7 is severely impaired) and a Quarterly MDS dated [DATE], BIMS score of 4. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE] and Quarterly Minimum (MDS) data set [DATE] revealed Resident # 24 requires extensive assistance/ one person physical assist for bed-mobility, transfers, and toileting. During initial tour on 09/19/17 with ADON she revealed Resident #24 was not Interviewable, used a wheelchair for mobility, continent of bowel and bladder, and had a history of [REDACTED]. Record review of Resident #24's Care Plan originally dated 05/01/17 handwritten updates were completed on the following dates: 05/30/17, 05/31/17, 06/09/17, 06/17/17, 07/15/17, 07/27/17 (2 entries), 07/31/17, 08/06/17, 08/14/17 (4 entries) 08/16/17, 08/17/17. Care Plan Problem: I have the potential risk of further falls and injury from falls due to recent history of falls. Care Plan Goals: Will minimize risk for injury or falls daily and ongoing by next care plan review. Care Plan Interventions: Monitor my environment for wet spots or items placed below field of vision on floor, Call light close, Instruct and remind me to call for assistance Observation of Resident #24 on 09/26/17 at 10:40 a.m. revealed the resident was up in wheelchair in patio in front of facility. Resident does not recall fall or going to hospital. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from 05/26/17 to 09/22/17 revealed Resident #24 had fallen a total of 16 times. Record review of the Care Plans revealed Resident #24 had actually fallen 19 times. The Fall Reports revealed the following: (1) Record review of Resident's # 24's Incident/Accident Report 05/26/17 at 1:00 p.m., revealed Resident #24 had a witnessed fall. Resident # 24 fell to his knees while making his bed. Record Review of the Interdisciplinary Post-Fall Evaluation dated 05/26/17 revealed recommendation: Moved to A Bed and probable cause of fall: Residents knee gave out. Record Review of the Care Plan dated on 05/30/17 revealed the Resident fell attempting to make bed wheelchair caught on bed. Care plan updated 05/31/17 revealed the Resident moved to room with A bed for better mobility. (2) Record review of Resident's # 24's Incident/Accident Report 06/09/17 at 8:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 slid out of bed onto the floor. Resident stated blanket was slippery. Small abrasion right thumb. Physician and family notified at 9:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/09/17 revealed recommendation: Use linens that are not slippery. Probable cause of fall: Slid out of bed. Care Plan Revision 06/12/17 Record Review of the Care Plan dated 06/09/17 revealed, educate to use call bell for assistance. No care plan revision noted for 06/12/17. (3) Record review of Resident's # 24's Incident/Accident Report 06/17/17 at 3:00 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found siting on floor with back against the bed No apparent injuries. Physician notified at 5:10 p.m. family notified at 6:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/17/17 revealed recommendation: Continue Interventions Probable cause of fall: Up without assistance Resident stated he was trying to lower bed rail, poor safety awareness. Impulsive. Care plan revised 06/19/17. Record Review of the Care Plan dated 06/17/17 revealed, continue interventions. Incident/Accident report requested none provided. No care plan revision noted for 06/19/17. (4) Record review of statement by CNA dated 07/15/17 and signed by LVN on 08/12/17 (no time) revealed Resident # 24 was found sitting on the floor with back against the bed frame. No injuries found upon assessment. Record Review of the Care Plan dated 07/15/17 revealed, Doctor HH to evaluate and continue antibiotics. (5) Record Review of the Care Plan dated 07/27/17 revealed, Resident # 24 fell on his back in the bathroom (2-10 shift). Record Review of the Care Plan dated 07/27/17 revealed [MEDICATION NAME] was discontinued, CBC, BMP, UA, x-ray as ordered orthostatic blood pressure x 3. No Incident/Accident Report requested none provided. (6) Record review of original care plan dated 05/01/17 updated on 07/27/17 revealed Resident # 24 slipped off edge of wheelchair in room. Educate to use call bell. Incident/Accident report requested none provided. Record Review of the Care Plan dated 07/27/17 revealed educate to use call lights. (7) Record review of statement by CNA dated 07/31/17 and signed by LVN (no date, no time) revealed Resident # 24 was found sitting on the floor close to his bed on the side by the door. He stated he slipped forward trying to put on his shoes. Record Review of the Care Plan dated 07/31/17 UA/C&S (negative). Neuro-checks completed x 3 days. (8) Record review of Resident's # 24's Incident/Accident Report 08/06/17 at 1:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in the 100 Hall hoper room. Physician notified at 3:22 p.m. Family notified at 3:20 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/06/17 revealed recommendation: Staff to at least check Resident every 2 hours. Resident refuses assistance from staff. Probable cause of fall: Attempting to toilet self. Care Plan revised 08/07/17. Record Review of the Care Plan dated 08/06/17 revealed, the staff was to check on resident at least every 2 hours. No care plan revision noted for 08/07/17. (9) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 6:15 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found at 11:00 p.m. to be sitting up at the right side of his bed on the floor. Physician and family notified at 6:15 a.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care. Probable cause of fall: His wheelchair was outside his room and he does not want his side rails up on his bed. Side rails are up now. Wheelchair is in his room and he agreed to use call button. Care plan revision 08/14/17. Record Review revealed there was no care plan revision noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/13/17 revealed recommendation of primary clinicians section left blank. (10) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 7:00 a.m , revealed Resident #24 had a witnessed fall. Resident # 24 was seen by nurse struggling to pull up his pants, lost his footing and fell on to his buttocks. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care document refusal. Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Care plan revised 08/14/17. Record Review revealed there was no care plan revision noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. Interview with DON on 09/26/17 at 10:15 AM revealed it was an unwitnessed fall LVN documented what Resident stated. (11) Record Review of Resident's # 24's Incident/Accident Report 08/12/17 at 5:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in restroom with pants and brief down. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care Probable cause of fall: up with(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure that the resident had the right to be free from neglect for 2 residents (Residents # 8, 24 and 18) of 35 residents reviewed for abuse and neglect related to falls in that they: 1. Failed to implement appropriate individualized interventions after Resident # 8's 14 falls over a 9 month period. Resident #8 sustained a fall on 9/12/17. The Resident was transported to the hospital after being found on the floor, confused with a 7.1 cm laceration located on the right side of her head at the hairline. 2. Failed to implement appropriate individualized interventions after Resident # 24's 19 falls over 4 months Resident # 24 sustained a fall and was transferred to a local hospital and diagnosed with [REDACTED]. 3. Resident #18 had an unwitnessed fall and presented with bruising and a fracture. The fracture was discovered four days after the fall and had not been thoroughly investigated or reported to the state. