Every finding on record at Edenbrook Pine Haven

Based on interview and document review, the facility failed to ensure nursing staff were appropriately oriented and trained for safe medication administration. This resulted in widespread medication administration errors affecting 16 of 25 residents (R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46) on 7/15/26.Findings include:(Cross-reference: Refer to F-760 for the specific medical record data and medication error details for residents R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46.)Review of the facility policy Change in Condition, dated 11/13/24, showed requirements to notify the provider and responsible party of any change in resident physical, psychosocial, or mental status. Line item two listed a medication error or adverse reaction as an example requiring notification. Line item three instructed the nurse to complete and document assessment findings, including vital signs and respiratory/cardiac status, and to notify the provider.During an interview on 7/16/26 at 1:39 p.m., the DON stated a night shift nurse first notified them of the widespread medication errors on the morning of 7/16/26. The DON confirmed that RN-A's orientation competency check-lists were completely missing from the facility records. The DON stated the nursing department did not know who authorized RN-A to clear orientation. The DON stated RN-A and LPN-B should have immediately notified nursing leadership and medical providers about the missed critical medications.During an interview on 7/16/26 at 3:13 p.m., Registered Nurse (RN)-A stated they worked the day shift on 7/15/26. It was their first shift independently off orientation. They were assigned to pass medications to 28 residents. RN-A stated they were unfamiliar with which residents received insulin or time-sensitive medications. At 2:30 p.m., RN-A had failed to pass all day medications, complete treatments, or take vital signs. Licensed Practical Nurse (LPN)-B instructed RN-A to stop passing the day medications and document the omissions. RN-A did not notify a medical provider or the Director of Nursing (DON) regarding the missed insulins or medications. RN-A stated orientation did not cover provider notification protocols.During an interview on 7/16/26 at 4:50 p.m., LPN-B stated they worked the afternoon shift on 7/15/26. RN-A reported missing approximately 50 percent of the scheduled day medications. LPN-B instructed RN-A to stop passing the day medications, leave them unadministered, and document the omissions. LPN-B did not contact medical providers or nursing leadership regarding the missed medications. LPN-B did not review the specific omissions for each resident. LPN-B notified a Nurse Practitioner (NP) about only one resident who experienced high blood sugar after a missed medication dose. Multiple residents experienced elevated blood sugars during the evening shift. LPN-B stated that nurses should contact a provider when insulin, diuretics, or blood pressure medications are missed.During a follow-up interview on 7/17/26 at 9:51 a.m., the DON confirmed the facility's orientation program lacked nursing department oversight and structured competency evaluations.During an interview on 7/17/26 at 10:42 a.m., the administrator confirmed RN-A's personnel file contained no nurse-specific orientation or competency tracking documentation.During an interview on 7/17/26 at 11:21 a.m., the Nurse Practitioner (NP) stated the facility did not provide notification of the multiple missed medications and treatments until 7/17/26. The NP stated they had not yet reviewed the specific written notifications in their inbox. The NP stated missed treatments and medications create a potential for resident decline. The NP stated errors involving anticoagulants, antipsychotics, Parkinson's medications, anti-seizure medications, antibiotics, and insulin require timely intervention to prevent decline. The NP stated they require immediate notification for significant medication errors. The NP stated that for a missed insulin dose, nursing staff must assess the resident, check the blood glucose level, and call the provider for orders.The facility policy Medication Error and Drug Interactions dated 8/15/22, directed residents were to be free of significant medication errors. All medication errors were to be reported promptly to the director of nursing, the attending physician, the responsible party, and documented according to established procedures. Significant medication error was defined as one which causes the resident discomfort or jeopardizes resident health or safety. A detailed account of the error should be recorded in the medical record, and a medication risk management report should be completed by the nurse for later review by quality.

Based on interview and record review, the facility administration team failed to provide oversight and implementation of a competency-based nursing orientation program. This administrative failure resulted in a new graduate nurse working independently without verified competencies, leading to a widespread medication error incident involving high-risk medications. This deficient practice had the potential to impact all residents residing at the facility.Findings include:The administrator job description dated 10/25, section Administrator Human Resources Management Responsibilities, identified the administrator was responsible for the elimination and control of safety and health hazards by regularly reviewing work practices and providing employees with training and instructions.The Director of Nursing (DON) job description dated 10/25, indicated the DON was responsible for staff development, effective departmental orientation, and ensuring staff are adequately oriented and trained to perform duties.During an interview on 7/16/26 at 2:00 p.m., the DON confirmed Registered Nurse (RN)-A was a newly hired nurse just off orientation who was involved in a widespread medication error incident on 7/15/26. The DON stated RN-A was not properly evaluated for clinical competency before being placed on the schedule. The DON stated they did not know who determined RN-A was ready to work independently. The DON confirmed that human resources (HR) and the scheduler coordinated nurse orientation, and completed competency checklists went to HR rather than the nursing department.During an interview on 7/16/26 at 3:13 p.m., RN-A stated the day shift on 7/15/26 was their first shift off orientation and their first time passing medications to the 28 residents in the front section. RN-A stated that while insulin management was covered, other high-risk medications, provider notification protocols, and post-fall evaluation protocols were completely omitted. RN-A stated the facility originally promised eight days of orientation, but HR reduced the training period to three days upon arrival. RN-A stated they did not know who their current supervisor was, never had anyone from nursing discuss their schedule, and still possessed their own physical orientation check-off sheets because they did not know where to turn them in. The scheduler was the only individual who communicated with RN-A regarding their placement on the floor schedule.During a follow-up interview on 7/17/26 at 9:51 a.m., the DON confirmed the facility's current nurse orientation program completely excluded oversight from the nursing department. The DON stated the nursing department made no decisions regarding when an orientee was ready to work independently, and a previous proposal to have the DON review orientees for clinical competency was never implemented by administration.During an interview on 7/17/26 at 10:42 a.m., the administrator confirmed they reviewed the personnel files for Licensed Practical Nurse (LPN)-A, LPN-C, LPN-D, and RN-A, and found that none of the files contained any nurse-specific orientation or competency tracking documentation. The administrator confirmed the facility lacked an operational process for checking nurse competency before scheduling independent floor shifts, and instead left it up to individual nurse orientees to self-determine if they felt ready. The administrator confirmed that floor nurses signed off on checklists, but those forms were turned into HR rather than nursing leadership.The facility policy Administering Medications, dated 1/22/24, line item three, indicated the DON was responsible for the supervision and direction of all personnel with medication administration duties and functions.

Based on interview and record review, the facility failed to develop and implement a comprehensive, competency-based nursing orientation program, failed to maintain required competency records in newly hired employee files. This failure resulted in a new graduate nurse working independently without verified competencies, leading to a widespread medication error incident. This deficient practice had the potential to impact all residents who received nursing care at the facility.Findings include:Review of the facility's personnel records for four nurses hired within the last seven months revealed a complete absence of role-specific training documentation:Licensed Practical Nurse (LPN)-A was hired on 6/25/26. The personnel file contained no orientation documents or completed competency evaluations specific to the LPN role.LPN-C was hired on 1/20/26. The personnel file contained no orientation documents or completed competency evaluations specific to the LPN role.LPN-D was hired on 1/20/26. The personnel file contained no orientation documents or completed competency evaluations specific to the LPN role.Registered Nurse (RN)-A was hired on 6/16/26. The personnel file contained no orientation documents or completed competency evaluations specific to the RN role.Review of the facility's Facility Assessment, dated 10/23/25, showed requirements to complete specific nursing staff competencies at the time of hire and annually. These mandatory competencies included lifts, isolation, personal protective equipment donning and doffing, hand hygiene, wound and skin assessment, safe drug administration, medication pass, wound care, blood glucose monitoring, and medication errors.During an interview on 7/16/26 at 11:38 a.m., RN-B stated they were currently in orientation and their fourth and final day of training would conclude the next day. RN-B stated floor nurses signed off on their checklists, but they were unsure if the compressed timeframe provided sufficient training.During an interview on 7/16/26 at 11:42 a.m., LPN-C stated they were precepting RN-B and signing off on the orientation checklists. LPN-C confirmed management recently cut floor orientation from eight days down to three days. LPN-C stated that three days of orientation was insufficient to learn the floor layout and requirements, noting that passing medications to 28 residents on the front unit was excessively difficult for a new nurse.During an interview on 7/16/26 at 2:00 p.m., the Director of Nursing (DON) confirmed RN-A was a newly hired nurse who was placed on the floor independently without proper competency evaluations. The DON confirmed this lack of verified training resulted in a widespread medication error incident on 7/15/26 during RN-A's first solo shift on the 28-resident front medication cart. The DON stated human resources (HR) and the scheduling department coordinated orientation, and completed forms went into an HR mailbox rather than to nursing leadership. The DON stated they did not know who authorized RN-A to clear orientation and start working independently.During an interview on 7/16/26 at 4:50 p.m., LPN-B stated that nurse orientation and facility staffing metrics changed after state oversight left. LPN-B confirmed orientation was cut from eight days to three or four days, which compromised resident safety and increased the risk of missed treatments or medications.During an interview on 7/17/26 at 9:40 a.m., the Staff Scheduler stated they held responsibility for setting up orientation, managing online training modules, and assigning schedules for newly hired RNs, LPNs, and nursing assistants. The Scheduler confirmed floor orientation was reduced from eight days to three days during the previous month. The Scheduler stated they distributed competency bundles to orientees and instructed them to drop the completed sheets directly into the HR mailbox. The Scheduler confirmed the nursing department was completely excluded from this process, no communication regarding competency occurred, and the scheduling system lacked a hard stop to verify a nurse's competency before assigning them to independent floor shifts.During a follow-up interview on 7/17/26 at 9:51 a.m., the DON confirmed the current nurse orientation program completely excluded nursing department oversight and had operated that way since November 2025. The DON confirmed that a previous administrative proposal to have the DON review new hires for clinical competency was never implemented.During an interview on 7/17/26 at 10:42 a.m., the administrator confirmed they reviewed the personnel files for LPN-A, LPN-C, LPN-D, and RN-A, and found none contained nurse-specific orientation or competency tracking documentation. The administrator confirmed the facility lacked a valid process to verify nurse competency before scheduling independent floor shifts, instead relying on the new hires to self-determine if they felt ready. The administrator confirmed that while floor preceptors signed off on competency checklists, those forms went to HR instead of nursing leadership for final approval.

Based on record review and interview, the facility failed to act upon grievances and recommendations made by the Resident Council regarding delayed call light response times and delayed resident care. This affected 9 of 9 residents who attended the Resident Council meeting.Findings include: R1, R4, R8, R20, R21 R25, R27, R31, and R37 attended a resident council review meeting on 7/15/26 from 10:00 a.m. to 10:40 a.m. During the meeting several residents stated they were concerned because they had not received their morning medications yet and attributed it to the new nurse working the cart. The residents expressed the following concerns r/t to perceived low staffing levels, care delays and long call light wait times. -Each hallway only had one nursing assistant on it to answer call lights and do transfers and cares.-It now took two staff to do device transfers, so they had to wait even longer to get help with getting out of bed or going to the toilet. It took time to find another available NA.-When two NAs were in a room doing a transfer, all the residents on those NA's hallways had to wait for them to finish the transfer before their call light got answered. -Staff answered their light, turned it off, said they would be back and then sometimes they came back, and sometimes they didn't come back at all or they did and said they still couldn't help them yet and would be back later. -Some reported they had urgency with using the toilet so sometimes it was too late by the time a staff was available to help them to the toilet. -One resident reported they had had bowel accidents where they had had to wait two or three hours before staff could get them changed. -Estimated wait times ranged from as little as five minutes and as long as thirty minutes to more than an hour depending on the time of day and shift.-One resident stated they had to wait 40 minutes on the toilet before someone came to help them off. Other residents expressed similar experiences waiting for help off the toilet.-Some staff have said they were short staffed. -Residents stated they did have less staff now then they did before. -It was hard for NAs to answer all the call lights with one NA per hallway. -one had their shower day changed Residents stated they had been bringing these issues up for several months at resident council. All agreed, they felt they had not received a real response from the facility. The administrator talked about meeting staffing numbers, and had talked about doing call light audits, but mostly they had been told they were working on it but none of them knew what that meant. There hadn't been any improvement or any explanation about what was being done. Things have felt worse since they started using two staff for transfers without adding anyone to help. During an interview on 7/15/26 at 11:05 a.m., the administrator stated they had attended four resident council meetings at the facility. Concerns voiced in resident council were recorded and then sent to a department manager to investigate. The administrator confirmed staffing concerns and call light response times had been consistently brought up in the resident council meetings. They had tried to explain the entire hours per patient day to the group several times. They have also told the residents they wished they could add a NA but they had to follow the staffing ratios. The administrator stated if the facility CMI was higher than they could add staff. They were in the process of providing all staff with documentation education to ensure resident levels of care were accurately captured. Residents did complain about call lights taking an hour or more to be answered but usually it turned out residents were not waiting more than a half hour.During an interview on 7/16/26 at 1:03 p.m., the activities director (AD) stated they regularly attended the resident council meetings. Meeting grievances got passed on to the administrator. The two biggest concerns residents continued to express were long call light response times and long waits for care. The recent change to have two staff instead of one with assistive transfer devices has impacted call lights. Residents have not understood the change was made for safety. They have been focused on having extra wait time for two staff to be available to do transfers, and how tying up two staff for transfers has created longer wait times for the rest of the residents. The residents have been told call lights can be answered by other staff; it didn't have to be just nursing. All staff have been instructed to answer call lights and get nursing staff if they can't help the residents. There has been some explanation to residents, but so far, they have not felt like they have gotten an adequate response. The AD confirmed call light audits had been brought up in a council meeting, but they were not aware if anything had been done with audit. During an interview on 7/16/26 at 10:48 a.m., the administrator confirmed May 2026, Resident Council Minutes indicated the facility would be conducting call light audits in response to call light concerns. However, this had not been done. They had just learned their call light system did not have the ability to generate wait time reports. The administrator confirmed nobody had conducted manual call light response times audits either and stated they were not sure how it was calculated that residents were not waiting more than thirty minutes for a call light response. In May and June, the big focus for call light response time had been getting staff education on accurate care level capture set-up. Now that this education was in place, they wanted to get call lights on the next quality meeting agenda so they could get a project started. During an interview on 7/16/26 at 1:23 p.m., the director of nursing stated they used to get invited to resident council meetings, but that had not happened in a long time. They had not been notified that there were ongoing call light concerns in resident council. From a nursing perspective, they had not conducted any spot audits of call light response times or completed any other projects related to resident wait times for lights or cares. The DON stated the size and layout of the building in relation to staffing levels made it more challenging to answer call lights and perform cares that required two staff. The DON stated they felt resident acuity should be incorporated into their process for determining staffing levels on the resident units instead primarily calculating numbers based on census. The facility policy Call Light Use and Response dated 7/18/23, indicated the purpose of the policy was to ensure prompt response to residents' call for assistance. The policy instructed lights were to be answered promptly and turned off as soon as staff entered the resident room and attended to the resident's needs.The facility policy Grievances/Concerns dated 10/29/24, identified the facility would make prompt efforts to resolve grievances. The policy identified the process and documentation components for an individual grievance which included resident statement, investigation and findings, facility actions, resolution and prevention, and resident satisfaction level with facility response.The facility policy Resident Council dated 2/2/23, directed when a resident group existed, the facility would listen to the resident views and act upon the concerns and recommendations of residents concerning policies and operation decisions affecting resident care and quality of life in the facility. A staff member would be designated to assist with group meetings and respond to any written requests that resulted from group meetings.