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 9/23/17. While the IJ was removed on 9/26/17, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 35 residents with a history of falls at risk for future falls and could result in injury or death. The findings were: 1.) Record review of Resident #8's Face Sheet not dated, revealed Resident #8 was admitted to the facility on [DATE] and was readmitted on [DATE] from the hospital, with the [DIAGNOSES REDACTED]. Record review of Resident #8's Fall Risk Assessment (FRA) dated 9/22/17 revealed a score of 23 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #8's Quarterly-Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 10 (where 8-12 is moderately impaired). A more recent MDS was not available as it was in progress. Record review of Resident #8's Quarterly MDS scores dated 8/24/17 revealed Resident #8 requires extensive assistance/ one person physical assist for transfers, and toileting. During an interview on 9/19/17 at 10:15 a.m., with the ADON revealed Resident #8 ambulated in a wheelchair, was continent of bowel and bladder, had weight loss, a history of falls and was on fall precautions. Record review of Resident #8's Care Plan originally dated 3/22/13, updates hand-written on the following dates: 11/01/16, 11/16/16, 12/5/16, 1/26/17, 2/24/17, 3/02/17, 3/19/17 (2 entries), 3/20/17 (2 entries), 7/21/17, 7/30/17, 9/8/17, 9/12/17 and 9/19/17. Care Plan Problem: I have had a history of [REDACTED]. Care Plan Goals: I will minimize risk of injuries from falls over the next 90 days. Care Plan Interventions: Monitor changes in Resident's condition that may warrant increased supervision/assistance and notify the physician. I am non-compliant with fall interventions. I will continually be encouraged to use call light. Observation of Resident #8 on 9/19/17 at 2:00 p.m. revealed the resident was in regular bed, with a quarter-sized skin tear to left elbow. Record review of the facility's Incident/Accident Reports. The reports were inconsistent and included some of the following documents: Incident Investigation, a Skin, Bruise or other Events, Interdisciplinary Post-Fall Assessment, a Witness Statement/First Responder Statement sheet. Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from the period between 11/16/16 to 9/9/17, revealed Resident #8 had fallen a total of 14 times. Record review of the Care Plan revealed Resident #8 had actually fallen a total of 17 times. The Fall Reports revealed the following: (1) On 11/01/16 Resident #8 had a fall, there was no report available, Care Plan Recommendations: Continue current interventions, I am non-compliant with fall interventions. I will continually be encouraged to use call light. Interview on 6/26/17 at 6:00 p.m., DON revealed that corrective actions were not taken and some were not fully investigated. Record Review of the Incident/Accident Reports book revealed, there was no IAR for the fall on 11/01/16. Care Plan dated 11/01/16 contained the following: I was trying to hang on to something on the wall as nurse came in I lost my balance and fell . (2) Record Review of the Resident #8's Incident/Accident Report dated 11/16/16 at 10:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor, noted to be alert and oriented. No injury noted. Record Review of the Resident #8's Incident Investigation sheet dated 11/16/16 revealed: immediate actions taken: neuro-checks. Report states the resident was found sitting in her own bathroom and was oriented, last toileting was at 9:50 am. Record Review of the Resident #8's Skin, Bruise or Other Event Investigation sheet dated 11/16/16: Resident oriented, uses wheel chair, wheel herself, and transfers independently. Resident was educated on safety and reminded to ask for assistance. Do not rush when doing ADL's, take her time. Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the resident slipped out of her chair when changing her diaper, no injuries noted, confused with unstable gait and ambulates independently. Recommendations: Continue current intervention. Record Review of the Resident #8's Care Plan revealed an update on 11/16/16: Continue current interventions. Record Review of the Therapy Screen dated 11/29/16 for falls that occurred on 11/01/16 and 11/16/16 had recommendations to continue physical therapy and occupational therapy. (3) Record Review of the Resident #8's Incident/Accident Report dated 1/26/17 at 12:15 p.m., Resident #8 fell unwitnessed, found sitting on the floor in the bathroom, alert and oriented. No injuries or bruises noted. Record Review of Resident #8's Therapy Screen dated 1/31/17. Recommendation: No skilled therapy at this time. Record Review of Resident #8's Care Plan dated 1/31/17. Recommendations: Continue current interventions, resident refuses any fall interventions, no new interventions documented (4) Record Review of the Resident #8's Incident/Accident Reports 2/24/17 at 6:40 p.m., Resident #8 fell , witnessed, Resident lost her balance while standing, bumped her head on the seat of the wheelchair. Resident #8 was sent to the hospital at 9:30 am. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 2/24/17 states, Resident, loses balance. Recommendations: Reinforce with resident that assistance is needed when ambulating or transferring. Record Review of Resident #8's Care Plan dated 2/24/17 revealed the following Recommendations: Continue on Therapy (Occupational Therapy initiated on 12/5/16 five times a week for 30 days), sent to hospital for evaluations and treatment. (5) Record Review of the Resident #8's Incident/Accident Report dated 3/02/17 at 7:00 a.m., Resident #8 fell , unwitnessed, found sitting on the floor. Resident stated, I lost my balance and fell on to the floor and hit my head on the bedside table. Small bruise to left elbow noted, no additional injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/02/17 states the Resident tries to ambulate without assist, loses balance independently. Recommendations: Encourage to use call light for staff assist and wait for help. Record Review of the Resident #8's Care Plan dated 3/02/17: Continue therapy. Record Review of the Therapy Screen dated 3/07/17 for falls that occurred on 2/24/17 and 3/02/17 had recommendations to continue physical therapy and occupational therapy. Physical therapy was initiated on 3/10/17 and continued to 3/24/17. (6) Record Review of the Resident #8's Care Plan revealed an update on 3/19/17 (2 entries) revealed, Resident #8 unwitnessed fall, where she was attempting to stand up in the room without assistance, lost her balance and fell at 10:40 a.m. No reports found for this incident: Recommendations: Continue physical therapy. (7) Record Review of the Resident #8's Incident/Accident Report dated 3/19/17 at 4:45 p.m., Resident #8 fell , unwitnessed, found lying on her right side, on the floor. Resident complained of back pain and was sent to the hospital. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/19/17 states the Resident, attempts to transfer by self. Recommendations: Orthostatic for 3 days. Record Review of the Resident #8's Care Plan revealed an update on 3/19/17: Recommendations: Orthostatic Blood Pressure for 3 days, Resident sent to Hospital. (8) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:00 p.m., Resident #8 fell , unwitnessed, found on the floor next to her bed. No injuries noted. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 3/20/17 states the Resident, attempts to ambulate without assist from staff, Resident not asking staff for help. Attempting to ambulate unassisted. Recommendations: Encourage resident to use call-bell, started on Keflex Twice a day for [MEDICATION NAME], Pacemaker implant. Record Review of the Resident #8's Care Plan revealed an update on 3/20/17. Recommendations: Encourage resident to use call-bell, on antibiotics for pacemaker implant. (9) Record Review of the Resident #8's Incident/Accident Report dated 3/20/17 at 4:20 p.m., Resident #8 fell , unwitnessed, found on the floor face down next to the toilet in the bathroom. Resident stated she hit her head on the floor. Resident #8 was sent to the Hospital. (Also noted: resident had vomited on her bed). Record Review of Resident #8's Interdisciplinary Post-Fall assessment dated [DATE] states the Resident, attempts ambulation without assist, Unassisted ambulation and transfers. Recommendations: Remind resident to ask for help. Record Review of the Resident #8's Care Plan revealed a second update on 3/20/17: Recommendations: Remind resident to call for help, sent to hospital for evaluation and treatment, on antibiotics four times a day for 7 days for bacterial infection [MEDICAL CONDITION], no new interventions noted. (10) Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident uses a wheelchair to ambulate and has very weak legs. She must have standby assistance when transferring to chair from bed. Sometimes needs weight bearing assistance. Resident with intermittent confusion, with 1-2 falls in the past 3 months. Patient will sometimes forget she has disabilities to her ambulation capabilities and try to transfer herself from the bed to the wheel chair, without calling for help. Resident Ambulatory and incontinent, has poor vision without glasses. Score 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Falls Investigation dated 7/25/17 at 6:30 (am/pm not specified, no nursing notes provided). Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Record Review of the Resident #8's Care Plan dated 7/21/17: Recommendations: Educate to use call light, no other/new interventions noted (11) Record Review of the Resident #8's Falls Investigation dated 7/30/17 at 2:00 (am/pm not specified, nursing note at 2:19 a.m. Unwitnessed fall, resident found on the floor, 2 other falls in past 30 days and 31-180 days. Resident alert x 3, with 1-3 falls. Resident ambulatory and continent. Record Review of the Resident #8's Fall Risk assessment dated [DATE] revealed the resident. Resident alert, with 1-2 falls in the past 3 months, is ambulatory and continent. Fall risk score 8, previous score on 7/21/17 was 20 (Score of a 10 or above represent a high risk). Record Review of the Resident #8's Care Plan dated 7/30/17: Recommendations: Follow-up labs, no interventions related to fall prevention. Record Review of the Therapy Screen dated 8/03/17 for falls that occurred on 7/30/17, had recommendations to continue physical therapy and occupational therapy. (12) Record Review of the Resident #8's Incident/Accident Report dated 8/04/17 at 6:10 p.m., Resident #8 fell , witnessed. Resident observed having lost her balance and falling onto the floor on her Left hip and left elbow. Skin tear to left elbow. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/04/17 states the Resident, attempts ambulation without assist, Non-compliant with calling for help. Recommendations: CBC/CMP due 8/5/17. Record Review of the Resident #8's Care Plan dated 8/04/17: Recommendations: Labs as ordered. (13) Record Review of the Resident #8's Incident/Accident Report dated 8/05/17 at 10:45 a.m., Resident #8 fell , unwitnessed. Resident found on the floor on her right side. Skin tear to the back of her left hand. Alert and oriented to self. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/05/17 states the Resident, Non-compliant with using call-light or asking for assistance, Possible UTI due to confusion prior to fall and previous fall the evening before. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, Complete Blood Count (CBC) in morning (AM), Tylenol as needed (PRN). Record Review of the Resident #8's Care Plan dated 8/05/17. Recommendations: [MEDICATION NAME] IV for 7 days, [MEDICATION NAME] for 7 days, CBC in AM, Tylenol PRN. Record Review of the Therapy Screen dated 8/08/17 for falls that occurred on 8/04/17 and 8/05/17 had recommendations to continue physical therapy and occupational therapy (started on 8/4/17 and ended on 8/18/17) (14) Record Review of the Resident #8's Incident/Accident Report dated 8/25/17 at 9:20 p.m., Resident #8 fell , witnessed. Resident seen falling to floor onto her buttocks. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 8/25/17 states the Resident, Attempting to ambulate self, has poor safety awareness. Recommendations: Continue current interventions. Record Review of Resident #8's SBAR Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental status. General weakness for her functional status, No changes observed for her behavioral status, the rest of this form including Primary care Clinicians recommendations was not fully completed, dated or signed. Record Review of the Resident #8's Care Plan dated on 8/25/17: Recommendations: Continue current interventions. Record Review of the Therapy Screen dated 9/01/17 for falls that occurred on 8/25/17, had recommendations to continue physical therapy and occupational therapy. Record Review of the Restorative Progress Report dated 8/30/17 at 9:58 a.m. revealed Resident #8 was seen one time that week. Not seen other days due to staffing issues. (15) Record Review of the Resident #8's Incident/Accident Report dated 9/08/17 at 4:50 p.m., Resident #8 fell , unwitnessed. Resident found on the floor in her restroom. Alert and oriented to self and place. No injuries reported. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/08/17 states the Resident, Has poor safety awareness. Recommendations: Therapy to screen. Record Review of Resident #8's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and progress notes for RN's/LPN/LVN's revealed the Resident had no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological or skin status. Resident reported to have pain in the Occipital Area. No recommendations were made by the Primary Care Clinician. Signed and dated 9/8/17 at 4:35 pm. Record Review of the Resident #8's Care Plan dated 9/08/17. Recommendations: therapy to screen. Record Review of the Therapy Screen dated 9/11/17 for falls that occurred on 9/08/17, had recommendations to continue with therapy interventions. (16) Record Review of the Resident #8's Incident/Accident Report dated 9/12/17 at 11:30 p.m., Resident #8 fell , unwitnessed. Resident found on the floor, alert and oriented to self and place, with a [MEDICAL CONDITION] to the right side of the head at the hairline measured at 7.1 cm. at 11:34 am, resident was reported alert and oriented to self only. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/12/17 states the Resident, Attempting to ambulate, poor safety awareness. Recommendations: Sent to the hospital. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/12/17 for RN's/LPN/LVN revealed the Resident had changes in mental status and was making confusing statements. Her functional status, general weakness with decreased mobility, needs more assistance with Activities of Daily Living and falls with generalized weakness. Resident's behavioral and respiratory status was not clinically applicable to the change in condition being reported. The second page of third report was not provided by the facility. Record Review of the Resident #8's Care Plan dated 8/25/17 revealed no interventions or recommendations. Record Review of the Resident #8's Care Plan dated 9/12/17 revealed no interventions or recommendations. Record Review of the Therapy Screen dated 9/13/17 for falls that occurred on 9/12/17, no skilled therapy needs at this time. (17) Record Review of the Resident #8's Incident/Accident Report dated 9/19/17 at 1:30 p.m., Resident #8 fell , witnessed. Resident was seen as she was going down onto the floor. Resident was reported to have intermittent confusion and an unsteady balance, scab from previous Skin tear to elbow fell off. Record Review of Resident #8's Interdisciplinary Post-Fall Evaluation dated 9/19/17 states the Resident, Non-compliant with fall precautions. Recommendations: Continue current interventions, Therapy to screen due to weakness. Record Review of Resident #8's SBAR Communication Form and progress notes dated 9/19/17 for RN's/LPN/LVN