Based on interview and document review, the facility failed to ensure immediate provider notification occurred for 16 out of 25 (R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46) ampled residents who experienced significant medication administration errors, treatment omissions, and missed clinical assessments on 7/15/26. Licensed nursing staff across the day, evening, and night shifts failed to contact the attending providers or conduct required physical assessments. In addition, the facility failed to notity the provider with a weight increase for 1 of 1 resident (R4) reviewed Findings include: Refer to F-Tag 760 for full medical record data on (R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, and R46) detailing specific medication omissions, clinical diagnoses, cognitive status, and specific treatment or assessment failures for the impacted residents. During an interview on 7/16/26 at 1:39 p.m., the DON stated they did not think the day, evening, or night shift nurse had notified a provider regarding residents with missed medications. The DON confirmed that the first notification the medical provider received regarding the massive omissions was when they personally contacted the NP the morning of 7/16/26. The DON stated that the provider should have been notified immediately yesterday regarding missed or late insulin and other missed critical medications. During an interview on 7/16/26 at 3:13 p.m., RN-A confirmed they worked the day shift on 7/15/26. RN-A stated they had not contacted a provider regarding the missed insulin or any of the other late or missed medications. RN-A noted that provider notification for errors had not been covered in their orientation. During an interview on 7/16/26 at 4:50 p.m., LPN-B confirmed they worked the afternoon shift on 7/15/26 and became aware that RN-A had missed approximately half of the day shift medications. LPN-B admitted they did not contact providers regarding the medications that were missed on the day shift. LPN-B only notified the NP about one single resident who had a high blood sugar because the NP happened to be on the floor at the time. LPN-B acknowledged that nurses should contact a provider when insulin, diuretics, and blood pressure medications are missed so the provider can give orders if needed. During an interview on 7/17/26 at 10:42 a.m., the administrator confirmed that proper provider notifications did not go out until the morning of 7/16/26. The administrator acknowledged that provider notification, medication review, and resident assessments should have been completed immediately during the evening shift on 7/15/26. During an interview on 7/17/2026 at 11:21 a.m., the nurse practitioner (NP) confirmed they did not receive notification from the facility regarding the medication omissions until 7/17/26. The NP stated they preferred to be notified immediately for significant medication errors that occurred. The NP expected nursing to assess the resident, get a blood glucose, and call the provider immediately for corrective orders or monitoring parameters following a missed insulin dose. R4 R4's comprehensive Minimum Data Set (MDS) assessment dated [DATE], identified R4 as cognitively intact. R4's diagnoses included chronic diastolic heart failure (a condition where the heart left ventricle becomes stiff and cannot fill properly, reducing blood flow to the body). R4's current physician order record signed and dated 6/29/26 indicated, daily weight one time a day, notify provider for weight gain greater than 2 pounds in 24 hours or 5 pounds in 1 week and torsemide 60 mg, 1 tablet daily by mouth for diastolic heart failure. R4's treatment administration recorded (TAR) dated July 2026 showed, weight recorded on 07/12/26 was 210.6-pounds, weight recorded on 7/13/26 was 216.4 pounds, and no weight recorded on 7/14/26. TAR indicated on 7/14/26 see progress note. R4's progress notes lacked reference to increase weight or the 7/14/26 missing daily weight. During an interview on 07/16/26 at 9.55 a.m., licensed practical nurse (LPN)-A stated, was aware of the change in condition notification process. During an interview on 7/16/26 at 11:37 a.m., assistant director of nursing (ADON), stated, provider notification of change in condition was expected to be completed before the end of the shift in which the change occurred. ADON indicated, provider notification of change in condition was completed by SBAR or when the provider was present in the building and documented in the progress note. ADON was unable to locate a change in condition notification sent to provider for R 4's 6 pounds weight gain in 24 hours. During an interview on 7/16/26 at 16:50 p.m., medical doctor (MD)-A stated, the expectation was to receive a notification from facility staff based on R 4's current orders and facility policy regarding provider change in condition notification. The facility's policy titled Change in condition, dated 11/13/24, indicated the policy was intended to ensure provider notification and responsible party notification occurred for any changes in the resident's physical, psychosocial and/or mental condition and or status occurred. Line item two outlined examples of when notification should occur included a medication error or adverse reaction. Line item three instructed the nurse will compete and document assessment findings including vital signs, respiratory/cardiac status when indicated, and notification of the provider. A policy on insulin administration was requested but not received. The policy Care of the Diabetic Resident dated 7/28/15, did not address missed insulin administrations. The facility policy Administering Medications dated 1/22/24, line item three indicated the DON was responsible for the supervision and direction of all personnel with medication administration duties and functions. Line item seven directed medications should be administered within one hour of prescribed times. Medications that are scheduled with liberated administration times will be administered during the documented time.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. Nursing staff administered medications up to 10 hours late or omitted them entirely, including critical medications such as insulin, anticoagulants, narcotics, and cardiovascular drugs. This affected 16 of 25 residents reviewed (R4, R7, R10, R12, R16, R18, R20, R23, R25, R27, R29, R30, R31, R37, R39, R46).Findings include:R4's comprehensive Minimum Data Set (MDS) assessment, dated 7/14/26 showed the resident was cognitively intact.R4's Face sheet diagnoses included congestive heart disease and obstructive pulmonary disease.R4's Medication Administration Audit Report showed the facility administered 6:30 a.m. scheduled medications late at 11:30 a.m. on 7/15/26. These late medications included budesonide inhalation suspension, gabapentin 300 mg, lisinopril 30 mg, apixaban 5 mg, torsemide 60 mg, and Anoro Ellipta inhalation. Staff also administered 7:00 a.m. scheduled pantoprazole 40 mg late at 11:31 a.m.R4's progress notes lacked documentation of nurse assessments or provider notifications regarding these delayed administrations.R7R7's annual MDS assessment, dated 7/3/26, showed the resident was severely cognitively impaired.R7's Face sheet diagnoses included neurocognitive disorder with Lewy bodies, hypertensive chronic kidney disease, chronic pain syndrome, and type 2 diabetes.R7's Medication Administration Audit Report and electronic medical record (EMR) entries by RN-A showed staff omitted the following ordered morning medications on 7/15/26: Dilaudid 6 mg, lorazepam 1 mg, lidocaine 4% patch, acetaminophen 650 mg, and diclofenac sodium 1% gel.R7's record noted RN-A documented the medications were not given due to time. Progress notes dated 7/15/26 lacked nurse assessments or provider notifications. A delayed entry on 7/16/26 at 12:26 p.m. later noted provider notification.R10R10's quarterly MDS assessment, dated 5/15/26, showed the resident was moderately cognitively impaired and received hospice services.R10's Face sheet diagnoses included dementia, kidney disease, non-pressure left foot ulcer, and reflux disease.R10's The Medication Administration Audit Report showed staff omitted the 12:00 p.m. dose of hydromorphone HCl 1 mg on 7/15/26. Staff administered the next 3:00 p.m. dose late at 5:00 p.m. Staff also omitted Ensure 8 ounces and diclofenac 1% gel. Staff failed to complete scheduled psychotropic monitoring, non-pharmacologic pain interventions, and wound dressing checks.R10's progress notes identified, on 7/16/26 at 12:27 p.m., the ADON documented the missed narcotic dose. EMR records lacked any provider notification or tracking on 7/15/26 or 7/16/26.R12R12's quarterly MDS assessment, dated 5/30/26, showed the resident was severely cognitively impaired.R12's Face sheet diagnoses included hypertensive chronic kidney disease, congestive heart failure, and venous insufficiency.R12's Medication Administration Report showed staff omitted the following ordered day-shift medications on 7/15/26: Vitamin B-12 1000 mcg, furosemide 20 mg, Fibercon 625 mg, Miralax 17g, senna, losartan potassium, calcium 500/D (8:00 a.m. and 2:00 p.m. doses), and acetaminophen 1000 mg (8:00 a.m. and 2:00 p.m. doses).R12's progress notes dated 7/15/26 and 7/16/26 lacked documentation of nurse actions, assessments, or provider notifications regarding the 10 missed medications.R16R16's quarterly MDS assessment showed the resident was cognitively intact.R16's Face sheet diagnoses included hypertension, chronic kidney disease, and dementia.R16's Medication Administration Audit Report showed staff omitted the following day-shift medications on 7/15/26: Acetaminophen 1000 mg (6:00 a.m. and 1:00 p.m. doses), Norvasc 5 mg, loratadine 10 mg, and calcium Vitamin D. Staff also failed to perform required WanderGuard placement checks, non-pharmacological pain interventions, and pain monitoring. RN-A documented that medications were not given due to time.R16's progress notes lacked provider notifications.R18R18's significant change MDS assessment, dated 6/9/26, showed the resident was severely cognitively impaired.R18's Face sheet diagnoses included dementia, hypertensive heart disease with heart failure, cardiomyopathy, hemiplegia, type 2 diabetes, and atrial fibrillation.R18's Medication Administration Audit Report showed staff omitted the following day-shift orders on 7/15/26: Daily weight monitoring, metoprolol tartrate 25 mg, torsemide 40 mg, losartan potassium 50 mg, aspirin 81 mg, ascorbic acid 500 mg, cholecalciferol 50 mcg, metformin HCl ER 500 mg, and acetaminophen 1000 mg.R18's progress notes lacked records of resident clinical assessments, missing weight alerts, or provider notifications.R20R20's comprehensive MDS assessment, dated 7/2/26, showed the resident was cognitively intact.R20's Face sheet diagnoses included type 2 diabetes.R20's Medication Administration Audit Report showed staff administered 6:30 a.m. scheduled medications late at 10:00 a.m. on 7/15/26, including Lantus insulin 6 units, lisinopril 40 mg, and nifedipine ER.R20's progress notes lacked clinical assessments or provider notifications regarding the delayed long-acting insulin.R23R23's quarterly MDS showed the resident was severely cognitively impaired.R23's Face sheet diagnoses included hypertensive heart failure, mitral valve insufficiency, palliative care, and Alzheimer's disease.R23's Medication Administration Audit Report showed staff omitted scheduled morphine sulfate 5 mg, a scheduled pressure-relief lamb's wool application between the left toes, and a topical nystatin powder application under the breasts.R23's progress notes lacked documentation of clinical assessments or provider notifications for the omitted narcotic and treatments.R25R25's quarterly MDS dated [DATE] showed the resident was cognitively intact.R25 Face sheet diagnoses included diabetes, congestive heart failure, and chronic kidney disease.R25's Medication Administration Audit Report showed staff omitted the scheduled 6:30 a.m. blood glucose check. Staff administered 6:30 a.m. scheduled medications late on 7/15/26. Lantus insulin 6 units was given at 11:18 a.m., pantoprazole 40 mg was given at 9:49 a.m., torsemide 40 mg was given at 4:16 p.m. (nearly 10 hours late), and metoprolol succinate ER was given at 9:49 a.m.R25's progress notes lacked documentation of provider notifications regarding the missing blood sugar check or delayed insulin and diuretic doses.R27R27's quarterly MDS dated [DATE] showed the resident was cognitively intact. R27 Face sheet diagnoses included hypertensive heart, chronic kidney disease with heart failure, and diabetes type two. R27's The Medication Administration Audit Report dated 7/16/26 at 10:36 a.m. showed staff omitted multiple medications, assessments, and orders during the day shift on 7/15/26. Staff omitted a scheduled daily weight and required provider notification for parameters, iron-vitamin C 65-125 mg, acetaminophen 1000 mg scheduled at 1:00 p.m., sliding scale aspart insulin scheduled at 11:30 a.m., and aspart 12 units scheduled at 12:00 p.m. Additionally, staff omitted the scheduled 12:00 p.m. blood glucose check.R27's Medication Administration Record dated 7/17/26 showed the resident's subsequent blood sugar at 5:00 p.m. on 7/15/26 was elevated at 288. R27's progress notes dated 7/15 and 7/16/26 lacked documentation of nurse actions or provider notifications regarding the missing blood sugar monitoring or omitted insulin doses. R29 R29's quarterly MDS dated [DATE] showed a cognitive assessment could not be completed. R29's Face sheet diagnoses included unspecified Parkinsonism, apraxia, degenerative disease of the nervous system, and hypertension.R29's Medication Administration Audit Report dated 7/16/26 at 10:43 a.m. showed staff omitted multiple scheduled medications during the day shift on 7/15/26. Staff omitted carbidopa-levodopa 25-100 mg (3 tablets), hydroxyzine HCl 25 mg, lorazepam 0.5 mg, and eight ounces of Ensure. Staff also omitted scheduled doses of Dilaudid 2 mg (ordered every four hours for pain) at 6:30 a.m., 10:00 a.m., and 2:00 p.m. Staff administered the scheduled 6:00 p.m. Dilaudid 2 mg dose late at 8:26 p.m. R29's Progress notes dated 7/15 and 7/16/26 lacked documentation of nurse actions or provider notifications regarding the missing medications. Multiple progress notes entered on 7/15/26 by RN-A indicated the identified medications were not given due to time. R30 R30's quarterly MDS assessment dated [DATE] indicated the resident was moderately cognitively impaired. Face sheet diagnoses included primary hypertension, depression, and cellulitis of the left lower leg. The Medication Administration Audit Report dated 7/16/26 at 10:39 a.m. showed staff omitted multiple medications and a scheduled skin treatment during the day shift on 7/15/26. Staff omitted morning artificial tears to both eyes, losartan potassium 100 mg, amlodipine besylate 10 mg, ipratropium-albuterol inhalation, sertraline 12.5 mg, pravastatin sodium 40 mg, and Senna S. Staff also omitted the scheduled 6:30 a.m. and 11:00 a.m. doses of cephalexin 500 mg. Additionally, staff omitted a scheduled skin treatment to the bilateral buttocks requiring cleansing with normal saline or wound cleanser and the application of a barrier cream. Progress notes dated 7/15 and 7/16/26 lacked documentation of nurse actions or provider notifications regarding the missing medications and skin treatment. R31 R31's annual MDS dated [DATE] showed the resident was cognitively intact. R31's Face sheet diagnoses included congestive heart failure, diabetes type 2, gastro-esophageal reflux, polyneuropathy, and fibromyalgia. R31's Medication Administration Audit Report dated 7/16/26 at 10:42 a.m. showed staff omitted multiple scheduled medications during the day shift on 7/15/26. Staff omitted metformin 500 mg, pantoprazole sodium delayed release 40 mg, iron slow release 45 mg, sennosides 8.6 mg, cyanocobalamin 1000 mcg, gabapentin 300 mg, and furosemide 40 mg. Staff also omitted the scheduled 6:00 a.m. and 1:00 p.m. doses of acetaminophen 1000 mg. R31's progress notes dated 7/15 and 7/16/26 lacked documentation of nurse actions or provider notifications regarding the missing medications. Multiple progress notes entered on 7/15/26 by RN-A indicated the identified medications were not given due to time. R37 R37's quarterly MDS dated [DATE] showed the resident was cognitively intact. R37's Face sheet diagnoses included pulmonary hypertension due to lung disease and hypoxia, chronic diastolic heart failure, diabetes type 2, and osteoarthritis. R37's Medication Administration Audit Report dated 7/16/26 at 10:41 a.m. showed staff omitted multiple medications, treatments, and assessments during the day shift on 7/15/26. Staff omitted Novolog sliding scale insulin, torsemide 40 mg, budesonide inhalation suspension 0.5/2ml, diclofenac sodium external gel to the knees, hydrocortisone topical cream, clotrimazole 1% topical cream, and miconazole nitrate topical powder. Staff failed to obtain a daily weight and provider notification if outside parameters. Staff also omitted scheduled wound care to the abdomen, groin, and breast crease, which required cleansing, application of antifungal cream, and a two-hour coverage with a moistened WypAll with 0.25% acetic acid. Additionally, staff omitted scheduled clinical assessments and treatments including monitoring for signs and symptoms of bleeding, pain assessment and non-pharmacological interventions, hypoglycemia/hyperglycemia monitoring, vital signs, oxygen saturation, and the morning application of compression wraps. R37's progress notes dated 7/15 and 7/16/26 lacked documentation of nurse actions or provider notifications regarding the missing medications, assessments, or treatments. R39 R39's quarterly MDS assessment dated [DATE] indicated the resident was cognitively intact.R39 Face sheet diagnoses included congestive heart failure and type 2 diabetes with a foot ulcer.R39's The Medication Administration Audit Report showed staff omitted the following ordered day-shift medications, treatments, and assessments on 7/15/26: an 8:30 a.m. blood glucose check, an 11:00 a.m. blood glucose check, a 7:30 a.m. dose of Novolog sliding scale aspart insulin, an 11:30 a.m. dose of Novolog sliding scale aspart insulin, and scheduled wound care to the third toe of the left foot. Staff also failed to complete multiple required shift-based clinical assessments, including taking a blood pressure reading, monitoring and recording fluid intake, tracking pain levels, applying non-pharmacological pain interventions, evaluating an alternating pressure mattress setting, checking for bleeding signs, checking for signs of congestive heart failure, and tracking daily weight against ordered provider notification parameters.R39's progress notes dated 7/15/26 and 7/16/26 lacked documentation of nurse assessments, corrective clinical actions, or provider notifications regarding these missed orders.R46R46's comprehensive MDS assessment dated [DATE] indicated the resident was cognitively intact.R46's Face sheet diagnoses included congestive heart failure, unspecified polyneuropathy, a stage 4 heel pressure ulcer, emphysema, chronic pain syndrome, and type 2 diabetes.R46's Medication Administration Audit Report and Medication Administration Record showed staff omitted the following ordered day-shift medications, treatments, and assessments on 7/15/26: Cymbalta 60 mg, acetaminophen 1000 mg, iron-vitamin C 65-125 mg, a 1:30 p.m. dose of baclofen 5 mg, a 1:30 p.m. dose of gabapentin 600 mg, a 12:00 p.m. dose of insulin glargine 10 units, a 12:00 p.m. blood glucose check, a topical lidocaine HCl application, and two scheduled doses of topical Biofreeze gel at 6:30 a.m. and 11:00 a.m. Staff also failed to perform required clinical monitoring for hypoglycemia, hyperglycemia, psychotropic medication side effects, signs of congestive heart failure, daily weights with provider notification parameters, and shift-based heel skin evaluations.R46's record identified, RN-A entered multiple progress notes on 7/15/26 stating the items were not given due to time.R46's progress notes dated 7/15/26 and 7/16/26 lacked documentation of nurse actions, skin assessments, or provider notifications regarding these omissions.During the facility's Resident Council meeting on 7/15/26 from 10:00 a.m. to 10:40 a.m., multiple residents reported current, active medication delays. Resident R20 stated they were supposed to receive their oral medications and diabetes injections at 8:00 a.m. but did not receive them until just before 10:00 a.m. Resident R25 stated staff normally perform their blood sugar check, oral medications, and insulin administration early in the morning, but it was 10:30 a.m. and they had not yet received anything. Residents R4, R27, and R31 stated they were actively waiting for their morning medications to arrive. Resident R37 stated they were diabetic and a nurse checked their blood sugar after the resident requested it, but they had not received any of their morning medications.During an interview on 7/16/26 at 11:42 a.m., Licensed Practical Nurse (LPN)-C stated passing medications for the 28 residents in the front section was a difficult assignment due to the number of residents. LPN-C stated that if a nurse falls behind on a medication pass, they must inform management and ask for assistance. LPN-C stated providers must be notified about significant medication errors and missed or late medications that could negatively impact a resident, specifying insulin, diuretics, blood pressure medications, psychotropics, and anti-seizure medications as examples. LPN-C stated the Director of Nursing (DON) must also be notified.During an interview on 7/16/26 at 1:39 p.m., the DON stated a night shift nurse first notified them of the widespread day-shift omissions on the morning of 7/16/26. The DON stated this was a serious situation that could have resulted in harm to multiple residents. The DON confirmed the day, evening, and night shift nurses failed to notify a provider regarding the missed medications on 7/15/26, and that the DON finally notified the NP on the morning of 7/16/26. The DON stated RN-A should have used a walkie-talkie to ask for help and provider notification assistance. The DON stated LPN-B should have immediately notified a nurse manager or the DON upon discovering the situation so that staff could assess residents, contact providers, and administer the missed medications and treatments. The DON stated the provider required immediate notification on 7/15/26 regarding the late and missed insulin doses and other critical medications, and that residents who missed diuretics required additional monitoring. The DON confirmed RN-A's file contained no orientation competency checklists and that it was unclear who cleared the nurse from orientation status.During an interview on 7/16/26 at 3:13 p.m., RN-A stated they worked the day shift on 7/15/26, which was their first shift off orientation and their first time passing medications to the 28 residents in the front section. RN-A stated they were unfamiliar with which residents received insulin or time-sensitive medications, and that it took them longer to verify identities, set up medications, and prioritize care because they were unfamiliar with the residents. RN-A stated that at 2:30 p.m., they had not completed the medication pass, treatments, or vital signs. RN-A stated LPN-B instructed them to stop passing the day medications, leave them unadministered, and document what was omitted. RN-A stated they did not contact a provider regarding the missed insulins or late medications because provider notification protocols were not covered during their orientation, and they did not notify the DON.During an interview on 7/16/26 at 4:50 p.m., LPN-B stated they worked the afternoon shift on 7/15/26. Before receiving report, RN-A stated they missed approximately 50 percent of the scheduled day-shift medications on their first day independent from orientation. LPN-B instructed RN-A to stop administering the day medications, leave them unadministered, and document the omissions in the chart. LPN-B stated multiple residents expressed concern over missing their medications. LPN-B did not contact medical providers or nursing leadership regarding the widespread day-shift medication omissions, nor did they review the specific omissions for each resident. LPN-B focused on the afternoon shift schedule and altered some medication administration times to space out the doses. Multiple residents experienced elevated blood sugars during the evening shift. LPN-B reported the facility Nurse Practitioner (NP) was on the floor, but LPN-B only notified the NP about one resident who had an elevated blood sugar reading. LPN-B stated that nurses must contact a provider when critical medications such as insulin, diuretics, and blood pressure medications are missed.During an interview on 7/17/26 at 10:42 a.m., the administrator confirmed they became aware of the multiple day-shift medication errors on the morning of 7/16/26. The administrator confirmed that multiple residents were involved, and that subsequent assessments showed no immediate negative effects. The administrator stated that notifications were sent to the providers, residents, and families. The facility suspended RN-A pending an investigation. The administrator stated that the evening shift staff should have conducted provider notifications, medication reviews, and resident assessments. The administrator stated that new graduates require more orientation and that a clear competency evaluation framework must be put in place going forward.During an interview on 7/17/26 at 11:21 a.m., the Nurse Practitioner (NP) stated the facility did not provide notification of the multiple missed medications and treatments until 7/17/26. The NP stated they had multiple resident-specific written notifications remaining in their inbox for review. The NP stated that omitting ordered treatments, assessments, and medications creates a potential for resident clinical decline. The NP specified that errors involving anticoagulants, antipsychotics, Parkinson's medications, anti-seizure medications, antibiotics, and insulin are concerning because they can cause resident decline if not addressed in a timely manner. The NP stated they require immediate notification for significant medication errors. For a missed insulin dose, the NP stated nursing staff must assess the resident, check the blood glucose level, and call the provider for corrective orders and monitoring parameters.Review of the facility policy Administering Medications showed in line item three that the DON is responsible for the supervision and direction of all personnel with medication administration duties and functions. Line item seven directed that medications must be administered within one hour of prescribed times.Review of the facility policy Change in Condition, dated 11/13/24, showed requirements to ensure provider and responsible party notification for any change in a resident's physical, psychosocial, or mental condition status. Line item two listed a medication error or an adverse reaction as an example requiring notification. Line item three instructed the nurse to complete and document assessment findings, including vital signs and respiratory or cardiac status, and to notify the provider.Review of the facility policy Care of the Diabetic Resident, dated 7/28/15, showed the policy lacked instructions or protocols regarding missed insulin administrations. The surveyor requested a specific policy regarding insulin administration, but the facility failed to provide it.

Based on observation, interview, and record review, the facility failed to ensure that discontinued and expired medications were locked and stored separately from active medications, and were disposed of in a timely manner, for 3 of 3 medication rooms reviewed (200/300-unit, 500-unit, and 600-unit medication storage rooms).Findings include:During a review of the 200/300-unit, 500-unit, and 600-unit medication storage rooms on 07/14/26, expired and discontinued medications were observed on the counters, unsecured and awaiting disposal. The medications belonged to residents who had been discharged between 05/04/26 and 07/03/26. The unsecured medications consisted of the following:-Eliquis, Hydrochlorothiazide, Prochlorperazine, Nitroglycerin, and Naloxone. Also present were Enoxaparin syringes, Nasal saline solution, Mupirocin cream, Artificial tears, Zinc oxide, and Fluticasone inhalers. The inventory included bottles of Acetic Acid, containers of Nystatin powder, Fluorouracil cream, Lidocaine, Gabapentin, Haloperidol, and Acetaminophen. Additional items found were Docusate/senna, Phenytoin sodium capsules, Hyoscyamine, Glycerin suppositories, Proctozone-HC suppositories, Acetaminophen suppositories, and Pediapap liquid. Finally, the collection contained Trazodone, Vitamin D3, Eplerenone, Fluoxetine, Propranolol, Torsemide, Baclofen, Pantoprazole, Lantus SoloStar prefilled pens, Potassium Chloride, Clopidogrel, Mirtazapine, Mucus relief, Metoprolol, Olanzapine, Cetirizine, and several bottles of stock over-the-counter medications.During an interview on 07/14/26 at 1:56 p.m., Licensed Practical Nurse (LPN)-C stated that the discontinued and expired medications sitting on the counter of the 200/300-unit room were supposed to be transferred to the 600-unit medication room for final disposal. LPN-C stated they were unsure how long those medications had been left sitting out on the counter. During an interview on 07/14/26 at 1:44 p.m., the Director of Nursing (DON) confirmed that the medications left on the counters in all 3 medication storage rooms were expired or discontinued and required disposal. The DON stated that due to recent staffing challenges, the facility experienced a delay in disposing of medications in a timely manner. Facility policy titled Destruction and Disposal of Medications revised on 11/22/24 indicate, all expired and discontinued medication will be placed in a designated, secure location for medication needing destruction.

Based on observation, interview, and record review, the facility failed to ensure proper personal protective equipment was used for 5 of 5 residents (R7, R17, R35, R59, R1) reviewed for enhanced barrier precautions (EBP). Findings include: R7's annual Minimum Data Set (MDS) assessment, dated 7/3/26 indicated R7 had severe cognitive impairment and was dependent on staff for bed to chair transfers as well as toilet hygiene. The MDS also indicated R7 had an indwelling urinary catheter and was frequently incontinent of bowel. R7 had a diagnosis of progressive neurologic disease, dementia, and had a stage 3 pressure injury (a deep wound in the skin that does not expose underlying structures). R7's diagnoses list included urinary retention, dementia, muscle weakness, and pressure injury of the sacrum (lower back). R7's provider orders included: change urinary catheter every 28 days, check to ensure dressing over sacral wound is clean and secured in place, sacral wound dressing changes, urinary catheter positioning instructions, and urinary output documentation. R7's care plans indicated R7 required assist of 1 staff for activities of daily living and assist of 2 with a mechanical lift for transfers. The care plan also indicated R7 was on enhanced barrier precautions due to urinary catheter use and provide personal protective equipment as needed. The care plan also indicated R7 had a stage 3 pressure injury to her sacrum. R7's nursing assistant care plan indicated R7 was on enhanced barrier precautions and provide personal protective equipment as needed. It also indicated R7 had a foley catheter and required 1 staff assist for ADL's and 2 staff with mechanical lift for transfers. During observation on 7/13/26 at 9:41 a.m., a sign titled Enhanced Barrier Precautions with instructions for PPE was on R7s door. The sign indicated staff must clean hands before entering and when leaving a resident's room. Providers and staff must wear gloves and a gown for high-contact resident care activities. The sign defines high-contact care activities as dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, device care, and wound care for wounds requiring a dressing. Gowns and gloves were located outside of R7's room. Nursing assistant (NA)-G and NA-H entered the room. NA-G did not don gloves or gown. NA-H donned gloves however no gown. R7 was laying in bed. A urinary drainage bag was attached to the side of R7's bed. Without donning gloves, NA-G pulled up R7's shorts and rolled R7 toward NA-H. NA-G's clothing came in contact with R7's bed. NA-G and NA-H positioning the mechanical lift sling under R7 and positioned the lift over R7. Wearing gloves but no gown, NA-H moved the urinary drainage bag from the side of the bed to the mechanical lift. NA-H then operated the mechanical lift while NA-G held on to the lift sling and R7's legs while R7 was lowered to the wheelchair. NA-G was not wearing gloves or a gown. Without donning a gown, NA-H reached to the opposite side of R7's bed to grab a blanket to cover R7's lap. NA-H's clothing came in contact with R7's sheets and blankets. NA-H then removed R7's urinary drainage bag from the mechanical lift and placed it under R7's wheelchair. NA-H removed gloves. NA-H and NA-G sanitized hands and left the room. During an interview on 7/13/26 at 10:28 a.m., NA-H stated infection control training occurs during onboarding upon hire. NA-H stated if a resident is on EBP, staff are to wash hands and wear gloves anytime you do anything with the resident. Staff wear gowns when working with urine or bowel movements. When asked if staff are required to wear gowns for any other time, NA-H reiterated staff are only required to wear gowns when working directly with bodily fluids. During an interview on 7/14/26 at 4:16 p.m., registered nurse (RN)-C stated infection control training occurs during onboarding. The facility also provides monthly meetings with changes to infection control practices as well as infection control information posted at nurses stations that staff have to sign and acknowledge. RN-C stated residents are placed on EBP when residents have a bug they don't want. Staff wear gown and gloves anytime care involves bodily fluids. If a resident is on precautions related to urine, staff wear gowns when doing incontinence care. If a resident is on precautions related to catheter use, staff wear gown and gloves when doing catheter cares. If a resident is on EBP because a resident's immune system is suppressed, then staff wear gown and gloves all the time. During interview on 7/16/26 at 1:13 p.m., the facility infection preventionist (ADON/IP) stated residents are placed on EBP if they have an indwelling catheter, feeding tube, central IV line, or chronic wounds to prevent the development of infection. Gowns and gloves are required during any high-contact activity such as peri care, bathing, dressing changes, and medication administration via feeding tube. Staff must also wear gown and gloves during transfers and when contacting bed linens. During an interview on 7/17/26 at 8:52 a.m., the director of nurse stated residents with chronic wounds, catheters, feeding tubes, or any other device that could invite a multidrug resistant organism (MDRO). Staff should wear gown and gloves for any contact at all even if it is just to drain a catheter, boost in bed, or provide cares. The DON stated staff should absolutely wear gown and gloves when transferring from bed to chair and adjusting linens. R17 R17's quarterly Minimum Data Set (MDS) assessment, dated 6/129/26, identified R17 as cognitively intact. R17's diagnoses included resistance to multiple antimicrobial drugs, pneumonitis due to inhalation of food and vomit, encounter for attention to gastrostomy and type 2 diabetes mellitus. R17's current care plan indicated, R17's required a feeding tube due to history of oropharyngeal cancer, received all nutrition and fluids via PEG- TUBE (feeding device that delivers nutrition directly into a part of the small intestine while also allowing access to the stomach for drainage or medication), suprapubic catheter (a flexible tube inserted through a small abdominal incision to drain urine directly from the bladder) use related to diagnosis of urinary retention and enhanced barrier precaution. R 17's current provider orders indicated R17's was on amoxicillin 875-125 mg tablet, give 1 tablet by mouth 2 times a day for Pneumonia for 7 days (7/10/ 26 to 7/17/26) and R 17 on was EBP. During observations on 7/13/26 at 9:23a.m., R17's door had an isolation sign which indicated R17 was on droplet precautions, enhanced barrier precaution and had drawer containing PPE (protective personal equipment) next to the door. The EBP sign indicated gown, and gloves had to always be worn when staff provided high contact care activities. Licensed practical nurse (LPN)-A approached R17's room with donned mask, gloves, held 2 cups containing crushed medications and entered R17's room. LPN-A administered R 17's morning medications via PEG Tube, with no gown. While in R17's room, director of nursing (DON) stood in R17 entry way and communicated to LPN-A, R17's was off Droplet precaution due to negative COVID PCR result. During an interview on 07/14/26, at 3:12 p.m., DON confirmed R17's was on EBP and acknowledged had witnessed LPN-A providing high contact care without a gown. DON Stated, LPN- A will be provided with more education on infection control as it was LPN-A first week on the floor. R35 R35's comprehensive Minimum Data Set (MDS) assessment, dated 06/13/26, indicated intact cognition. R35's current provider orders indicated left buttock wound treatment daily and enhanced barrier precaution. During an observation on 07/14/26 at 10:08 a.m., nursing assistant (NA)-A, assisted R35 in bed with incontinent product change, gloves were in use and no gown in use. R35's door had an enhanced barrier precaution sign indicating, gown, and gloves had to always be worn when staff provided high contact care activities and had drawer containing PPE (protective personal equipment). NA-A came out of R35's room and asked licensed practical nurse (LPN)-B for assistance with 2 persons and a mechanical lift transfer. NA-A reentered R35's with no glove or gown and a mechanical lift. LPN-B arrived at R35's door, donned on a gown and gloves prior to entering R35's room. During an interview on 07/14/26 at 10:13 a.m., NA-A acknowledged, R35 was on EBP and acknowledged did not use proper PPE and stated, the nurse reminded me. During an interview on 07/14/26 10:13a.m., LPN-B acknowledged R35 was on EBP and confirmed NA-A did not wear proper PPE to provide high contact resident care activity. During an interview on 07/14/26, at 3:12 p.m., DON stated, staff was expected to use proper PPE when providing cares to residents on EBP. R59 R59's care plan revised on 07/09/26 indicated risk for infection as evidenced by chronic vascular wound to lower extremity, enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). R59's current provider order dated 07/09/26 indicated enhanced barrier precaution due to chronic wound and wound care dressing change to left ankle every evening. During an observation for medication administration on 07/14/26 at 7:31 a.m., licensed practical nurse (LPN)-A entered R 59's room with morning medications, no gloves or a gown was in use. R59's door had an enhanced barrier precaution sign indicating, gown, and gloves had to always be worn when staff provided high contact care activities and had drawer containing PPE (protective personal equipment). R59 requested assistance to put on socks and assistance into the bathroom after morning medications were administered. LPN-A assisted R59 to put socks on both feet, transferred R59 from the bed to the wheel chair, and from the wheel chair to the toilet. R1 R1's quarterly Minimum Data Set (MDS) assessment, dated 6/25/26, identified R1 was cognitively intact and was dependent on staff for mobility and required moderate to extensive assistance for activities of daily living. R1's care plan revised on 04/17/26 indicated risk for infection due to indwelling foley catheter use with history of neurogenic bladder, required PEG tube (feeding device that delivers nutrition directly into a part of the small intestine while also allowing access to the stomach for drainage or medication) due to Hernia Hiatal and EBP (enhanced barrier precaution). During medication administration observations on 7/15/26 7:50 a.m., NA-B, stated to LPN-A, R1's PEG tube had a kink, needed adjusting and NA-B also needed assistance to transfer R1 as R1 was a 2-persons assist with a mechanical lift. LPN-A followed NA-B, entered R 1's room with no gloves or gown. R1's door had an enhanced barrier precaution sign indicating, gown, and gloves had to always be worn when staff provided high contact care activities and had drawer containing PPE (protective personal equipment) next to the door. R1 was lying in bed, LPN-A leaned over R1, adjusted R1's PEG tube, removed a catheter secure tape next to PEG tube and sated the PEG tube was twisted and the catheter secure tape needed to be changed. LPN-A exited R 1's room, used hand sanitizer and returned to the medication administration cart. During observation on 07/15/26 at 8:01 a.m., LPN-A prepared 13 medications for R1 and reentered R1's room with no gloves or gown. R1 was lying on the bed, being attached/hooked to the mechanical lift with a sling by NA- B. NA -B had on gloves and no gowns. LPN-A directed the mechanical lift, NA-B directed R1 in the sling and managed R1's foley catheter bag. Once R1 was placed in the power chair, NA-B removed the slings, adjusted R1 in a comfortable sitting position while LPN-A administered morning medications. During an Interview on 7/15/2026 8:39 a.m., NA-B indicated was aware of EBP precautions as indicated by the sign and PPE equipment present at R1's door. NA-B stated, had been unable to put on a gown consistently due to time constraint. NA-B stated, there are too many call lights, I sometimes do not even look at the door, I just go in. During an interview on 07/15/2026 at 8:32 a.m., LPN-A indicated had been instructed during the orientation process by 3 different staff members, donning a gown was only required for wound care when a resident was on EBP. A policy titled Enhanced Barrier Precautions issued 3/26/24 indicated It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism such as a resident with chronic wounds requiring a dressing, indwelling medical devices or residents with 'infection or colonization with an MDRO' EBP is defined as an infection control intervention designed to reduce transmission of MDRO that employees targeted gown and glove use during high contact resident care activities. The policy indicated the purpose of EBP is to prevent opportunities for transfer of MDROs to employee's hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High-contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care, wound care.