revealed the Resident had a period of intermittent confusion, no changes in mental, functional, behavioral, cardiovascular, abdominal/gastrointestinal, neurological, pain or skin status. No recommendations from the primary care clinician. Signed and dated on 9/19/17 at 1:40 pm. Record Review of the Resident #8's Care Plan dated 9/20/17 revealed no interventions or recommendations. Record Review of the Therapy Screen dated 9/21/17 for falls that occurred on 9/19/17, had recommendations to restart physical therapy and occupational therapy. Record Review of Restorative Progress Notes dated 09/06/17, 9/13/17 and 9/20/17 revealed Resident #8. Was not seen due to staffing issues. During an interview on 9/21/17 at 11:32 a.m., the DON stated, that Resident #8 was, very, very non-compliant and stuck in her ways. She revealed that Resident #8 had to be, redirected and that redirection was all you can do with her, She wants to be independent. She also stated that this Resident takes herself to the bathroom and is at risk for UTI's. She then revealed regarding her numerous falls, Resident #8, Will continue to do what she wants and would Continue falling., They have the right to fall. During interview on 9/21/17 at 10:30 a.m. the Administrator, revealed that he was aware that Resident #8 was a frequent faller. He revealed, more could have been done to prevent more fall. During an interview on 9/23/17 at 6:00 p.m., the DON stated, that falls were not fully investigated and that they had not implemented sufficient corrective actions to prevent further falls. During interview on 9/23/17 at 1:00 p.m. the Administrator, revealed Resident #8's, repeated falls, were part of her normal. He then went on to state, that with this resident her First fall was not normal, repeated falls are the normal for her. 2). Record review of Resident #24's Face Sheet revealed Resident # 24 was initially admitted on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Final Report History and Physical dated 09/22/17 at 11:05 a.m. revealed the Chief complaint was: left [MEDICAL CONDITION]. Assessment/Plan: Forehead contusion with CT scan of head showed no acute findings. Fracture of femoral head with an Orthopedic consult which revealed the patient is not a good surgical candidate, due to a history of cardio embolic [MEDICAL CONDITIONS]- a history of frequent falls secondary to patient being unaware of limitations due to advanced Dementia. Recommendations were: Continue with fall precautions. Record review of Hospital Discharge Summary dated 09/23/17 revealed Resident # 24 returned to nursing home on hospice. Record review of Resident #24's Fall Risk assessment dated [DATE] revealed a score of 16 where a resident who scored a 10 or higher was at risk for falls. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE], Brief Interview for Mental Status (BIMS) score of 3 (where 0-7 is severely impaired) and a Quarterly MDS dated [DATE], BIMS score of 4. Record review of Resident #24's Comprehensive Admission Minimum Data Set ((MDS) dated [DATE] and Quarterly Minimum (MDS) data set [DATE] revealed Resident # 24 requires extensive assistance/ one person physical assist for bed-mobility, transfers, and toileting. During initial tour on 09/19/17 with ADON she revealed Resident #24 was not Interviewable, used a wheelchair for mobility, continent of bowel and bladder, and had a history of [REDACTED]. Record review of Resident #24's Care Plan originally dated 05/01/17 handwritten updates were completed on the following dates: 05/30/17, 05/31/17, 06/09/17, 06/17/17, 07/15/17, 07/27/17 (2 entries), 07/31/17, 08/06/17, 08/14/17 (4 entries) 08/16/17, 08/17/17. Care Plan Problem: I have the potential risk of further falls and injury from falls due to recent history of falls. Care Plan Goals: Will minimize risk for injury or falls daily and ongoing by next care plan review. Care Plan Interventions: Monitor my environment for wet spots or items placed below field of vision on floor, Call light close, Instruct and remind me to call for assistance Record review of the facility's Incident/Accident report and Interdisciplinary Post-Fall Evaluation Form from 05/26/17 to 09/22/17 revealed Resident #24 had fallen a total of 16 times. Record review of the Care Plans revealed Resident #24 had actually fallen 19 times. The Fall Reports revealed the following: (1) Record review of Resident's # 24's Incident/Accident Report 05/26/17 at 1:00 p.m., revealed Resident #24 had a witnessed fall. Resident # 24 fell to his knees while making his bed. Record Review of the Interdisciplinary Post-Fall Evaluation dated 05/26/17 revealed recommendation: Moved to A Bed and probable cause of fall: Residents knee gave out. (2) Record review of Resident's # 24's Incident/Accident Report 06/09/17 at 8:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 slid out of bed onto the floor. Resident stated blanket was slippery. Small abrasion right thumb. Physician and family notified at 9:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/09/17 revealed recommendation: Use linens that are not slippery. Probable cause of fall: Slid out of bed. Record Review of the Care Plan dated 06/09/17 revealed, educate to use call bell for assistance. Record review of Restorative progress notes dated 06/14/17 revealed Resident # 24 was started on Restorative Nursing Program on 06/07/17. Record review of Resident # 24's restorative progress note dated 06/16/17 revealed resident's back pain was worse today and he was only able to take a couple of steps, nurse notified. (3) Record review of Resident's # 24's Incident/Accident Report 06/17/17 at 3:00 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found siting on floor with back against the bed, No apparent injuries. Physician notified at 5:10 p.m. family notified at 6:00 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 06/17/17 revealed recommendation: Continue Interventions Probable cause of fall: Up without assistance Resident stated he was trying to lower bed rail, poor safety awareness. Impulsive. Record Review of the Care Plan dated 06/17/17 revealed, continue interventions. Incident/Accident report requested none provided. No new interventions related to falls noted. Record review of Resident # 24's restorative progress note dated 06/19/17 revealed resident only took a couple of steps and sat back down stating he couldn't ambulate. Record review of Resident #24's restorative nursing progress note dated 06/21/17 reveals, Resident # 24 is unable to ambulate due to pain in lower back and left knee. Record review of Resident #24's restorative progress note dated 06/28/17, 06/29/17, 06/30/17, and 07/05/17 revealed Resident #24 unable to ambulate due to left knee pain. Record review of Resident#24's restorative progress note dated 07/12/17 revealed resident does not tolerate ambulation due to knee pain and his left knee is bending outwards making it unsafe for him to ambulate. Record review of Resident #24's restorative progress note dated 07/14/17 revealed resident did not ambulate today due to extreme discomfort and pain to left knee. (4) Record review of statement by CNA dated 07/15/17 and signed by LVN on 08/12/17 (no time) revealed Resident # 24 was found sitting on the floor with back against the bed frame. No injuries found upon assessment. Record Review of the Care Plan dated 07/15/17 revealed, Doctor HH to evaluate and continue antibiotics. Record review of Resident #24's restorative progress note dated 07/19/17, 07/21/17, 07/26/17, resident did not want to participate due to knee pain. (5) Record Review of the Care Plan dated 07/27/17 revealed, Resident # 24 fell on his back in the bathroom (2-10 shift). Record Review of the Care Plan dated 07/27/17 revealed [MEDICATION NAME] was discontinued, CBC, BMP, UA, X-Ray as ordered orthostatic blood pressure x 3. No Incident/Accident Report requested none provided. (6) Record review of original care plan dated 05/01/17 updated on 07/27/17 revealed Resident # 24 slipped off edge of wheelchair in room. Educate to use call bell. Incident/Accident report requested none provided. Record Review of the Care Plan dated 07/27/17 revealed, educate to use call lights, no other/new interventions noted. (7) Record review of statement by CNA dated 07/31/17 and signed by LVN (no date, no time) revealed Resident # 24 was found sitting on the floor close to his bed on the side by the door. He stated he slipped forward trying to put on his shoes. Record Review of the Care Plan dated 07/31/17 UA/C&S (negative). Neuro-checks completed x 3 days. Record review of Resident #24's restorative progress note dated 7/31/17, 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (8) Record review of Resident's # 24's Incident/Accident Report 08/06/17 at 1:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in the 100 Hall hoper room. Physician notified at 3:22 p.m. Family notified at 3:20 p.