Based on observation, interview, and record review, the facility failed to ensure a dignified dining experience was provided when staff stood assisting with meals for 3 of 3 residents (R29 ,R43, R37) reviewed for dignity. Findings include:R29's electronic medical review (EMR) indicated dependence with activities of daily living and enrolled in a hospice program (a specialized model of end-of-life medical care of people with terminal illness and life expectancy of about six months or less, focusing on comfort, symptoms relief, and quality of life).R43's EMR reviewed indicated dependence on staff for activities of daily living and enrolled in a hospice program.During an observation on 07/14/26 at 12:35 p.m., 4 residents were seated at a table in the dining room, 3 of the residents were in Broda chair (high back positioning chair) and nursing assistant (NA)-C in a standing position, assisted all 3 residents simultaneously with eating.During an interview on 7/14/26 at 2:15 p.m., (NA)- C confirmed R 29, R43, R37 needed assistance with meals. NA-C confirmed, had assisted all 3 residents with eating simultaneously while in a standing position. NA-C stated, I made sure 1 resident swallowed before I moved to the next.During an interview on 7/14/26 2:25 p.m., licensed practical nurse (LPN)-C confirmed, R29, R37, R43, needed assistance with meals and expected any staff member aiding with feeding to be in a sitting position.During an interview on 7/15/26 at 2:27 p.m., assistant director of nursing/infection preventionist (ADON/IP) verified all staff assisting a resident to eat should be seated for face-to-face contact. ADON/IP stated that it was not dignified to stand over a resident while helping them with their meal.Facility policy titled Dinning and Food Service revised on 2/15/25 indicated, when feeding a resident remember to sit down next to resident, and feed resident one resident at a time. Do not stand while feeding a resident.

Based on observation, interview, and record review, the facility failed to ensure care was provided in accordance with a resident's care plan for 1 of 1 residents (R22) reviewed for activities of daily living. Findings include: R22's quarterly Minimum Data Set (MDS) assessment, dated 4/20/26, indicated R22 had severe cognitive impairment, no psychosis, and no history of rejection of care. R22 was also dependent on staff for toilet hygiene and required substantial assist for toilet transfers. The MDS also indicated R22 was frequently incontinent of bowel and bladder. R22 had a history of non-traumatic brain dysfunction, and dementia. R22 was also at risk for developing pressure injuries and received antipsychotic (used to treat behavioral and disturbances), antianxiety (used to treat anxiety), and antidepressant (used to treat depression) medications. R22 had a history of falls, and received hospice care. R22's diagnoses list included dementia with psychotic disturbances, restlessness and agitation, repeated falls, history of femur fracture, and chronic kidney disease. R22's careplan indicated R22 had poor safety awareness and required 1 staff to assist with toileting. It also indicated R22 had urinary urgency and would often transfer without staff assistance. Staff should offer toileting upon awakening, after each meal, and every 2 hours after R22 goes to bed. The careplan also indicated toileting might relieve agitation. R22 also has a history of incontinence and is a high risk for falls. R22's fall careplan indicated, when [R22] is asking where bathroom is, accompany to the room and assist if she allows. Notify nurse if refusing assistance. R22's physical mobility careplan indicated R22 had poor safety awareness, reduced mobility and a history of femur fracture. It also indicated R22 required 1 staff assist for transfers however often refuses assistance or use of call light. R22's July medication administration record (MAR) indicated R22 has scheduled toileting due to frequent falls. Please assure staff are both assisting with encouraging R22 to use toilet upon awakening in the morning, after each meal, and every 2 hours after going to bed for safety. R22's nursing assistant (NA) kardex (careplan used by NA staff instructing care for the resident) indicated if 22 asks where the bathroom is, accompany her to her room and assist if she allows. Notify nurse if refusing assistance. It also indicated R22 was a staff assist of 1 and R22 has urgency and will often transfer without putting on the call light. Offer toileting upon awakening in the morning, after each meal, then every 2 hours after going to bed. The Kardex also indicated attempt toileting if able, as being able to urinate sometimes help relieve agitation. During interview on 7/13/26 at 3:20 p.m., family member (FM)-A stated R22 can be stubborn and has a strong sense of independence and does not always allow staff to assist. FM-A stated most of R22's falls are related to needing to use the bathroom. During interview on 7/15/26 at 11:09 a.m., NA-F stated R22 can be feisty. R22 will occasionally tell staff she does not have to use the bathroom and then attempt to toilet herself when staff walk away. Occasionally R22 will agree to use the bathroom. During continuous observation on 7/15/26 from 12:36 p.m.-1:43 p.m.,-at 12:36 p.m., NA-E was seated in the dining room assisting residents with eating. R22 was sitting in wheelchair across the dining room. An unidentified dietary staff member asked R22 if she was finished with her meal. R22 told the dietary staff member she needed to go to the restroom. The staff member replied let me go call someone. At that time the dietary staff member walked toward the kitchen and used a walkie talkie to state R22 needed to use the bathroom. Message was heard coming from the walkie talkies in the area. At that time, R22 started independently leaving the dining room. -at 12:41 p.m., R22 was observed wheeling passed the nurses station toward the 300 hall. NA-D and another unidentified nursing assistant were sitting at the nurses station. The floor nurse was standing at the medication cart. -at 12:44 p.m., NA-D was observed walking down a hall to answer call lights. A message over the walkie talkie it would be nice if someone could help in the dining room because there are a lot of call lights going off down 2, 3, and 400 halls. R22 wheeled back into the dining room. NA-E remained in the dining room assisting resident's with eating. NA-E looked towards R22 and made conversation about her stuffed animal. R22 then wheeled toward the dining room window.-at 12:55 pm., R22 remained in the dining room dozing off. -at 1:00 pm., NA-E took a resident who was being assisted out of the dining room. R22 remained in the dining room sleeping. Other NA's were observed answering call lights down the hall. -at 1:08 p.m., NA-E returned to the dining room to retrieve another resident then stopped to speak to a resident who was sitting on a bench near the door. -at 1:17 p.m., R22 remained in the dining room sleeping. -at 1:24 pm., resident remained in the dining room. NA staff were answering call lights down the 300 hall. The floor nurse was at the medication cart passing medications. -at 1:31 pm., R22 continued to be sitting in the dining room sleeping. One other resident was in the dining room. Dietary staff were observed in the kitchen. -at 1:43 p.m., 1 hour and 7 minutes after first informing staff she needed to use the restroom, R22 as awake in the dining room. R22 stated she was not tired, just bored and doesn't have anything to do. R22 told surveyor she does have to go to the bathroom but it's not that big of a deal. At that time, the surveyor updated NA-D and NA-E, R22 had to use the restroom. R22 was taken to her room. NA-D and NA-E attempted multiple times to encourage R22 to go to the bathroom, however R22 started becoming frustrated and headed for the bedroom door. At that time, NA-D and NA-E decided to allow R22 to leave her room to prevent R22 from becoming more agitated. During an interview on 7/15/26 at 1:48 p.m., NA-D stated R22 was toileted before lunch and did not hear the request over the walkie talkie R22 needed to use the restroom. During an interview on 7/15/26 at 1:55 p.m., NA-E stated R22 was toileted at 10:45 a.m., when R22 got up for the morning. NA-E stated staff try to assist residents within 5 minutes of calling for help however residents have had to wait a lot longer today due to staffing issues. NA-E stated floor nurses do not always assist with answering call lights or toileting. During an interview on 7/15/26 at 11:06 a.m., licensed practical nurse (LPN)-C stated staff try to keep R22 close due to R22's history of self transferring. R22 has a history of agitation requiring as needed medication at times. LPN-C stated when R22 states she needs to use the restroom, she must be taken immediately due to her history of self transferring. R22 continues to have behaviors at times however it is not common for R22 to refuse toileting. During an interview on 7/17/26 at 8:52 a.m., the director of nursing (DON) stated she would expect staff to toilet a resident within 2-5 minutes of a resident's request. The DON stated a 1 hour wait would be absolutely too long to wait to use the bathroom. A policy titled Activities of Daily Living dated 2/25/25 indicated the facility will assist residents with using the bathroom and maintaining cleanliness based on the residents' careplan.

Based on observation, interview, and record review, the facility failed to ensure the past 3 years of survey results were readily available and accessible to residents and visitors. This affected 9 of 9 residents reviewed for survey accessibility.Findings include:During an observation on 7/15/26 at 7:20 a.m., a survey results binder was located inside a wall-mounted holder between the oxygen storage room and storage room [ROOM NUMBER]A. The binder contained the recertification survey results dated 10/17/23. The binder contained no recertification or complaint survey results for the years 2024 or 2025.During an interview on 7/15/26 at 9:43 a.m., the administrator reviewed the binder and stated the 2024 and 2025 survey results should be inside. The administrator stated staff might have removed the 2024 and 2025 binders for use.During a Resident Council meeting on 7/15/26 at 10:00 a.m., Residents R1, R4, R8, R20, R21, R25, R27, R31, and R37 stated they did not know past survey results were available for review. No residents recalled facility staff informing them that the results existed or where they were located.During a follow-up interview on 7/15/26 at 11:03 a.m., the administrator had three survey binders on their desk. The administrator stated they retrieved the binders from the opposite side of the building.During an interview on 7/15/26 at 1:41 p.m., the facility Scheduler stated the facility kept survey results at both building entrances. The Scheduler showed an empty holder outside their office. The Scheduler stated they gave the 2023 and 2024 binders to the Administrator earlier that day. The Scheduler stated they never had the 2025 results on their hallway.

Based on observation, interview, and document review, the facility failed to ensure daily nurse staffing hours were consistently posted at the start of each shift. This had the potential to affect all residents, families, and visitors.Findings include:During observations on consecutive survey days, the facility failed to update and post current daily staffing hours:On 7/13/26, the facility posted the daily staffing list.On 7/14/26 at 10:00 a.m., the facility posted the daily staffing list.On 7/15/26 at 7:23 a.m., the staffing list from the previous day (7/14/26) remained posted. The facility did not post the current staffing list for 7/15/26.During an interview on 7/15/26 at 12:43 p.m., the Administrator confirmed the staffing hours for 7/15/26 were not posted. The Administrator confirmed the posted list was from 7/14/26. The Administrator stated they expected staff to post the current staffing hours every morning.The surveyor requested the facility policy regarding posted nursing hours, but the facility failed to provide it.

Based on interview, and document review, the facility failed to prevent the loss of resident's personal clothing by not investigating the root cause of the missing items. Findings include: Facility grievances dated 3/25-8/25, indentified five grievances were filed related to missing clothing items. The resolution/follow up for all 5 was to reimburse the resident/family after the item was replaced. During an interview on 8/26/25 at 2:01p.m., the administrator stated social services does an inventory of all belongings and a check list is uploaded to the resident's chart. Clothing items are labeled by laundry. During an interview on 8/27/25 at 7:21 a.m., laundry aide (LA)-F stated any staff can take a report about a missing item. Once reported, staff will look for the item on the unit and she will look through the laundry room for the items. The facility has a no name cart that contains all unclaimed clothing items. LA-F stated upon admission, all resident items are cataloged and put in a green bag and sent down to laundry. The green bag tells laundry there are unlabeled items in the bag. All items in the bag are labeled with the resident's name and room number. Any new clothing items after admission go through the same process. LA-F stated the label maker is old. The pressing plate on the top of the label maker is no longer on the machine so the clothing labels don't always stay on. When labels fall off, they will use a marker to label the resident clothing. LA-F stated they told maintenance about the label maker a while ago however could not pinpoint exactly when. During interview on 8/27/25 at 8:34 a.m., nursing assistant (NA)-B stated clothing is sent to the laundry in a green bag marked with the resident's name and room number. Laundry staff will label the clothing and send it back to the resident's room. During an interview on 8/27/25 at 8:38 a.m., licensed practical nurse (LPN)-C stated all washable items are sent to the laundry in a green bag with the resident's name and room number on it. Once labeled the items are sent back up. If an item is reported missing, a missing items form is filled out and given to the social worker. All staff will look for the item on the unit and then in laundry. If an item cannot be found, then family can submit to have the item reimbursed. During an interview on 8/27/2025 at 10:08 a.m., the maintenance director (M)-A stated he was not aware the label maker in the laundry room was broken. If it was having issues and was reported, he would know about it. During an interview on 8/28/25 at 1:59 p.m., the administrator stated the current process for lost clothing is to search for the items. The families are given the option to order the item and provide a receipt or the facility will order a replacement item for them. The administrator stated they have noticed a pattern of missing clothing however have not identified a reason for the missing clothing items. The facility noticed an issue for residents in the rehab unit where families initially choose to do the laundry themselves so the clothing is not marked, however sometimes the families change their minds so the clothing is sent down to the facility laundry unlabled. The facility also identified the isolation carts contain a receptacle for laundry and garbage so staff may be placing clothing items in the wrong receptacle. The administrator stated she was unaware the label maker in the laundry was broken and that could be part of the problem. A policy titled Grievance Policy dated 3/2025 indicated, the facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The grievance official will work with facility staff utilizing the root cause analysis process for resolution of the grievance or concern.

Based on observation, interview and document review, the facility failed to ensure a proper procedure was in place to identify a residents resuscitation wish was appropriately updated in the electronic medical record (EMR) in a timely manner based on a signed Physician Orders for Life Sustaining Treatment (POLST, a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest) for 1 of 1 residents (R60) reviewed for advanced directives.Findings include:R60's was admitted to the facility on [DATE].R60's medical record electronic medical record (EMR) banner indicated R60 was on hospice however lacked code status on the banner.Further review of R60's medical record identified Hospice admission documents located under a tab labeled documents included hospice orders for code status of DNR/DNI signed on [DATE]. A Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], was included in the hospice admission documents on page 16 of 22. During an observation and interview on [DATE] at 9:40 a.m., registered nurse (RN)-A stated the quickest and the first place to identify code status was to review the banner in the EMR or check in the paper chart binder. RN-A opened a cupboard above the nurse station, and was unable to locate resident paper charts closed the cupboard and sat at a computer, selected a random resident's profile and verified code status on the banner. RN-A stated, a code status could also be verified with the POLST. RN-A opened the document tab, typed CTRL tab and the letter F tab and typed the word POLST. The residents POLST was located, RN-A opened the document, and verified the residents code status. RN-A stated the hospital included code status during verbal report with all admissions. The admission paperwork was given to the admissions team or the nurse manager to verify and enter code status into the residents EMR. Once the code status was entered into the EMR the banner would reflect code status. If there was no code status on the banner and no POLST under the document tab the resident was considered full code and cardiopulmonary resuscitation (CPR) was started.During an interview on [DATE] at 10:01 a.m., nursing assistant (NA)-C stated if there was no code status noted for a resident I would contact a nurse immediately.During an interview on [DATE] at 10:10 a.m., registered nurse (RN)-C stated code status was verified in the resident's profile, first on the banner. If no code status was on the banner, a second document was used to verify status. RN-C navigated the computer and stated, go through documents, miscellaneous, scanned documents and search for the word POLST. If no POLST and no banner, and the resident was unresponsive as a nurse, when in doubt, CPR was started per Good Samaritan laws. During an observation and interview on [DATE] at 10:12 a.m., registered nurse (RN)-D stated a code status would be observed in the Kardex or in the care plan. RN-D was observed searching a resident's chart and stated the banner was supposed to be up to date and pointed to the banner. RN-D verified no paper charts were used on the unit and was unable to identify where to locate a POLST and referred the question to the nurse manager.During a subsequent interview on [DATE] 10:20 a.m., RN-A accessed R60's EMR and verified the record lacked code status under the heading advance directive and was unable to locate a POLST. RN-A stated the area titled special instructions on the banner indicated hospice and this indicated DNR/DNI. RN-A stated all hospice residents are DNR/DNI and if R60 was unresponsive CPR would not be started. During an observation and interview on [DATE] 10:45 a.m., RN-D accessed R60's EMR and stated code status was verified on the banner. RN-D verified R60's EMR lacked documentation of code status on the banner and lacked documentation of a POLST. RN-D stated R60 was on hospice and assumed the status was DNR/DNI because all hospice residents were DNR/DNI.During an interview on [DATE] at 3:35 p.m., licensed practical nurse (LPN)-B stated code status was found on the banner and if no code status was listed the POST could be verified under miscellaneous tab. If a resident was on hospice, that would indicate a code status of DNR/DNI but would call to verify the status. If no code status was listed and was unsure CPR would be started. LPN-B stated in their twenty years of long- term care experience there has never been a resident on hospice that wasn't DNR/DNI, but there was no assumption that automatically meant all hospice were DNR/DNI. The facility educated staff to verify code status by banner or POLST.During an interview on [DATE] 3:51 p.m., licensed practical nurse (LPN)-A stated code status was verified on the banner with DNR or Full Code. If there was no code status on the banner and no POLST to verify, even if the resident was on hospice CPR would be started. LPN-A stated the nurse managers kept code status up to date and has never seen hospice special instructions used as code status. During an interview on [DATE] at 3:57 p.m., registered nurse (RN)-F indicated resident's code status was verified on the banner or by accessing the POLST scanned into the documents. If a resident had no code status, first confirm code status with hospice, but if a resident became unresponsive and the situation was emergent, when in doubt, assume full code. There was no assumption that residents on hospice are automatically considered DNR/DNI because some hospice residents were full code.During an interview on [DATE] 2:56 p.m., registered nurse (RN)-E stated if there was no code status in the computer, they would be full code by default. Generally, code status was completed on admission day. The repercussions of having the incorrect code status could be traumatic for the resident and family. There were no assumptions hospice implied the resident was automatically DNR/DNI. During an interview on [DATE] at 11:02 a.m., the director of nursing (DON) stated staff would verify code status on the resident's banner or the POLST located in the scanned documents. Code status was updated by whom ever views the POLST upon admission. If there was no code status located on the banner it was the expectation to assume the resident was full code. Staff were not to assume all residents on hospice were DNR/DNI.A policy for advance directive was requested and not received.

Based on observation, interview and document review, the facility failed to notify the physician in a timely manner for 1 of 1 resident (R5) who frequently refused important medications from certain staff. Findings include:R5's comprehensive Minimum Data Set (MDS) assessment dated [DATE], identified intact cognition with no behaviors towards others. R5's diagnoses included atrial fibrillation (an abnormal heartbeat that caused quiver instead of normal heartbeat), heart failure, hypertension, diabetes mellitus, depression, left knee amputation and one, stage three pressure ulcer. R5's care plan dated 6/21/21, identified goals and interventions to maintain blood glucose levels, reduce risk related to a history of atrial fibrillation, stroke, and pulmonary embolism, maintain mood, and report changes to the provider. R5's provider orders, included evening medications of acetaminophen for pain three times per day, apixaban for atrial fibrillation (blood thinning medication to reduce stroke) two times per day, atorvastatin for cholesterol at bedtime, cefadroxil for left amputation infection two times per day, gabapentin for diabetes pain three times per day, insulin to regulate blood sugar in the morning and evening, melatonin at bedtime for insomnia, novolog insulin before meals, novolog insulin sliding scale (dose dependent on blood sugar levels and food consumed), roxicodone a narcotic for pain every four hours as needed, sennoside docusate sodium used for constipation associated with narcotics twice a day, torsemide related to chronic congestive heart failure twice a day.R5's medication administration record for July 2025, indicated all evening medications and treatments offered by one nurse were refused on 7/16, 7/19, 7/20, 7/21, 7/22, 7/25, and 7/28.R5's medication administration record for August 2025, indicated all evening medications and treatments offered by the same nurse were refused on 8/2, 8/4, 8/5, 8/8, 8/11, 8/12, 8/17, 8/18, and 8/22.R5 grievance form dated 6/26/25, included R5 and a nurse didn't get along well.During an interview on 8/25/25 at 12:58 p.m., R5 stated there was an incident with a nurse on Christmas and the social worker was aware. A grievance form was completed, and the result of the grievance was R5 was told the nurse had the right to work anywhere in the facility. R5 stated all cares and medications were refused while they were on the unit even when another nurse from another unit was assigned to care for R5. R5 felt it wasn't fair to the other nurse to come all the way over just to do extra work and R5 refused cares from the assigned nurse as well. During an interview on 8/27/25 at 2:52 p.m., registered nurse (RN)-E stated R5 completed a grievance form dated 6/26/25 and was aware of an incident occurred between the resident and an evening nurse on 12/25/24. Since the event R5 refused to receive any medications or treatments from the nurse while they were assigned to the unit. RN-E stated R5 refused weights and other treatments and thought the provider was aware medications were refused. During an interview on 8/28/25 at 10:24 a.m., the medical director stated the expectation was to be notified if a resident wasn't taking medication, especially if the resident didn't take a medication three days in a row and the implication of R5 not taking medication could lead to stroke or a hyper or hypoglycemic event. The medications R5 refused were vital medications.During an interview on 8/28/25 at 11:02 a.m., the director of nursing (DON) stated the staff were expected to notify the provider if a resident refused medications typically after three doses of the same medication and this was important because the provider assumed the resident received the ordered treatments.During a subsequent interview on 8/28/25 at 9:45 p.m., R5 confirmed during the month of August 2025 the nurse never came into R5's room, provided cares, medications or treatments while scheduled on their unit. A bed bath was scheduled for Wednesday evenings and if the nurse was on the unit, R5 did allow another male nurse to come from another unit to perform a skin check. Besides the skin check Wednesday evenings, no other cares were performed and any documentation noted by the nurse would have been done through communication with the nursing assistant. A policy for provider notification was requested and not provided.

Based on observation, interview and document review, the facility failed to assess and develop non-pharmacological interventions to promote comfort for 2 of 5 residents (R12, R16) reviewed for pain management.Findings include:R12's admission Minimum Data Set (MDS) assessment, dated 6/9/25, indicated R12 had intact cognition. Further the assessment identified R12 frequently has pain which occasionally effects sleep, interferes with rehabilitation therapy and day-to day activities and rated pain at a 2 out of 10 on a pain scale and R12 receives pain medications.R12's face sheet, identified the following diagnoses: fractures of the third, fourth and fifth lumbar vertebrae (a break in the bones of the lower back), low back pain, spinal stenosis of cervical region(spinal canal in the neck narrows compressing the snail cord and nerves), fibromyalgia (condition characterized by widespread chronic pain), polyneuropathy (general term for nervous system disorder that is characterized by symptoms like numbness, and burning pain in distal parts of the arms and legs) and disease of the spinal cord.During an interview on 8/25/25 at 1:41 p.m., R12 stated she was in the facility due to a broken back. R12 stated she will ask for ice packs to help with pain as they are not offered to her, and she finds the ice packs help with the pain.R12's care plan, identified resident was on pain medication therapy related to lower lumbar fracture. The care plan indicated to review pain medication efficacy, assess whether pain intensity was acceptable to resident and monitor for side effects. The care plan lacked evidence of offering non-pharmacological interventions prior to administering as needed (PRN) medications, what non-pharmacological interventions have been tried, what has been effective and not effective and what non-pharmacological interventions should be used.R12's August MAR/TAR (medication administration record and treatment administration record) included the following order:-oxycodone (opioid pain medication) give 2.5 milligrams (milligrams) every 4 hours as needed for pain of 4-6 out of 10 with a start date of 7/10/25. The medication had been administered a total of 43 times in August. A pain scale was used on the administration of Oxycodone which showed pain scale ratings of 0-9 and effectiveness of medication was documented.-oxycodone give 5 mg every 4 hours as needed for pain of 7-10 out of 10 with a start date of 7/10/25. This medication had been administered a total of 14 times in August. A pain scale was used on the administration of Oxycodone which showed pain scale ratings of 0-9 and effectiveness of medication was documented.MAR/TAR lacked evidence of non-pharmacological interventions being offered prior to administration of as needed pain medication.R12's progress notes, dated 8/1/25 to 8/27/25 were reviewed. Progress notes lacked evidence of non-pharmacological interventions being offered to R12 for pain.R16R16's significant change MDS assessment, dated 8/5/25, indicated R16 had severely impaired cognition. Further the assessment identified R16 frequently has pain which occasionally effects sleep and day-to day activities and rated pain at a 2 out of 10 on a pain scale and receives pain medication.R16's face sheet, identified the following diagnoses: end stage renal disease, malnutrition, acute kidney failure, alcoholic cirrhosis of liver with ascites (chronic liver disease with leads to scarring of liver which led to fluid accumulation in the abdominal cavity), heart attack and chronic liver failure.On 8/25/25 at 1:57 p.m., R16 stated has chronic pain. R16 stated his back gets very sore along with his shoulders. R16 stated they do not offer ice packs or heating pads to help with the pain. R16 stated no non-pharmacological interventions are offered for pain management.R16's care plan, indicated, resident has the potential for acute pain r/t (related to) end of life which included offer non-pharmacological interventions for pain relief such as heat, cold, repositioning, rest, music, family/ friend time and relaxation.R16's August MAR/TAR included the following orders:-hydromorphone (opioid medication used to treat moderated to severe pain) oral liquid 1milligram/milliliter (mg/ml) give 2 ml by mouth every 1 hour as needed for pain for dyspnea, moderate pain with a start day of 7/21/25 and discontinue date of 8/14/25. This medication was administered 6 times from 8/7/25 to 8/13/25 which showed pain scale ratings of 2-5 and effectiveness of medication was documented.-hydromorphone 1mg/ml give 2 ml by mouth every 3 hours as needed for pain for dyspnea with pain great 4/10 with a start date of 8/14/25. This medication was administered 8 times from 8/14/25 to 8/25/25. The MAR has an area NP, which was located above the pain level scale on the MAR, which had an X marked in all the boxes on the MAR.MAR/TAR lacked evidence of non-pharmacological interventions being offered prior to administration of as needed pain medication.R16's progress notes, dated 8/1/25 to 8/27/25 lacked evidence of non-pharmacological interventions being offered to R16 for pain prior to administering PRN opioid pain medication. During an interview on 8/27/25 at 10:05 a.m., nursing assistant (NA)-B stated they were familiar with R16. NA-B stated R16 requests pain medication, but he doesn't always complain of pain. NA-B stated they would report pain to the nurse for the nurse to administer medications and follow up with the resident.During an interview on 8/27/25 at 1:08 p.m., LPN-A stated when a resident complains of pain, the nurse would have the resident rate their pain if able or do a non-verbal pain scale and then look at the MAR to see what medications would be available. LPN-A stated they would try non-pharmacological as certain resident have it on their MAR/TARs as they could have ice packs. LPN-A stated if they do a non-pharmacological, it would be documented in a progress note. LPN-A stated they do not put orders in the electronic medical record, typically, unless it was a standing house order as the nurse managers put orders in which would include the non-pharmacological that should be done. LPN-A stated that R16 does have pain, received as needed pain medications and required a lot of staff assistance.During an interview on 8/27/25 at 1:59 p.m., registered nurse manager (RN)-B stated the expectation would be staff attempt a non-pharmacological intervention prior to administering PRN pain medication. RN-B reviewed R16's EMR and verified there was no documentation of non-pharmacological interventions being attempted prior to administration of PRN pain medications.During a follow up interview on 8/28/25 at 10:18 a.m., RN-B verified R12 has pain and had been receiving PRN pain medication. RN-B, verified there was no non-pharmacological interventions attempted prior to administration of PRN medications and should have been. RN-B stated they would be documented in the progress notes. RN-B stated they are working on adding non-pharmacological interventions on the residents MARs so staff will have to document interventions when administering PRN pain medication. RN-B verified NP on a resident MAR would indicate non-pharmacological interventions.During an interview on 8/28/25 at 10:35 a.m., director of nursing stated the expectation would be non-pharmacological interventions would be attempted and documented in the progress notes prior to administration of PRN pain medication.A facility policy on use of non-pharmacological interventions for pain was requested but not provided.

Based on observation, interview, and record review the facility failed to ensure proper hand hygiene for 1 of 1 resident (R9) reviewed for contact precautions. In addition, the facility failed to ensure proper PPE usage for 2 of 2 (R20, R46) reviewed for enhanced barrier precautions. Findings include: R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R9 was cognitively intact with no behaviors. R9 had no upper or lower body range of motion impairment. R9 was independent with eating, oral hygiene, toileting, mobility, and all activities of daily living. R9 had an indwelling urinary catheter and was always continent of bowel. R9's diagnoses list included cancer, received chemotherapy treatments, chronic kidney disease, diabetes, and malignant lung cancer. R9's careplan indicated R9 was diagnosed with clostridium difficile infection (c-diff-a contagious bacterial infection of the small and large intestine). Interventions included contact-based precautions, educate the resident/family/caregivers the importance of hand washing and use of antibacterial soap and disposable towels. Wash hands immediately after ADL's, care tasks, and activities. R9 was also independent with transfers, eats independently, dresses independently, and toilets independently. R9 was a standby assist of one for showers. During observation and interview on 8/26/26 at 2:24 p.m., R9 was observed sitting on the bed. An enhanced barrier and contact precautions sign were noted outside room. Registered Nurse (RN)-C applied proper PPE prior to entering the room. After assisting R9, RN-C took off Personal Protective Equipment (PPE), had R9's meal tray in his right hand, and used hand sanitizer in left hand. RN-C handed the meal tray to another staff member. Without performing hand hygiene, RN-C then grabbed an empty water pitcher with his right hand, walked over to the sink placing the water pitcher on the counter. RN-C then washed his hands, picked up the water pitcher, and filled it with water. RN-C then took the pitcher to R9's room and placed it on the table outside the room while applying PPE and brought it to R9. Upon leaving R9's room, RN-C used hand sanitizer and took a red bag outside to the main garbage. RN-C performed hand washing upon returning from the main garbage. During interview RN-C confirmed R9 has C-diff and stated hand sanitizer is not effective against c-diff. Staff should be washing hands upon exiting the room. RN-C confirmed he should have washed his hands prior to touching the water pitcher and when exiting with the garbage. EBP R20 R20's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated R20 was cognitively intact with no behaviors. R20 had no upper or lower extremity impairment. R20 required set up assist for eating, independent with oral hygiene, independent with toilet hygiene, dependent with bathing, independent with upper and lower body dressing, footwear, personal hygiene. R20 was independent going from sitting to standing, independent with transfers to and from bed/chair, independent with toilet transfers, supervision with tub transfer, supervision/touching assist with walking, and independent with wheelchair mobility, R20 required intermittent catheterization, and was always continent with urine and bowel. R20's diagnosis list included benign prostatic hyperplasia, obstructive uropathy, and urinary retention. R20's provider order dated 7/18/25 included, indwelling foley catheter 14 fr (French) change every 30 days and as needed for obstructive uropathy and urinary retention, and enhanced barrier precautions related to indwelling device. R20's care plan indicated R20 has a history of self-transferring and refusal of cares. R20 requires assist of 1 to stand/pivot transfer and assist of 1 with ambulation. R20 has diagnosis of benign prostatic hypertrophy, obstructive uropathy and urinary retention requiring an indwelling foley catheter. During interview on 8/25/25 at 1:43 p.m., R20 stated the indwelling catheter was put in place during his last hospitalization. R20 stated staff do wear isolation gowns most of the time but not all the time. During observation and interview on 8/27/25 at 11:50 a.m., licensed practical nurse (LPN)-C arrived to R20's room to switch R20 from the large urinary drainage bag to the leg bag. An isolation cart and orange enhanced barrier precautions (EBP) signage were noted outside R20's room. LPN-C sanitized her hands and applied gloves however did not put on an isolation gown. LPN-C assisted R20 to a standing position from the recliner and with pulling R20's pants down. LPN-C then removed her gloves and left the room to get more supplies. LPN-C entered again wearing new gloves and a yellow isolation gown. R20 was switched from the large drainage bag to the leg bag using proper infection control practices. After emptying the large drainage bag in the bathroom, LPN-C removed gloves and gown and washed hands. Without donning another gown or gloves, LPN-C placed a hand under R20's arm and assisted him to a standing position. While R20 was standing, LPN-C used both arms to reach behind R20's right side and assisted with pulling R20's pants up. LPN-C then placed both hands under R20's armpits and assisted him with transferring to his wheelchair. After R20 was seated in the wheelchair, LPN-C assisted R20 with putting on his sweater, attaching the foot pedals to the wheelchair, and putting R20's feet on the pedals. During an interview, LPN-C stated proper infection control practices for catheter care include washing/sanitizing hands prior to entering room, using an alcohol wipe to clean catheter, and wearing a gown. LPN-C confirmed a gown should have been put on prior to entering R20's room the first time. RN-C stated there is some training upon hire, however feels there could be more explanation why specific residents are placed on precautions During an interview on 8/27/25 at 11:14 a.m., the infection preventionist (IP) stated hand hygiene, gowns, and gloves are required prior to entering a resident's room who has c-diff. When exiting the room, staff must wash hands with soap and water. When staff are hired, they are educated. When residents are put on c-diff precautions, you notify employees that work with the resident what they are supposed to do. Not following proper procedures could risk spreading the infection to yourself, other residents, staff, and your family. During an interview on 8/28/25 at 11:01 a.m., the director of nursing (DON) stated it is expected staff would follow the directions on the signs posted outside of the resident's room. Staff are expected to wash their hands with soap and water for any resident diagnosed with c-diff. This is important to prevent the spread of infection to staff and other residents. R46's Minimum Data Set (MDS) assessment dated [DATE], indicated R46 had intact cognition, was diagnosed with diabetes mellitus and peripheral vascular disease, and required assistance with all care activities. The MDS indicated R46 had one arterial ulcer present. R46's care plan dated10/9/23, indicated R46 required the assistance of one staff member for dressing and personal hygiene, and the assistance of one staff and a mechanical lift for toileting and transfers. R46's orders, indicated R46 was placed on enhanced barrier precautions (EBP) on 3/7/25. The orders also indicated cares for a right great toe and left knee dated 8/22/25. During an observation on 8/26/25 at 10:42 a.m., outside R46 room was a three-drawer plastic bin was to the right of the doorway and inside the bin were gowns. On top of the bin were two bottles of hand sanitizer and one box of gloves. On the wall to the right of the door was a single page sign , Enhanced Barrier Precautions, clean hands, before entering and when leaving the room. Providers and Staff must also: wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wounds Care: any skin opening requiring a dressing. R46 was in her room sitting in her wheelchair. Nursing Assistant (NA)-A was positioning the mechanical lift, wearing gloves, without a gown NA-A touched R46's upper body when fastening a transfer belt around R46 waist and under her arms. R46 asked NA-A about her name written on tape and placed on her scrubs while transferring R46 to the bathroom. NA-A was observed pulling the curtain open with one hand ungloved while the other hand remained gloved and held a bag of trash that contained a brief (undergarment) and white paper like contents. NA-A performed hand hygiene with sanitizer with her free hand and walked across the hall, opened a door with that same hand and threw the trash into a bin, removed the one glove and threw that into the bin. NA-A shouted out to the nurse, going to get some briefs. R46 remained in the bathroom with the mechanical lift. During an observation on 8/26/25 at 10:50 a.m., R46's call light alerted, and the nurse manager responded. The nurse manager was observed performing hand hygiene, donning a gown and gloves, then responded to R46's call light. NA-A returned with a package of brief and handed the package to the nurse manager and left the area. During an interview on 8/26/25 at 1:18 p.m., R46 confirmed NA-A did not wear a gown while she transferred into the bathroom and could be confident because NA-A wore a handmade name tag located on the chest of her blue scrubs and the nametag was discussed during the transfer. R46 stated staff never wore gowns before and wasn't sure why they started now. During an interview on 8/26/25 at 1:20 p.m. NA-A stated, to be honest with you, you saw me run in and out, transferred her to the toilet, and didn't put on a gown. NA-A confirmed infection control training was provided and EBP was included in that training. NA-A stated the facility never educated or explained which residents needed gowns, but then confirmed the directions for EBP were on the signage outside R46's door. NA-A stated that gown and gloves should be worn with all transfers with all residents on EBP. NA-A stated R46's had a covered wound, wasn't sure why it was important to wear EBP, and that maybe it was to protect herself. During an interview at 8/26/25 at 4:00 p.m., infection control preventionist (ICP) stated the expectation was when a resident was in their room and on EBP all staff wore gloves and gown while in close contact with the resident. Staff were expected to practice EBP precautions during transfers with residents in their rooms and especially when transferred to the bathroom. During an interview on 8/28/25 at 11:01 a.m., the director of nursing (DON) stated staff were to follow the directions on the Enhanced Barrier Precaution sign. A contact precautions policy was requested but not received. The facility Infection Prevention and Control Manual Transmission-Based Precautions policy dated 2024, indicated staff were to wear personal protective equipment while high-contact resident care was performed. Gown and glove with dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care.