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/06/17 revealed recommendation: Staff to at least check Resident every 2 hours. Resident refuses assistance from staff. Probable cause of fall: Attempting to toilet self. Record Review of the Care Plan dated 08/06/17 revealed, the staff was to check on resident at least every 2 hours. No new interventions related to falls noted for 08/07/17. Record review of Resident #24's restorative progress note dated 08/06/217, and 08/07/17, resident did not want to participate due to knee pain. (9) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 6:15 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found at 11:00 p.m. to be sitting up at the right side of his bed on the floor. Physician and family notified at 6:15 a.m. Record Review of the Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care. Probable cause of fall: His wheelchair was outside his room and he does not want his side rails up on his bed. Side rails are up now. Wheelchair is in his room and he agreed to use call button. Record Review revealed there was no care plan for fall precautions or prevention noted for 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/13/17 revealed recommendation of primary clinicians section left blank. (10) Record review of Resident's # 24's Incident/Accident Report 08/12/17 at 7:00 a.m , revealed Resident #24 had a witnessed fall. Resident # 24 was seen by nurse struggling to pull up his pants, lost his footing and fell on to his buttocks. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care document refusal. Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed there was no care plan interventions noted for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. Interview with DON on 09/26/17 at 10:15 AM revealed it was an unwitnessed fall LVN documented what Resident stated. (11) Record Review of Resident's # 24's Incident/Accident Report 08/12/17 at 5:45 p.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on the floor in restroom with pants and brief down. Physician notified at 9:00 p.m. Family notified at 6:00 p.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/12/17 revealed recommendation: Continue current plan of care Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review revealed, there was no care plan interventions for the fall on 08/12/17. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/12/17 revealed recommendation of primary clinicians section left blank. (12) Record review of Resident's # 24 Incident/Accident Report 08/14/17 at 4:30 a.m , revealed Resident #24 had an unwitnessed fall. Resident # 24 was found sitting on his bathroom floor beside the toilet and his wheelchair. Physician notified and family notified at 6:00 a.m. Record Review of the facility's Interdisciplinary Post-Fall Evaluation dated 08/14/17 revealed recommendation: Continue current plan of care Probable cause of fall: up without assistance wheelchair unlocked footing/balance lost. Record Review of the facility's SBAR (Situation, Background, Appearance, and Review) dated 08/14/17 revealed recommendation of primary clinicians section left blank. Record Review of the facility's Care Plan dated 08/14/17 revealed continue to check on resident every 2 hours, offer toileting every 2 hours and document refusal, continue current plan, hip x-ray, and offer toileting every 2 hours (TRUNCATED)

Based on observation, interview and record review, the facility failed to follow plan of care for 1 of 21 residents (Residents # 5) sampled for following plan of care when: Resident #5 did not receive the physician ordered nutritional supplement for 3 weeks. Resident #5 sustained a 26.4 lbs. (pound) or 20.7% weight loss in 2 months. This deficient practice affected 1 resident with the potential to affect the 97 other residents in the facility. Failure to provide nutritional supplements could contribute to weight loss, compromised nutritional status and could delay or prevent healing leading to a decline in ADLs (Activities of Daily Living). Findings Include: Interview on 09/28/10 at 10:00 AM, Licensed Vocational Nurse (LVN G) stated Resident #5 was admitted to the facility from the hospital following surgical repair for a [MEDICAL CONDITION]. Since the admission the resident acquired a pressure ulcer on the left heel and has lost weight. LVN G further stated Resident #5 has a poor appetite, but receives fortified foods and supplements. Review of Resident #5 ' s facility clinical record reflected: ? On the Face Sheet Resident #5 was [AGE] years old admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5 did not have a pressure ulcer on admission. ? The History and Physical Report from the hospital dated 07/19/10; Resident #5 fell at home and broke the left hip. ? The hospital Physical Therapy Evaluation dated 07/20/10; Resident #5 reported a fall on 07/19/10, while using the rolling walker. Resident #5 was transported to the hospital and found to have a broken hip. Further review of notes indicated Resident #5 had hip surgery on 07/21/10. ? The Nutritional Evaluation dated 07/27/10; Admission height 64 inches, and weight 127.4#. Review of Comprehensive Care Plan reflected the following problems dated 08/05/10: impaired mobility and decrease mobility, approaches included; Provide medical nutrition therapy as directed. The care plan for the problem of weight loss dated 09/14/10 reflected the approach; provide supplement/snack as ordered. Observations on 09/28/10 at 12:15 PM, revealed Resident #5, a very thin woman, in her room, sitting in a wheel chair with a multi podus boot on her left foot with the lunch tray on the bedside table. Resident #5 stated the food was good but she was not real hungry. Resident #5 ate about 25% of the meal. Observation on 09/29/10 at 8:10 AM, Resident #5 had eaten approximately 25% of her meal including 3 (three) 8 ounce containers of orange juice. In an interview on 09/29/10 at 8:30 AM, the ADON (Assistant Director of Nursing) stated Resident #5 was being weighed weekly, and the resident's nutritional status had been discussed during the weekly skin meeting. The ADON further stated Resident #5 was receiving supplements as recommended. Review or Resident #5 ' s Weekly Weight Record reflected the following weights: ? (08/01/10) - 127.4 lbs (pounds) (08/09/10) - 128.4 lbs ? (08/16/10) - 122.2 lbs --- decrease of 5.2 lbs, (4.1%) in 2 weeks. (Pressure injury first noted on Resident #5 on 08/12/10) ? (08/31/10) - 116.0 lbs --- decrease of 11.4 lbs, (8.9%) in 3 weeks - Severe weight loss ? (09/01/10) - 116.0 lbs --- decrease of 11.4 lbs , (8.9%) in 4 weeks (Physicians order to increase nutritional supplement on 09/07/10) ? (09/20/10) - 102.4 lbs --- decrease of 25 lbs, (19.6%) in 8 weeks ? (09/27/10) - 101.0 lbs --- decrease of 26.4 lbs , (20.7%) in 9 weeks Review of the Resident #5's Lab report revealed a below normal [MEDICATION NAME] on 08/12/10 (14 mg/dL) and on 09/23/10 (15 mg/dL). ([MEDICATION NAME] is a test used to diagnose protein-calorie [MEDICAL CONDITION] in people who are critically or chronically ill. Normal serum range is 18 to 45 mg/dL for an adult female). Review of Resident #5's consolidated physician's orders [REDACTED]. Review of Resident #5's Medical Nutrition Therapy notes reflected: ? Initial assessment on 07/27/10, with nutritional lab report (07/23/10) [MEDICATION NAME] below normal. ? On 08/03/10, Resident feeds self. Recommended Boost Glucose Control, 8 ounces, BID (twice a day), 10 AM and HS (Hour of Sleep). ? On 08/10/10, "suspected DTI (Deep Tissue Injury to left heel per skin report." Boost Glucose Control ordered 08/04/10 per recommendations. ? On 08/31/10, weight was reviewed with the most recent weight 116 lbs (8/30/10) a decrease of 12.4 lbs (9.7%) in 3 weeks. The Dietitian also noted Resident #5's meal intake varied from refused to 100% consumed and the resident's [MEDICATION NAME] was below normal. The Dietitian recommended; 1. Super cereal at breakfast. 