Based on interview and document review, the facility failed to ensure 1 of 5 sampled residents (R23) was offered and/or provided updated vaccinations for pneumococcal disease, in accordance with Centers for Disease Control (CDC).Findings include: Review of the current, 10/26/24, Centers for Disease Control (CDC): Pneumococcal Vaccine Recommendations, located at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, identified based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or PCV 21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV 21 if they have received both the PCV13 (but not PCV15, PCV20, or PCV 21) at any age and a PPSV23 at or after the age of [AGE] years old. R23's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R23 was [AGE] years old. It also indicated R23's pneumococcal vaccination status was not up to date and the pneumococcal vaccine was not offered. R23's immunization record indicated R23 received the pneumococcal-conjugate vaccine-13 (PCV13) on 11/2015 and pneumococcal polysaccharide vaccine 23-valent (PPSV23) on 8/8/2001. It did not indicate record of R23 receiving the PCV-20 vaccine. R23's vaccine consent form dated 10/27/23 indicated R23 consented to receiving the COVID-19 and influenza vaccine however did not offer the pneumococcal vaccine. During interview on 8/27/25 at 1:57 p.m., the infection preventionist (IP) indicated the facility does offer the PCV-20 vaccination via immunization clinics offered during the summer and fall. New admissions are offered vaccinations upon admission in an individual basis. The last immunization clinic was 10/24 however R23 had COVID19 during that time and did not participate in the clinic. The IP stated he was under the impression R23's pneumococcal vaccination status was considered complete because R23 had received the PCV-13 and PPSV-23 vaccinations and confirmed there is no record of shared decision making and/or offering of PCV-20 vaccine to R23. During an interview on 8/28/25 at 11:01 a.m., the director of nursing (DON) stated it is expected the facility would follow CDC guidelines and offer vaccinations upon admission and during appropriate season. A 2024 policy titled Infection Prevention and Control Manual Pneumococcal Vaccine Program indicated It is the policy of this facility that residents will be offered immunization(s) against pneumococcal disease in accordance with Advisory Committee on Immunization Practices (ACIP recommendations. Pneumococcal disease is a serious illness that can cause sickness and even death. It continues, Recommendation for shared clinical decision making. Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 if they have received PCV13 at any age and PPSV at or after the age of [AGE] years old

Based on interview and record review the facility failed to ensure allegations of staff to resident physical abuse were immediately reported to the State Agency (SA) no later than 2 hours after the knowledge of the allegation of abuse, for 1 of 1 residents (R1) reviewed for abuse. Findings include: Facility reported incident (FRI) submitted on 12/18/24 at 9:27 p.m., identified that on 12/18/24 at 4:10 p.m., the facility was notified by registered nurse (RN)-D that R1 stated her leg was sore because someone had kicked her in the leg and pinched her in the groin area. Two finger sized bruises noted to inner thigh. In addition, R1 stated she had been slapped in the cheek and her glasses were knocked off of her face. R1 identified it was a staff member from 2 weeks ago and had not seen staff member since. R1's quarterly, Minimum Data Set (MDS), dated [DATE], indicated R1's cognition was moderately impaired. R1's diagnoses included dementia. R1's progress note dated 12/18/24 at 6:12 p.m., identified R1 made an accusation of abuse that happened 'a couple weeks ago'. R1 stated it was a female and it happened in the morning. R1 stated the caregiver slapped her on the cheek, knocking her glasses off. The person purposely kicked her in the left leg and pinched at the left inner thigh. At 6:17 p.m., identified R1 had relayed the abuse accusation at 6:05 p.m. Writer called the on-call manager phone at 6:10 p.m., and 6:15 p.m., without connecting to anyone in person. Writer left a voice message describing the basic situation and left a phone number to call back. At 6:22 p.m., R1 was unable to identify her accuser. During an interview on 12/23/24 at 3:29 p.m., RN-D (agency nurse) stated on 12/18/24, at around 6:00 p.m. R1 reported a nurse aide kicked her in the left ankle and pinched her inner thigh a few weeks prior. Shortly after he called the DON, but she did not answer the phone, so he left a message. RN-D could not recall the exact time he had left the message. RN-D stated at 7:00 p.m., the DON called back with the instructions to obtain more information and get a description of the nursing assistant involved. RN-D stated at 7:45 p.m., he spoke with DON to inform her of the description that R1 gave. RN-D thought allegations were reported within 2 hours; RN-D asked surveyor Does this mean the 2-hour timeframe would be from 2 hours of being reported by the resident or would it be 2 hours when we report it to management? During an interview on 12/24/24 at 11:06 a.m., director of nursing (DON) indicated on 12/18/24, RN-D called her phone at 6:13 p.m. and left a voice message. DON had missed the call and did not get the message. At 8:14 p.m. she talked to RN-D, had him collect more information, then reported to the SA. DON indicated RN-D had told her R1 had reported the allegation to him at 4:10 p.m. however was documented in the record a little after 6:00 p.m. When asked what the time period of reporting abuse to the SA was, DON stated, immediately but within 24-hours. DON verified R1's allegation of abuse was reported to the SA on 12/18/24, at 9:27 p.m. which was more than 2-hours of when the allegation was made by R1. During an interview on 12/24/24 at 1:19 p.m., director of social services (DOS)-A stated all abuse allegations should be reported to the SA no later than 2 hours. DOS-A stated she provides all staff upon hire during orientation and staff were required to do abuse training annually. DOS-A indicated she does not educate agency staff of abuse reporting. During an interview on 12/24/24 at 1:47 p.m., administrator stated all allegations of abuse should be reported to the SA no later than 2-hours and verified R1's abuse allegation was reported late. Administrator indicated when the DON had called her on 12/18/24, she had informed the DON allegations of abuse needed to be reported to the SA immediately. During an email correspondance on 12/27/24, at 12:03 p.m., DON indicated she had made an error in the reporting time and stated she had put 4:10 p.m., for the initial report in error and should have been 6:12 p.m. On 12/30/24 at 8:45 a.m., via phone DON stated the report would still be late. Facility policy, ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY, policy revised 1/2021 identified it is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation .The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements .It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. 51576

51576 Based on observation, interview, and document review the facility failed to assess and monitor non-pressure related skin injury (bruises) for changes until resolved for 1 of 1 resident (R1), reviewed for abuse. Findings include: R1's admission, Minimum Data Set (MDS), dated [DATE], indicated R1's cognition was moderately impaired. R1's care plan dated 4/9/24, identified a focus of R1 had history of potential for/actual impairment to skin integrity however did not identify and/or direct a monitoring plan for the potential or actual impairment. R1's progress note dated 12/17/24 at 10:31 p.m., included R1's skin issues on arms and back still present. Facility reported incident (FRI) submitted on 12/18/24 at 9:27 p.m., identified that on 12/18/24 at 4:10 p.m., the facility was notified by registered nurse (RN)-D that R1 reported allegations of physical abuse. Two finger sized bruises noted to inner thigh. R1's record was reviewed between 12/18/24 through 12/24/24, and did not include a comprehensive skin assessment and monitoring of the bruises identified in the FRI dated 12/18/24. During an interview on 12/23/24 at 3:29 p.m., RN-D stated R1 informed him on 12/18/24 of being pinched on inner thigh and kicked on her leg. RN-D indicated he had observed two small bruises on R1's left inner thigh that were about 1/2 inch in diameter and dark purple in color but he did not measure or record the information into R1's medical record. During an observation and interview on 12/23/24 at 12:10 p.m., R1 indicated a staff member had pinched her leaving bruises. She lifted the blanket to show her left inner thigh where there was two purple oval bruises in proximity to each other. The two bruises were each approximately 1.0 cm in diameter. During an interview on 12/23/24 at 1:28 p.m., nursing assistant (NA)-A stated she cared for R1 today and stated around 11:30 a.m., the director of nursing was in R1's room with her looking at R1's two bruises to her inner thigh. NA-A indicated she was not aware of where the bruises came from or how long they had been there. During an interview on 12/24/24 at 8:29 a.m., registered nurse (RN)-C indicated she was the nurse responsible for R1. RN-C explained she was aware R1 had two bruises on her inner thigh becasue someone told her two days ago (12/22/24). RN-C reviewed R1's record and reported there was nothing that identified R1 had bruises or that directed monitoring. RN-C stated she was agency staff and was unaware of the facility process for documenting skin impairments such as bruises. At 11:51 a.m RN-C stated she had just obtained measurements of R1's bruises on left inner thigh today. Measurements were 1.25 cm x 1.25 cm (purple/maroon in color) and 1.5 cm x 1.25 cm purple/maroon in color. During an interview on 12/24/24 at 11:06 a.m., director of nursing (DON) stated RN-D initially found R1's two bruises on her left inner thigh on 12/18/24. DON further stated that no comprehensive skin assessment or monitoring of R1's bruises for healing were in R1's medical record and there should be. A follow-up email correspondance sent by the DON on 12/27/24, at 12:03 p.m., included a a skin ulcer policy. On 12/30/24 at 8:45 a.m., via phone DON indicated the facility did not have a non pressure skin policy, however the skin ulcer policy did direct monitoring of residents skin integrity. Facility policy, Skin Ulcers, reviewed 7/2022, identified D.Monitor Skin Integrity: Skin will be observed daily during cares done by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse. Weekly skin audits on the bath/shower day will be performed by the Licensed Nurse. The Care Plan for Skin Integrity is to be evaluated and revised by Nurse Manager based on response, outcomes, and needs of the resident. E.Identified risk factors and problems will be care planned . Review of Skin ulcer Policy did not address the facility process for monitoring and assessing for non-pressure skin integrity concerns.

Based on observation, interview and document review, the facility failed to ensure a transfer belt to assist with a safe transfers for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which which resulted in a fall with a pelvic fracture and subdural hematoma (brain bleed) requiring hospitalization . This deficient practice is being cited at past non-compliance related to corrective action taken to ensure proper use of transfer belt prior to the survey. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition with diagnoses of stroke with left sided hemiplegia (paralysis on one side of body) and a history of falling. R1 required extensive assist of one staff with bed mobility, dressing, toileting, and transfers. R1 had functional limitation in range of motion (ROM) on one side of upper and lower extremity and used a walker and wheelchair for mobility. R1 had a history of falls prior to admission. R1's care plan dated 12/18/23, identified R1 was at risk for falls. R1 was able to transfer with an assist of one with a gait belt. R1 needed an assist of one staff with toileting. R1's Fall Risk assessment dated [DATE], identified R1 was at high risk for falls due to having a balance problem while standing and walking, decreased muscular coordination, change in walking pattern when walking through a doorway, jerking and unstable when making turns, and required the use of assistive devices. R1's Incident Audit Report dated 1/11/24, identified a fall occurred at 4:10 a.m. The nursing assistant stated R1 stood up from the toilet, went to leave the bathroom and R1's legs gave out. R1 landed on her bottom and bumped their head on the wall. R1 stated their legs gave out and she went down and bumped their head. R1 was instructed to let staff know if she was feeling weak. R1 had an cut to the right elbow and the care plan was reviewed on 1/22/24. The report did not identify if a transfer belt was in use during the fall. R1's progress note dated 1/11/24, identified at 4:10 a.m. R1 had a witnessed fall in the bathroom and hit the back of R1's head on the wall. There was no bruising. A transfer belt and gripper socks were in use (although, interviews below determined the transfer belt was not in use). R1's Post Fall Huddle Form dated 1/11/24, identified at 4:10 a.m. R1 had a fall while using the walker. Root cause of fall indicated that R1's legs gave out. A new intervention was added for R1 to alert staff if R1 was feeling weak. R1's provider visit dated 1/11/24, indicated R1 sustained a fall that morning and R1 hit their head. R1 was taking a blood thinner after a recent stroke and had a hematoma (a solid swelling of clotted blood within the tissues)present on the back of R1's head. R1's hip was injured and not able to bear weight or pivot due to severe pain. Physical therapy (PT) evaluated R1 with worry that R1 might have a pelvic fracture. Recommendation for R1 to be seen urgently to the emergency department with computed tomography (CT) [an imaging test] of head to rule out intracranial bleed as well as trauma evaluation of hip/pelvis. R1's progress note(s) identified the following: - 1/11/24, at 11:08 a.m. R1 was sent to the emergency department (ED) for evaluation following fall with hematoma to the back of head and pain in the pubic area and unable to bear weight. - 1/11/24, at 11:38 p.m. family member (FM)-A called to give an update that R1 was being placed in observation at the hospital with a small brain bleed. R1's After Visit Summary (AVS) dated 1/16/24, identified R1's hospital stay in the trauma critical care general surgery (TCGS) from 1/11/24 to 1/16/24 for management of trauma related injuries. Final diagnoses sustained from R1's fall included subdural hematoma (bleeding in the brain from a traumatic incident such as a blow to the head), fractured pubic (crack or break in pelvis). During an interview on 1/18/24 at 2:54 p.m., physical therapy assistant (PTA)-A identified R1 was in therapy for strengthening, mobility, transfers, and balance since admission and needed minimal assist with transfers and maximum assist for hygiene and toileting tasks. PTA-A stated it was important to use a transfer belt to stabilize a resident when moving, for balance purposes and recommended that all residents use transfer belt for transfers unless contraindicated. During an interview on 1/18/24 at 2:56 p.m. physical therapist (PT)-A stated on 1/11/24, in the late morning a bump was found to the back of R1's head. PT-A stated R1 was adamant that no gait belt was used during the transfer when R1 fell earlier the morning of 1/11/24. On 1/18/24 at 4:02 p.m., R1 was observed seated in the recliner with legs elevated in R1's room. R1 stated early in the morning on 1/11/24, R1 was helped to the bathroom, using a platform walker (a walker used for patients who can't use both hands). Upon standing up from the toilet, nursing assistant (NA)-E was standing next to R1's left side. R1 did not have a transfer belt on. R1 stated, I would have waited for one, I made it a few steps, lost my balance, and fell right by the shower landing on my butt and hit my head on the wall. R1 noticed a difference in her walking and had an intense level of left sided groin pain. R1 stated the next thing you know I was being hauled to the hospital by an ambulance. During a phone interview on 1/22/24 at 11:49 at a.m., registered nurse (RN)-A identified on 1/11/24 before 6:00 a.m., RN-A was notified by NA-E that R1 fell in the bathroom. RN-A assessed R1 and R1 had no pain or injury that was identified. RN-A walked R1 back to bed. RN-A stated it was a professional standard of practice to use of a transfer belt with a resident who needed extensive assist of one. During a phone interview on 1/22/24 at 12:06 p.m., NA-E stated on 1/11/24 around 4:00 a.m., NA-E walked R1 to the toilet without a transfer belt as the transfer belt could not be found. R1 stood up from the toilet took two steps and R1 stated, I feel like my legs are spaghetti. R1 had the walker and NA-E stood to R1's left side. Then boom down R1 went. R1 hit her head and sustained a skin tear to the left elbow. R1 was assisted to the wheelchair and pivot transferred back to bed with the transfer belt. Although RN-A stated RN-A had walked R1 back to bed During an interview on 1/22/24 at 12:24 p.m., director of nursing (DON) identified R1 had a fall on 1/11/24. NA-E assisted R1 off the toilet without a transfer belt and when R1 got weak R1 fell resulting in a head strike. The use of the transfer belt with extensive assist of one staff would be a professional standard of practice. R1 fell because there was not transfer belt in use when R1's legs gave out. The facility started education with staff about the importance of transfer belt use and will be getting command hooks to put up in the bathroom where a gait belt would be available for all staff to use so there is a transfer belt always available. They had a plan in place to ensure all staff were educated on the use of transfer belts. During an interview on 1/23/24 at 9:34 am licensed practical nurse (LPN)-A any resident who is extensive assist with transfers we would use a transfer belt for safety. If a resident was weak or start to fall staff would have something to hang on to. During an interview on 1/23/24 at 9:37 a.m. occupational therapist (OT)-A identified staff should be using a transfer belt with all residents as long as they were not independent. The facility started writing on the resident whiteboards to use a transfer belt along with the residents transfer status as a cue to staff. The use of a transfer belt is our expectation. During an interview on 1/23/24 at 9:38 a.m. trained medication aide (TMA)-A stated a transfer belt should always be used for any resident who required extensive assist, because they could have problems with their balance. During an interview on 1/23/24 at 9:43 a.m. (NA)-F stated when someone required extensive assist with transfers you would always use a transfer belt. A transfer belt was used for stability and safety in case the resident got weak and fell . . During an interview on 1/23/24 at 9:47 a.m. NA-A stated a transfer belt should always be used when a resident required extensive assist with transfers. NA-A would use a transfer belt with anyone so if they get weak you have something to hang onto, it can help prevent a fall, if a resident refused the gait belt NA-A would go get the nurse. During an interview on 1/23/24 at 9:48 a.m. NA-G stated a transfer belt should be used when a resident required extensive assist with transfers. Using the transfer belt gave more support and safety, if someone's leg gives out you, have a better chance of keeping them safe. During an interview on 1/23/24 at 9:49 a.m., NA-H stated that transfer belt requirements are located in the care plan or Kardex. NA-H stated that use of a transfer belts were promoted at the facility. The facility provided undated Kardex included direction that R1 was able to ambulate short distances in R1's room with assistance of one staff, walker and transfer belt. During an interview on 1/23/24 at 9:50 a.m., NA-I stated that a transfer belt was used for any resident that does not use a machine lift. A transfer belt was used when walking residents and if a resident refused the gait belt education would be provided on transfer belt safety for the resident. During the survey resident observations and resident and staff interviews identified the facility was using transfer belts during all non-mechanical transfer that required staff assistance and the facility had corrected the non-compliance of not transferring residents without a transfer belt who required the use of a transfer belt prior to entrance on 1/17/24, prior to survey entrance. The facility policy Fall Prevention and Reduction Policy revised 8/2023, identified individual fall precautions and interventions would be developed for all residents who admit to the facility. The facility would implement appropriate gall interventions and precautions. A transfer belt policy was requested and not received.

Based on observation, interview and document review, the facility failed to appropriately assess and implement known interventions to prevent repeated falls for 2 of 2 residents (R1 and R2), who were at high risk for falls. This failure resulted in actual harm for R1 who had an unwitnessed fall and received two rib fractures. Findings include: R1 R1's admission record, indicated R1 had diagnoses of history of falls, dementia, muscle weakness and other specified cognitive deficit. R1's 5/25/22, Significant Change, Minimum Data Set (MDS) indicated R1 had severe cognitive impairment, inattention and disorganized thinking that would not fluctuate, required extensive assistance of 1 staff with Activities of Daily Living (ADL)'s and used a walker and wheelchair for mobility. R1 was frequently incontinent of bowel and bladder. R1's 7/5/22, physician visit (MD)-A) progress note identified R1 was outside enjoying the sunshine that day. She was brought back to her room and was in good spirits but quite confused. She denied any pain and had as needed pain medicine available but had not used it all month. The MD reported she had no falls and required ambulation with supervision. She was to use a wheelchair for long distances and required mechanical assist with transfers. There was no indication MD-A was aware of R1's multiple falls or identified interventions to assist in preventing further falls. R1's 7/24/22 at 9:15 p.m., Post Fall Huddle form identified a post fall huddle was not called. R1 had attempted to get to her wheelchair which was not close to her bed and was agitated earlier in the evening and had reportedly wanted to drive her car. R1's 7/24/22, progress note identified at 9:15 p.m., R1 was found on the floor by her door with her head facing upward. The back of her head was noted to be swollen. She appeared confused, had moderate pain, and was last toileted at 7:30 p.m. R1 reportedly fell when she self-transferred into the wheelchair. R1 was sent to the hospital. R1's current, undated care plan identified on 11/1/19, R1 required assistance with ADL completion and mobility secondary to dementia and weakness. R1 required assist of 1 staff for transfers, hygiene, and dressing. R1 was to be toileted every two hours and was on a toileting program. R1 was at risk for falls related to her confusion, deconditioning, gait/balance problems, incontinence, diagnosis of retinal [CONDITION(S)] (swelling of the retina which may cause [CONDITION(S)]), dementia, history of falls, right ankle pain, muscle weakness and high blood pressure. R1 was to have grippy socks on when in bed and staff were to ensure R1 had well-lit, low glare lighting and provide frequent checks. Staff were not to leave her alone in her room unless she was in her bed or recliner. They were also to encourage her to remain in common areas. A Dycem (specialized cushion to prevent accidental forward sliding) was to be placed in her wheelchair and grip strips were to be placed on the floor in front of her bed. On 7/20/22, staff were to add wheelchair pedals only when staff would need to push R1 long distances, or she would need to leave the facility. R1 was known to have a history of tripping on them during attempted self-transfer. Staff were also to ensure they placed her wheelchair in locked position close to bed when in bed beginning 7/25/22. There was no indication why the facility had identified the need for increased supervision after her numerous falls, nor if they identified R1 may need to be toileted more often than her 2 hr toileting program. During an observation on 8/1/22, at 11:48 a.m. R1 was seated in the hallway in her wheelchair holding onto a baby doll, her foot pedals were on the wheelchair and R1's feet were placed on top of the wheelchair pedals. At 4:53 p.m. R1 was observed to be in the hallway, seated in her wheelchair with her feet resting on her wheelchair pedals, holding onto a baby doll. There was no indication R1 had her foot pedals removed, so it would not create increased risk if she self-transferred. R1's 7/25/22, Fall Report identified R1 had a fall on 7/24/22. That was noted to be R1's first fall in 30 days, 4th fall in 6 months, 8th fall in 1 year and 15th fall since her admission on 8/20/19. R1 was found on the floor, lying on her back in her room at 9:15 p.m R1 denied pain at that time. When she was returned to bed, the attending nurse noted that she had swelling to the back of her head. The nurse called 911 immediately. R1 was sent to the hospital. The facility noted R1 had been in bed when they believe she got up and attempted to get to her wheelchair by herself. R1 was noted to be unable to say what she was going to do after getting in her wheelchair. She was last toileted at 7:30 p.m. The root cause of fall was determined to be restlessness and agitation likely from impaired cognition and emotional lability (tendency to shift rapidly and dramatically between different emotional states). Contributing factors identified were severe cognitive impairment, received medications such as [MEDICATION(S)] (antidepressant) and [MEDICATION(S)] (narcotic pain reliever). Contributing diagnoses were noted to be a history of falling, dementia, muscle weakness and major depressive disorder. The new fall intervention identified at that time was staff were to place R1's wheelchair in locked position close to bed while in bed. There was no indication the facility had identified the potential need for increased supervision for R1 or had identified why R1 continued to fall. R1's, 7/25/22, Falls Follow-up Notation identified the new fall intervention was to place wheelchair in a locked position close to bed. There was no indication the post fall notation identified the need for increased supervision. R1's Treatment Administration Record (TAR) for July 2022, indicated 30-minute safety checks were discontinued on 7/22/22, at 1:30 p.m. There was no indication why those checks were discontinued or how that determination was made. During an interview on 8/1/22, at 12:00 p.m. licensed practical nurse (LPN)-B stated R1's fall preventions were to have her bed in low, offer toileting every 2 hours, have her call light in reach, provide frequent rounds and give her her baby doll. LPN-B stated R1 liked to sit by the nurse's desk. I have never heard that she had any behaviors. I have not known [R1] to have any recent falls LPN-B was unaware R1 had any fractures. R1's current, undated Kardex, identified R1 preferred to get up at 7:00 a.m. and go to bed at 9:00 p.m Staff were to toilet her every two hours and document crying or weeping episodes. R1 preferred to have a baby doll for comfort. Staff were to ensure her wheelchair was in locked position next to her bed when she was in bed. Wheelchair foot pedals were to be used only for pushing [R1] for long distances or out of facility due to history of tripping on them during attempted self-transfer. There was no mention R1 should have increased supervision at times when behaviors of self-transferring were more likely to occur or that R1 may require more frequent toileting. R1's 7/25/22. at 5:30 a.m., progress note identified R1 returned from the emergency room . R1 arrived via ambulance, was alert and crying she was hurting .[MEDICATION(S)] [narcotic pain medication for severe pain] given for pain. During an interview on 8/1/22, at 11:49 a.m. with registered nurse (RN)-B, she verified she was R1's nurse for the day (8/1/22). When asked if R1 had any recent falls, RN-B stated that R1 has not had any recent falls and does not know of any resident that has had a recent fall with a fracture. RN-B stated R1's fall interventions were to make sure her bed was in a low position while R1 was in it, and to assist her with all transfers and have her call light within reach. RN-B further stated that R1 can talk but gets very confused, we try and keep her out by us to keep an eye on her. I don't think she ever self-transfers. R1's 7/25/22 at 12:50 p.m., Falls Follow-up Notation identified the interdisciplinary team (IDT) met, and R1's fall was reviewed. Physical Therapy (PT) was noted to have not worked with R1 for a long time. Staff were to obtain an order for PT to evaluate and treat and place anti-roll back breaks on wheelchair. There was no indication the facility identified the need for increased supervision or ensure interventions were appropriate. R1's progress note dated 7/28/22, identified the fall committee reviewed the fall on 7/24/22. A root cause was identified, and interventions were deemed appropriate. There was no mention the facility had identified the need for increased supervision to prevent R1's numerous falls to prevent further injury. During an interview on 8/1/22, at 1:46 p.m., nursing assistant (NA)-E verified she was familiar with R1. She stated that R1 will have behaviors like crying, she sometimes thinks no one likes her and gets very tearful and wanders. Staff were to give her a baby doll as it gave her comfort. R1 was mostly incontinent. When she's having a 'good day', she is able to tell us when she needs to go to the bathroom . otherwise we are supposed to offer toileting every 2 hours. Staff were to transfer her with 1 assist and a walker. NA-E stated recently staff had been trying to walk her. I don't think she was able to before. NA-E was not aware of any residents who had had a recent fall with a fracture, and stated, I would know if someone had a fall with a fracture, because my nurse would tell me. During an interview on 8/1/22, at 2:00 p.m., NA-D stated she was the aide responsible to care for R1. With R1's memory, she does not remember much. Sometimes she can be upset and screaming . sometimes calm and sleepy. NA-D stated R1 was a fall risk so she was not to be left alone in her room. I heard today that last week she had a fall but I didn't get any details. I don't think she got any injuries. I know her routine. When she lays down in bed, it must be in the low position. If she keeps getting up, that means she wet herself. She does not use her call light. When she's awake, we keep her in the hallway so we can keep a close eye on her. During an interview on 8/1/22, at 3:02 p.m. with the clinical manager (CM) and interim director of nursing (IDON) identified the root cause of R1's fall was she self-transferred from her bed to her wheelchair. She was last toileted at 7:30 p.m., Staff were to keep her wheelchair locked at bedside. IDON verified LPN-C was working the evening of the fall and failed to do the post fall huddle per policy and procedure. When LPN-C called her to report the fall, he should have done a post fall huddle. The IDON and CM were unaware, staff that were currently working had no information about R1's recent fall with a fracture or any new interventions related to her fall. During an interview on 8/1/22 at 4:46 p.m., LPN-C verified he worked the evening shift when R1 fell on [DATE], at 9:15 p.m He stated R1 was found outside her room into the hallway on her left side. He felt R1 may have gotten herself out of bed and walked across her room to get her wheelchair. He stated he had not identified any new or revised interventions. LPN-C agreed he failed to follow the facility's policy and did not do a post-fall huddle. When asked how R1 was acting prior to the fall, LPN-C stated during suppertime on 7/24/22 R1 was troubled at one point. She was saying, I have no one . I have no family . He tried to comfort her. R3 had come to the nurse's station and stated to R1, I have been taking care of you for years. You are my daughter. LPN-C was unable to tell if this upset R1 as she was already upset. He stated he had to deal with R3 so he was unsure what staff took R1 to bed. He believed it to be around 7:00 or 7:30 p.m., as that was the time R1 usually went to bed. During an observation on 8/2/22, at 9:25 a.m., R1 was seated near the front desk in her wheelchair with her feet resting on her wheelchair pedals holding onto her baby doll. There was no indication staff identified R1 was not to have pedals on her wheelchair as identified. During an interview on 8/2/22, at 10:34 a.m. NA-F verified she was scheduled to provide care for R1. R1 was assisted in her wheelchair from her bed at around 7:00 a.m. that morning. NA-F stated when she got R1 up at that time, her brief was wet. R1 was to be offered toileting every two hours. NA-F had been unable to toilet R1 since she got up that morning, stating she had not had a chance to do that because she had been very busy down the hall with getting residents, assisting them to get up and answer call lights. It is just me down this hallway today. NA-F was unable to articulate what fall prevention interventions were in place for R1 and was not aware R1 had any recent falls or any fractures. During an interview on 8/2/22 at 10:41 a.m., LPN-A stated she had worked at the facility for about 4 years. LPN-A stated R1 had poor cognition, was oriented to herself only and needed 1 assist for transfers. RN-A stated R1 will cry if she doesn't have her baby doll. R1 was different during the evening hours. She was known to cry saying, Mamma! R1 could get up on her own and self-propelled in her wheelchair. 9 times out of 10 we have her foot pedals on, and then she can't self-propel in her wheelchair. She was unaware of R1's rib fractures. LPN-A then asked the clinical manager (CM)-A why the intervention to have her wheelchair locked at bedside was in place and was told it was due to R1 self-transferring. LPN-A stated she did not think it would be safe for R1 to self-transfer from her bed to her wheelchair. LPN-A was unsure why R1's 30-minute checks were taken away on 7/22/22. LPN-A stated, There is usually something in the risk management communication page about a residents fall. She verified there was nothing there. During a phone interview on 8/2/22, at 11:02 a.m., NA-C stated he was working the evening of 7/24/22. R1 was in a rampage that night. She was looking her for her car keys. We tried to give her a baby doll for distraction, but it only lasted a few minutes. R1 was upset when he came to work that day. NA-C reported the day shift had told staff she had a tough day. NA-C stated they did not do a fall huddle after R1 fell . During an interview on 8/2/22, at 11:11 a.m. trained medication aide, (TMA)-A stated she was scheduled to R1's wing the evening of 7/24/22. TMA-A stated she has known R1 for years used to work with her prior to her becoming a resident. TMA-A stated R1's cognition is poor, occasionally R1 would have a fleeting moment when she remembered who TMA-A was. When she first got there that day, R1 was saying she wanted to go home. Staff tried redirection and 1:1 supervision when able. Staff also gave her some pudding to eat, and after supper she was little better. TMA-A stated I was the one that found her when she fell . I was in the little nurse's station down that hallway. I was doing some of my charting when I heard her hollering and found her on the floor in the hallway outside of her room. LPN-C assessed and performed vitals on R1. Then we got her up with a total mechanical lift and placed her back into bed. At that time, staff observed the bump on the back of her head. When TMA-A first found her, she was her lying on her left side in the middle of the hallway and her wheelchair was behind her facing towards her room. TMA-A recalled NA-A put R1 to bed and advised TMA-A he put her wheelchair across her room by the window when he put her into her bed. Earlier, R1 was upset because R3 agitated her. Usually when we put R1 to bed she stays in bed and sleeps. Right before emergency services (EMS) arrived, R1 she told TMA-A she had to go potty. TMA-A then took her to the bathroom. TMA-A stated she was not aware R1 ended up with 2 fractured ribs from the fall and stated, This is something we should be told. During an interview on 8/2/22, at 10:34 a.m. NA-F stated she was able to get R1 toileted at 11:00 a.m. and then again at 2:00 p.m., stated she will be working a double shift. NA-F further stated, I know she is care planned to be offered to be toileted every 2 hours I was very busy today and I didn't have time to do that, but I know that is what she is care planned for. During an interview on 8/2/22, at 12:49 p.m. IDON verified R1's fall on 7/24/22, was not thoroughly investigated to determine a root cause of her fall. IDON verified that she had only interviewed LPN-C and he had stated the fall was unwitnessed. The IDON stated she had not proceeded with any further investigation. The IDON stated LPN-C did not follow the facility fall policy and do a post fall huddle to determine the root cause. The IDON verified no one interviewed all the staff that worked that evening to determine an actual root cause of R1's fall, if interventions were implemented, or if increased supervision should have occurred when R1 had known behaviors. The IDON agreed a potential root cause may have been R1 needing to go to the bathroom and staff failing to anticipate her needs. The IDON stated moving forward, the facility needed to ensure 1 staff was designated to oversee the fall investigation and stated the current process was not working. IDON agreed R1's care plan intervention to keep foot pedals off was not being followed. She agreed staff should anticipate R1's needs, follow the care plan interventions, and provide increased supervision when R1 showed behaviors known to cause her to potentially self-transfer. Interview and video footage review on 8/2/22 at 6:12 p.m., of R1's 7/24/22, fall with the interim administrator, IDON and maintenance staff, it was determined R1 was brought to her room at 7:19 p.m. At 8:45 p.m. an unidentified aide was seen wheeling R1 who was dressed in a facility gown, out of her room and into the hallway. She was then seen wheeling R1 back to her room shortly after at 8:46 p.m. At 8:47 p.m., the unidentified aide was seen leaving the room. At 9:03 p.m. R1 walked independently out of her room pushing her wheelchair. R1 appeared to have tried to turn her wheelchair around in her doorway, lost her balance, and fell backwards onto the floor in the hallway, hitting the back of her head on the floor. R1 then turned to her left side while she was lying on the floor and placed her hands under the left side of her head. NA-A was the first on the scene and placed a pillow under her head. LPN-C was seen bringing equipment to do R1's vital signs. The IDON stated the intervention to keep R1's wheelchair in a locked position by her bed may not be appropriate after watching the video footage. The IDON verified she was not aware that R1 could get up on her own and walk. R2 R2's 7/22/22, Client Coordination Note Report (hospice note) identified the hospice nurse got to R2's room at 4:30 p.m. and found R2 on the floor screaming. 2 facility staff came and used a Hoyer lift to get R2 into the bed. No fracture was identified at that time. R2 could get up and move around in her wheelchair. The hospice nurse asked facility staff to give R2 some [MEDICATION(S)] (narcotic pain medicine) and [MEDICATION(S)] (used for anxiety and muscle relaxation). The facility nurse stated R2 had no current orders for that. Verbal orders were obtained for the [MEDICATION(S)] and [MEDICATION(S)] which were given to the facility nurse so they could update it in their system. The facility nurse gave R2 the [MEDICATION(S)] and [MEDICATION(S)] but R2 proceeded to spit it out. A new hospital bed with an air mattress and a fall floor mat was ordered. R2 was brought to the dining room for dinner and ate 100% of her dinner. R2's admission record, indicated R2 had diagnoses of dementia with behavioral disturbance, anxiety disorder, low back pain, unspecified hearing loss, mixed incontinence, and [CONDITION(S)] (eye disease leading to [CONDITION(S)]), disorientation, abnormalities of gait (walking) and mobility and muscle weakness. R2's Significant Change, Minimum Data Set (MDS), dated [DATE], indicated R2 had severe cognitive impairment, inattention that came and went, hallucinations, and delusions. R2 required extensive assistance of 1 staff with ADL's and used a wheelchair for mobility. R2 was frequently incontinent of bowel and bladder. R2 had 1 fall with no injury noted. R2's 7/19/22, Fall Risk Assessment identified R2 was at risk for falls and the clinical suggestions were to utilize a toileting program. R2's 7/22/22, Fall Risk Assessment identified R2 was at risk for falls and clinical suggestions were to now utilize a toileting plan with addition of non-skid slippers worn for ambulation. Review of R2's Treatment Administration Record (TAR) for July 2022, indicated 30-minute safety checks that were discontinued on 7/22/22. R2's 7/22/22 at 1:46 p.m., progress note identified the IDT met and agreed 30-minute checks could be removed due to the intervention of adding anti-roll back breaks have been added to the wheelchair. R2's current, undated care plan identified R2 had an ADL self-care performance deficit related to impaired balance, limited mobility, Intervention to offer toileting every 2 hours. R2 had a history of falls due to dementia, incontinence, anxiety disorder, history of a stroke, [CONDITION(S)], and abnormal gait. Staff were to encourage R2 to be in public places when restless or agitated, wear gripper socks while in bed, keep bed in lowest position, offer to use toilet or offer ambulation when she became agitated, ensure her environment was free of clutter, and apply anti-roll breaks to wheelchair. 30-minute checks due to high risk of falls were initiated on 4/12/20 but discontinued on 7/22/22. Staff were to ensure a fall mat was beside her bed, initiated on 7/23/22. R2's current, undated Kardex, identified R2 preferred to get up at 8:00 a.m. and go to bed at 8:00 p.m Staff were to offer toileting every hour or when R2 became agitated. A hi/low bed was ordered and had arrived from hospice. Staff were to keep the bed in the lowest position, ensure she wore gripper socks when in bed, and ensure her fall mat was at her bedside. During an observation on 8/1/22, at 1:35 pm, R2 was lying on her back in her bed. A blue fall mat was located under her bed and not beside her bed as care planned. R2 was covered with a blanket but was noted to have red shoes on and not wearing gripper socks. A pillow was placed on the left side of R2's back where the soft touch call light was also located, out of R2's reach. Her walker and wheelchair were not within R2's reach. During an interview on 8/1/22, at 1:42 p.m. NA-E stated that most of the time R2 would become really irritated. If she tries to self-transfer, that means she has to go to the bathroom. She had some falls, but it was usually on the evening shift. R2 had liked to wander around. I think she is supposed to be checked every hour, but I am not sure if the evening staff know that or not. When NA-E would put her to bed or lay her down for a nap, she would place a pillow on her left side for positioning and then put her soft touch call light on top of that pillow. NA-E recalled R2 had a mat to put next to her bed on the floor but thought that was to be done only during the evening shift, Not for our shift though. R2's 7/25/22, progress note identified the IDT team met and falls were reviewed since 5/1/22. The care plan was determined to be updated and appropriate. There was no indication the facility audited interventions to determine if staff were carrying out the interventions to prevent further falls. During an observation and interview on 8/1/22, at 1:48 p.m. R2 was still noted to be sleeping in her bed, the fall mat was now next to her bed and not underneath it. Clinical consultant (CC)-A and CC-B were noted to be in the hallway outside the room, a tray table with printed documents was noted to sitting on top along with an electronic device. CC-B verified she just put the mat down next to R2's bed. CC-B stated it is supposed to be there it is on her care plan. CC-A stated they were now performing the fall audits. During an interview on 8/1/22, at 2:06 p.m. NA-D stated that R2 was not known to lay down. She liked to wander around from room to room and staff walked her with a walker. She will just get up and start walking so we have to keep an eye on her. She is a high fall risk, but no recent falls that I know of. When we lay her down at night she will stay in the bed unless she has to go to the bathroom. During an interview on 8/1/22, at 2:46 p.m. CM-A was present and IDON identified no fall huddle was completed after the fall R2 had on 7/22/22, so the IDON could not determine a root cause. LPN-C was the nurse responsible to do it. The IDON stated she had re-educated LPN-C. The IDON verified she did not go back and interview staff that were working the evening of the fall to try and determine a root cause. The IDON recalled she did not identify any new interventions or review previously implemented interventions to determine if staff were implementing them or if they needed to be revised, because she was unaware what the root cause was. When IDON was notified that none of the staff that were working today were aware that R2 had a recent fall, the IDON stated, It may be because there was no new intervention put in her care plan, and it wouldn't have showed up on the communication board. IDON was informed that R2's care plan was not being followed during observations of her fall mat not being placed next to the bed and the appropriate footwear applied. The IDON agreed staff should follow the care plans and oversight was needed to ensure investigations, analysis of interventions, and auditing were critical to preventing further falls. Additional interview on 8/2/22, at 11:58 a.m. IDON stated regarding R2's fall, she identified her fall occurred at approximately 4:30 p.m The IDON was not sure what time R2 was assisted to bed for her nap but guessed around 2:00 p.m R2 was last offered toileting at 11:58 a.m She was unsure if she was incontinent at the time of her fall as that was not noted by staff in the incident report. that was not identified. She now determined the root cause of R2's fall identified R2's call light was on. R2 may have had to go to the bathroom. R2 wanted to get up she had been in bed for 3 hours after she was done with her nap. She stated she had added an intervention to wake R2 daily at 3:00 p.m Review of the July 2022, Fall Prevention and Reduction policy identified individual fall precautions and interventions were to be developed for all residents who were admitted to the facility. All falls were to be reviewed, and preventative measures taken to decrease falls whenever possible to prevent injury. Interventions were to be identified related to the residents' specific risks and causes to reduce falling and to try to minimize complications from falling. All residents were to be assessed for fall risk. All falls were to be analyzed to determine the root cause of the fall. Procedure for staff to follow after a fall occurred were: 1. A licensed nurse will evaluate resident's pain, range of motion and level on consciousness or change in cognition level before moving or assisting resident to a safer position. 2. Keep resident comfortable and avoid moving if there is suspected fracture. 3. A resident on the floor should not be lifted from the floor. Mechanical lift equipment is to be used to lift a resident to a chair or a bed. 4. Vital signs will be completed after all fall events; if possible, complete orthostatic blood pressure comparison. 5. If resident is diabetic, blood glucose levels should be determined. 6. Perform a skin and wound check. 7. If on anticoagulant and head strike suspected, or falls unwitnessed, note last INR reading and current dose. 8. If fall is unwitnessed or resident hits head, neurological checks will be initiated. 9. Complete post fall huddle with staff working on the unit where the resident fell . 10. Seek immediate medical care if needed: notify provider and seek orders or call 911 if the situation demands the need. 11. Notify the provider immediately for all resident falls. 12. Notify the administrator and DON immediately if the resident has a change in condition after a fall or resident hit their head. 13. Notify the administrator and the DON by office phone and leave message if no injury from the fall, no head strike. 14. Notify the administrator and the DON immediately if the resident requires transport to the hospital within 72 hours of a fall. Includes evenings, nights, and weekends. 15. Contact the resident representative on same shift for all resident falls. 16. Document the fall in risk management using appropriate fall progress note. 17. Determine the root cause as to why the resident fell and implement intervention specific to the cause of the fall. 18. Start immediate intervention to attempt to prevent further falls. (See fall intervention list.) 19. Update the care plan and the Kardex with the fall intervention. 20. Hall nurse to complete the fall risk assessment after the fall to identify the new or changing risk factors for resident fall. 21. Hall nurses begin documentation for Falls Follow up Notation a minimum of once per shift for 72 hours. Complete VS ROM, neurological checks (if required). 22. Nurse Manager for designee is responsible to ensure the completion of the Risk Management for a fall. Procedure for Fall Risk Assessment included in the policy was for staff to: 1. Completed a fall risk assessment upon admission, prior to annual MDS, quarterly (reviewed), significant change and following a resident fall. 2. Implement appropriate interventions/precautions. All member of the interdisciplinary team will participate and contribute to the plan of care with resident specifics fall reduction efforts. 3. Notify the resident representative and medical provider as appropriate.