2. Increase of Boost Glucose Control to 8 ounces tid (three times a day). 3. Two (2) scoops of [MEDICATION NAME] (protein supplement) everyday. ? On 09/21/10, noted weight 102.4 lbs (09/21/10) a decrease of 20.4 lbs (16.6%) in 4 weeks. Also noted Physician ordered increase in supplements on 09/07/10 and recommended continuing with current supplements. Review of the Physicians orders revealed on 09/07/10 Resident #5 had an order for [REDACTED]. 3. Super cereal at Breakfast. In an interview on 09/29/10, at 12:15 PM, the Wound Care Doctor stated Resident #5's weight loss and nutritional status had affected the healing process of the DTI (deep tissue injury / unstageable pressure ulcer). The wound had not gotten worse, but it had not improved. The Wound Care Doctor further stated he does not know if the facility had done everything possible to improve Resident #5's nutritional status, however, the Doctor stated he was aware Resident #5 did refuse to eat at times. In an interview with LVN J on 09/29/10 at 4:45 PM, stated Resident #5 likes the Boost Control and she drinks all of the supplement and when a nurse signs the MAR (Medication Administration Record) that the supplement was given it means 100% of the supplement was consumed. LVN J confirmed there was no increase in the amount of Boost Glucose Control offered or the addition of [MEDICATION NAME] supplement to Resident #5 during the month of September 2010 as the Physician ordered. LVN J further stated she was not aware Resident #5 had a physician's orders [REDACTED]. Review of Resident #5's clinical records revealed no documentation reflected Resident #5 had an increase in Boost Glucose Control, or the addition of [MEDICATION NAME] as ordered by the Physician on 09/07/10 in the Nurse's Notes, Treatment Administration Record (TAR), Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was confirmed by LVN J and the ADON on 09/29/10. In an interview on 09/29/10 at 4:50 PM the ADON stated when the Charge Nurse receives a telephone order from the physician, the Charge nurse writes the order in the Physicians orders and then writes the order in the MAR indicated [REDACTED]. The Director of Nurses (DON), Assistant Director of Nurses (ADON), or assigned administrative staff should also review the Resident Charts weekly to assure the orders are transcribed. In an interview on 09/29/10 at 4:55 PM, LVN J stated when an order is received; the Charge Nurse is responsible for making the changes on the MAR indicated [REDACTED]. Review of facility undated policy titled Clinical Nurses-Start-Up revealed: Audit Telephone orders to make sure all entries are on MARS and TARS, also medications are available. Review of Resident #5's Meal Intake Record dated September 2010 revealed the meal intake was documented 65% of the time and 63% of the recorded intake reflected 75 to 100% of the meal was consumed. For 14 of the 19 recorded meal intakes below 50% there was no documentation of substitute offered. Five (5) of the 20 snacks offered were refused. In an interview on 09/29/10 at 6:10 PM the Registered Dietitian (RD )stated the purpose of the addition of Boost Glucose Control and Hemeproteins was to provide more calories to prevent weight loss and add protein to promote wound healing. The RD further stated she does not remember if she checked the MAR indicated [REDACTED]. In an interview on 09/30/10 at 9:00 AM Resident #5 ' s Physician stated it would have been beneficial for #5 to receive the supplements as ordered. Nutrition is important in the promotion of wound healing. Review of the facility CMS 672 dated 09/28/10 reflected a census of 98 and identified 10 residents had a phyicians order for nutritional supplements.

Based on observation, interview, and record review, the facility failed to provide nutritional interventions as ordered by the physician for 1 of 11 sampled residents (Resident #5) for weight loss when: Resident #5 sustained an unplanned 26.4 # or 20.7% weight loss (severe) in 2 months. The facility failed to initiate the physician ordered nutritional supplement for 3 weeks; Severe weight loss is defined as greater than 5% in one month, greater that 7.5% in three months, or greater than 10% in six months. This deficient practice affected 1 resident with the potential to affect the 6 residents who were were receiving nutritional supplements. This failure could result in weight loss and compromised nutritional status could delay or prevent healing leading to a decline in Activities of Daily Living (ADLs). The Administrator and Director of Nursing were informed of Substandard Quality of Care in the area of Quality of Care on 09/30/10 at 11:45 AM. Findings Include: Interview on 09/28/10 at 10:00 AM, Licensed Vocational Nurse LVN G stated Resident #5 was admitted to the facility from the hospital following surgical repair for a [MEDICAL CONDITION]. Since the admission the resident acquired a pressure ulcer on the left heel and has lost weight. LVN G further stated Resident #5 does not eat much, but receives fortified foods and supplements. Review of Resident #5's facility clinical record reflected: ? On the Face Sheet Resident #5 was [AGE] years old admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident did not have a pressure ulcer on admission. ? The History and Physical Report from the hospital dated 07/19/10; Resident #5 fell at home and broke the left hip. ? The hospital Physical Therapy Evaluation dated 07/20/10; Resident #5 reported a fall on 07/19/10, while using the rolling walker. Resident #5 was transported to the hospital and found to have a broken hip. Further review of notes indicated Resident #5 had hip surgery on 07/21/10. ? The Minimum Data Set (MDS) admitting assessment dated [DATE], reflected the resident did not have pressure ulcers at the time of the assessment or in the past 90 days. The assessment also reflected the resident and the direct care staff believed the resident was capable of increased independence with ADLs (Activities of Daily Living). ? The Nutritional Evaluation dated 07/27/10; Admission height 64 inches, and weight 127.4#. ? The Wound Care Consult dated 08/12/10; Resident #5 had blue/black bruise to left heel (pressure injury) and a blister to the left calf distal. Review of Comprehensive Care Plan reflected the following problems dated 08/05/10: impaired mobility and decrease mobility, approaches included; Record percentage of meals eaten daily and provide medical nutrition therapy as directed. The resident's Care Plan for the problem of weight loss dated 09/14/10 reflected the approach; provide supplement/snack as ordered. Observations on 09/28/10 at 12:15 PM, revealed Resident #5, a very thin woman, in her room sitting in a wheel chair with a multi podus boot on her left foor, the lunch tray on the bedside table. Resident #5 stated the food was good but she was not real hungry. Resident #5 ate about 25% of the meal. Observation on 09/29/10 at 8:10 AM, Resident #5 had eaten approximately 25 % of her meal including 3 (three) 8 ounce containers of orange juice. In an interview on 09/29/10 at 8:30 AM, the ADON (Assistant Director of Nursing) stated Resident #5 was being weighed weekly, and the resident's nutritional status had been discussed during the weekly skin meeting. The ADON further stated Resident #5 was receiving supplements as recommended. Review or Resident #5 ' s Weekly Weight Record reflected the following weights: ? (08/01/10) - 127.4 lbs ? (08/09/10) - 128.4 lbs ? (08/16/10) - 122.2lbs --- decrease of 5.2 lbs, (4.1%) in 2 weeks. (Pressure injury first noted on Resident #5 on 08/12/10) ? (08/31/10) - 116.0lbs --- decrease of 11.4lbs, (8.9%) in 3 weeks - Severe weight loss ? (09/01/10) - 116.0lbs --- decrease of 11.4lbs , (8.9%) in 4 weeks (Physicians order to increase nutritional supplement on 09/07/10) ? (09/20/10) - 102.4lbs --- decrease of 25lbs, (19.6%) in 8 weeks ? (09/27/10) - 101.0lbs --- decrease of 26.4lbs , (20.7%) in 9 weeks Review of the Resident #5's Lab report revealed a below normal [MEDICATION NAME] on 08/12/10 (14) and on 09/23/10 (15). ([MEDICATION NAME] is a test used to diagnose protein-calorie [MEDICAL CONDITION] in people who are critically or chronically ill. Normal serum range is 18 to 45 mg/dL for an adult female). Review of Resident #5's consolidated physician's orders [REDACTED]. On 08/04/10 and order for Boost Control 8 ounces BID (twice a day) at 10 AM and 2 PM. Review of Resident #5's Medical Nutrition Therapy notes reflected: ? Initial assessment on 07/27/10, with nutritional lab report (07/23/10) [MEDICATION NAME] below normal. ? On 08/03/10, Resident feeds self. Resident had own teeth, no swallowing or chewing problems, past food restrictions - sugar, appetite fair and no reported food dislikes. No skin breakdown or [MEDICAL CONDITION] per nurse. Recommended Boost Glucose Control, 8 ounces, BID (twice a day), 10 AM and HS (Hour of Sleep). ? On 08/10/10 "suspected DTI (Deep Tissue Injury) to left heel per skin report." Boost Glucose Control ordered 08/04/10 per recommendations. ? On 08/31/10, weight was reviewed with the most recent weight 116lbs (8/30/10) a decrease of 12.4lbs (9.7%) in 3 weeks. The Dietitian also noted Resident #5's meal intake varied from refused to 100% consumed and the resident's [MEDICATION NAME] was below normal. The Dietitian recommended; 1. Super cereal at breakfast. 2. Increase of Boost Glucose Control to 8 ounces tid (three times a day). 3. Two (2) scoops of Beneprotien everyday. ? On 09/21/10, noted weight 102.4lbs (09/21/10) a decrease of 20.4lbs (16.6%) in 4 weeks. Also noted Physician ordered increase in supplements on 09/07/10 and recommended continuing with current supplements. Review of the Physicians orders revealed on 09/07/10 Resident #5 had an order for [REDACTED]. 3. Super cereal at Breakfast. During an interview with LVN J on 09/29/10 at 4:45 PM, stated Resident #5 likes the Boost Control and she drinks all of the supplement and when a nurse signs the MAR indicated [REDACTED]. LVN J confirmed there was no increase in the amount of Boost Glucose Control offered or the addition of [MEDICATION NAME] supplement to Resident #5 during the month of September 2010 as ordered by the physician. LVN J further stated she was not aware Resident #5 had a physician's orders [REDACTED]. Review of Resident #5's clinical records (Nurse's Notes, Treatment Administration Record (TAR), Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was confirmed by LVN J and the ADON on 09/29/10. Review of Resident #5's Meal intake record dated September 2010 revealed the meal intake was documented 65% of the time and 63% of the recorded intake reflected 75 to 100 % of the meal was consumed. For 14 of the 19 recorded meal intakes below 50% there was no documentation of substitute offered. Five (5) of the 20 snacks offered were refused. In an interview on 09/29/10, at 12:15 PM, the Wound Care Doctor stated Resident #5's weight loss and nutritional status had affected the healing process of the DTI (deep tissue injury / unstageable pressure ulcer). The wound had not gotten worse, but it had not improved. The Wound Care Doctor further stated he does not know if the facility had done everything possible to improve Resident #5's nutritional status, however, the Doctor stated he was aware Resident #5 did refuse to eat at times. In an interview on 09/29/10 at 6:10 PM the Registered Dietitian stated the purpose of the addition of Boost Glucose Control and [MEDICATION NAME] was to provide more calories to prevent weight loss and add protein to promote wound healing. Further stated she does not remember if she checked the MAR indicated [REDACTED]. Typically she will follow-up on recommendations made every 1 to 2 weeks. In an interview on 09/30/10 at 9:00 AM Resident #5's Physician stated it would have been beneficial for Resident #5 to receive the supplements as ordered. Nutrition is important in the promotion of wound healing. Review of the facility undated Pressure Ulcer Protocol reflected; ? Goal of treatment: Prevent further skin breakdown and promote early healing. Prevention: c. Nutritional Assessment and interventions. Interventions: Dietary intervention with particular emphasis on protein and nutritional supplements. ? At the time a pressure ulcer is identified, the following must be put into place immediately. #7 Obtain dietary consult. Supplements, increased protein, large portions, vitamin therapy. Review of a facility computer generated list titled Weight Change Alert Report dated 10/01/10, reflected 6 residents with weight loss and all six had a physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents who enter a facility without pressure sores does not develop pressure sores for 1 of 3 sampled residents (Resident #5) reviewed for pressure sores when: Resident #5 was admitted to the facility for rehabilitation for a [MEDICAL CONDITION], without evidence of a pressure ulcer. Resident #5 had evidence of a pressure injury on the left heel 2 weeks after admission. This facility deficient practice has the potential to affect the 98 residents identified by the facility as receiving preventative skin care. Failure to prevent pressure ulcers can contribute to a resident's increased pain and a decline in ADLs (Activities of Daily Living). Findings Include: Interview on 09/28/10 at 10:00 AM, Licensed Vocational Nurse LVN G stated Resident #5 was admitted to the facility from the hospital following surgical repair for a [MEDICAL CONDITION]. Since the admission the resident acquired a pressure ulcer on the left heel. LVN G further stated Resident #5 has a poor diet, but receives fortified foods and supplements. Review of Resident #5 ' s facility clinical record reflected: ? On the Face Sheet Resident #5 was [AGE] years old admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident did not have a pressure ulcer on admission. ? The History and Physical Report from the hospital dated 07/19/10; Resident #5 fell at home and broke the left hip. ? The hospital Physical Therapy Evaluation dated 07/20/10; Resident #5 reported a fall on 07/19/10, while using the rolling walker. Resident #5 was transported to the hospital and found to have a broken hip. Further review of notes indicated Resident #5 had hip surgery on 07/21/10. ? The Minimum Data Set (MDS) admitting assessment dated [DATE], reflected the resident did not have pressure ulcers at the time of the assessment or in the past 90 days. The assessment also reflected the resident and the direct care staff believed the resident was capable of increased independence with ADLs (Activities of Daily Living). ? The Nutritional Evaluation dated 07/27/10; Admission height 64 inches, and weight 127.4#. ? The Wound Care Consult dated 08/12/10; Resident #5 had blue/black bruise to left heel (pressure injury) and a blister to the left calf distal. Observations on 09/28/10 at 12:15 PM, and on 09/29/10 at 8:10 AM, revealed Resident #5, a very thin woman, sitting in a wheel chair with a multi podus boot on her left foot. In an interview on 09/29/10 at 8:30 AM, the ADON (Assistant Director of Nursing) stated Resident #5 was being weighed weekly, and the resident ' s nutritional status had been discussed during the weekly skin meeting. The ADON further stated Resident #5 was receiving supplements as recommended. Review of Resident #5's wound /skin record revealed on the left heel: Plan of Care: Skin prep Left heel, off loading pillow. ? 08/12/10, a 4.0 x 5.0 cm (centimeter) stage I pressure ulcer bluish in color. ? 08/19/10 and 08/24/10, a 4.0 x 5.0 centimeter stage I pressure ulcer, closed/flat ? 09/02/10, 09/06/10 and 09/08/10, a 4.0 x 5.0 centimeter stage I pressure ulcer, flat intake, lifting - improved ? 09/10/10 and 09/13/10 - a 4.0 x 5.0 cm flat and dark ? 09/14/10, 09/16/10 - SDTI (suspected deep tissue injury) not measured, flat, intact. Plan of Care: hard podus boot/ [MEDICATION NAME] soaked gauze. ? 09/17/10, 09/20/10, through 09/24/10 (daily) - closed, black eschar (scab or dry crust). ? 09/27/10 - SDTI, no other description provided. Review of Resident #5 ' s Comprehensive Care Plan for STDI (Suspected Deep Tissue Injury). Problem: ? 08/12/10 Seen by wound doctor - skin prep. ? 09/02/10 wear foam multi podus boot for protection. Edges of black eschar started to lift up. (Left heel) DTI, dry dressing and offloading. 09/09/10 Continue [MEDICATION NAME] wrap with [MEDICATION NAME] and multi podus boot. ? 09/15/10 - [MEDICATION NAME] soaked gauze - Multi Podus boot on. ? 09/23/10 - seen by wound care doctor. ? 09/29/10. Seen by wound care doctor, continue with current treatment. Review of Resident #5's consolidated physician's orders [REDACTED]. Review of Resident #5's Medical Nutrition Therapy notes reflected: ? On 08/03/10, No skin breakdown or [MEDICAL CONDITION] per nurse. Recommended Boost Glucose Control, 8 ounces, BID (twice a day), 10 AM and HS. ? On 08/10/10 suspected DTI to left heel per skin report. Boost Glucose Control ordered 08/04/10 per recommendations. ? On 08/31/10, weight was reviewed with a decrease of 12.4 lbs (9.7%) in 3 weeks. The Dietitian also noted Resident #5's meal intake varied from refused to 100% consumed and the resident ' s [MEDICATION NAME] was below normal. The Dietitian recommended; 1. Super cereal at breakfast. 2. Increase of Boost Glucose Control to 8 ounces tid (three times a day). 3. Two (2) scoops of [MEDICATION NAME] everyday. ? On 09/21/10, noted weight 102.4 lbs (09/21/10) a decrease of 20.4 lbs (16.6%) in 4 weeks. Also noted Physician ordered increase in supplements on 09/07/10 and recommended continuing with current supplements. Review of the Physicians orders revealed on 09/07/10 Resident #5 had an order for [REDACTED]. 3. Super cereal at Breakfast. Review of Resident #5's clinical records revealed no documentation reflected Resident #5 had an increase in Boost Glucose Control, or the addition of [MEDICATION NAME] as ordered by the Physician on 09/07/10 in the Nurse ' s Notes, Treatment Administration Record (TAR), Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was confirmed by LVN J and the ADON on 09/29/10. In an interview on 09/29/10, at 12:15 PM, the Wound Care Doctor stated Resident #5's weight loss and nutritional status had affected the healing process of DTI. The wound has not worsened, but it had not improved. The Wound Care Doctor further stated he does not know if the facility had done everything possible to improve Resident #5's nutritional status, however, the Doctor stated he was aware Resident #5 did refuse to eat at times. Review or Resident #5's Weekly Weight Record reflected a weight loss of 26.4 lbs , (20.7%) in 9 weeks (127.4 lbs on 08/01/10 to 101.0 lbs on 09/27/10.) In an interview with LVN J on 09/29/10 at 4:45 PM, stated Resident #5 likes the Boost Control and she drinks all of the supplement and when a nurse signs the MAR indicated [REDACTED]. LVN confirmed there was no increase in the amount of Boost Glucose Control offered or the addition of [MEDICATION NAME] supplement to Resident #5 during the month of September 2010. Review of Resident #5's Meal intake record dated September 2010 revealed the meal intake was documented 65% of the time and 63% of the recorded intake reflected 75 to 100 % of the meal was consumed. For 14 of the 19 recorded meal intakes below 50% there was no documentation of substitute offered. Five (5) of the 20 snacks offered were refused. In an interview on 09/29/10 at 6:10 PM the Registered Dietitian stated the purpose of the addition of Boost Glucose Control and [MEDICATION NAME] was to provide more calories to prevent weight loss and add protein to promote wound healing. Further stated she does not remember if she checked the MAR indicated [REDACTED]. Typically she will follow-up on recommendations made every 1 to 2 weeks. In an interview on 09/30/10 at 9:00 AM Resident #5 ' s physician stated it would have been beneficial for #5 to receive the supplements as ordered. Nutrition is important in the promotion of wound healing. Review of the Resident #5's Braden Scale-for Predicting Pressure Sore Risk dated 09/14/10, reflected a score of 14, (a score of 12 or less represents a high risk for developing a Pressure Sore). In an interview on 09/30/10 at 10:45 AM, the ADON stated the facility was unable to find Resident #5's Nursing Admitting Assessment or the documentation of Resident #5's previous ADL function. In an interview on 09/30/10 at 12:00 PM the ADON stated Resident #5 had an in house acquired DTI. The DTI was due to Resident #5 ' s hip and knee being flexed which put pressure on the left heel. The current size of the DTI was 2 x 3 cm, hard, flat, black eschar. The facility refers to the SDTI is also known as an unstageable pressure ulcer. The ADON further stated the Braden Scale was completed on 09/14/10, when she could not find a previous Braden Scale Review of Resident #5 ' s Admitting Care Plan dated 07/27/10 revealed the goal for nutritional status was to Maintain stable weight. No specific approaches were identified. There was no Care Plan or concern identified for Pressure Sores / Skin Care. Special Problems Affecting ADL (Activities of Daily Living) included Left [MEDICAL CONDITION]; nonweightbearing bearing left leg and resident is deaf. There was no documentation indication Resident #5 was admitted with a Decubitus Ulcer. Further review of Comprehensive Care Plan reflected the following problems dated 08/05/10: impaired mobility and decrease mobility, approaches included; Record percentage of meals eaten daily and provide medical nutrition therapy as directed. The care plan for the problem of weight loss dated 09/14/10 reflected the approach; provide supplement/snack as ordered. Review of the undated facility policy for wound/skin care #7. All residents will be assessed for risk of skin breakdown using the Braden Scale Form. This will be done upon admission and updated at least every 90 days thereafter. 8. A plan of care for risk of skin breakdown will be initiated and implemented for each resident with a Braden Scale score of 17 and below. Care Plan will be immediately implemented as appropriate. #22. **Document pressure ulcers with eschar as " unable to fully determine stage due to presence of black necrotic tissue. " Review of the facility undated Pressure Ulcer Protocol reflected; ? Goal of treatment: Prevent further skin breakdown and promote early healing. Prevention: c. Nutritional Assessment and interventions. Interventions: Dietary intervention with particular emphasis on protein and nutritional supplements. ? At the time a pressure ulcer is identified, the following must be put into place immediately. #7 Obtain dietary consult. Supplements, increased protein, large portions, vitamin therapy. Review of the facility CMS 672 dated 09/28/10 reflected 98 residents receiving preventative skin treatment, 6 of these reisdents had pressure sores (zero had pressure sores upon admission).