Based on observation, interview and document review, the facility failed to complete comprehensive fall assessments with root cause analysis, identify patterns of falls, and failed to consistently implement immediate individualized appropriate interventions to prevent additional falls for 3 of 25 residents (R8, R5, R4), who were at high risk for falls. This deficient practice resulted in an immediate jeopardy (IJ) when R8 sustained a fractured neck and ultimate death, R5 who sustained degloving of the hand and a facial laceration requiring emergency room visit, and R4 who sustained a fall with a pelvic fracture. In addition to the resident(s) in immediate jeopardy, the facility failed to comprehensively assess each fall for R6 and failed to provide prevention interventions to decrease future falls resulting in the potential for harm to R6. The IJ began on [DATE], when R8 had not been comprehensively assessed and individualized apropriate interventions were implemented. The interim administrator and interim director of nursing (IDON), were notified of the IJ on [DATE], at 5:19 p.m. The IJ was removed on [DATE], at 4:20 p.m. but noncompliance remained at the lower scope and severity level 2 at an E which indicates a pattern and no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings included: R8's, hospital, After Visit Summary (AVS) dated [DATE], identified R8 was hospitalized from [DATE], until [DATE], for increased falls with [CONDITION(S)], new medications to start are [MEDICATION(S)] (medication to help with low blood pressure that can cause severe dizziness or [CONDITION(S)]), and was not able to walk due to [CONDITION(S)]. R8's admission record, identified R8 was admitted on [DATE], with diagnoses that included history of falling, [CONDITION(S)], Lewy bodies dementia, restless leg syndrome, abnormalities of gait and mobility, and long term use of anticoagulants. R8's Fall Risk Evaluation, dated [DATE], identified R8 was a moderate risk for falls, and indicated interventions of rubber soled shoes for walking and utilize a toileting plan. R8's admission, minimum data set (MDS), dated [DATE], identified moderate cognitive impairment, exhibited delusions and other behaviors for ,d+[DATE] days that significantly interfered with his care and activities. R8 required extensive assistance with activities of daily living (ADL)'s and used a wheelchair for mobility. R8 was occasionally incontinent of bowel and bladder. Further identified R8 had a fall 1 month prior to admit, 1 fall without injury and 1 fall with major injury. R8's, Physical Therapy (PT) Treatment Encounter Note, dated [DATE], identified that R8 reported weakness upon standing for short periods of time. R8's blood pressure was taken in a seated position with a reading of ,d+[DATE], upon standing his blood pressure reading was ,d+[DATE], after 3 minutes of standing blood pressure rechecked with a reading of ,d+[DATE]. (Normal blood pressure reading is ,d+[DATE]). R8's medical record between [DATE] to [DATE], identified R8 had sustained three falls. Dates of the falls were [DATE], which resulted a lumbar spinal fracture, [DATE], and [DATE]. After each fall event, R8's record lacked a comprehensive assessment for causal factors, identification of probable root cause, and immediate appropriate interventions to prevent and/or mitigate risk of recurrent falls. In addition, it was not evident the care plan and/or interventions were evaluated for effectiveness, nor evident the care plan was reviewed or revised after the fall. Following R8's fall on [DATE], there was no indication R8 had been assessed for injuries nor evidence the physician was notified. R8's fall on [DATE], resulted in death according to his death certifcate. R8's Fall Report, dated [DATE], at 6:30 a.m. identified R8 had an unwitnessed fall in the bathroom and was found to be incontinent, immediate action taken was R8 was reoriented to the call light usage and hourly safety checks were started. R8's incident report identified the aforementioned information. Despite R8 being found in the bathroom and incontinent, it was not evident R8's toileting plan was assessed or revised. R8's Physician Progress note, dated [DATE], identified that prior to admit that R8 had been hospitalized for recurrent falls and had hematuria (blood in the urine) following a transurethral resection of bladder tumor. R8 had several episodes of bilateral limb shaking and decreased level of consciousness and was found to have significant positive [CONDITION(S)]. Additionally, describes that R8 had a fall overnight with some back pain this morning that is congruent with findings of sacral and S4 fractures seen back in early March. R8 had reported he needed to use the restroom, could not find his call button, he attempted to get up on his own, and fell from standing height landing on hips without injury. Physician orders were updated to include staff to complete hourly safety checks, due to high risk for falls and history (of falls). R8's fall care plan, dated [DATE], identified R8 was at high risk for falls related to confusion, deconditioning, and [CONDITION(S)]. Corresponding interventions included the following: anticipate and meet R8's needs, be sure the call light is within reach and encourage to use it for assist as needed, waist high compression stockings on in AM and off at HS (bedtime), and hourly checks for safety. R8's progress noted dated [DATE], at 9:50 p.m. identified that R8 had increased confusion and staff had to do a 1:1 with R8 since 9:00 p.m. because R8 was caught self-transferring and ambulating in his room three times after supper and had complained of chest pain, increased respirations, shaking and acting non-sensible at times. At 10:30 p.m. R8 was sent to the emergency department (ED) for a change in condition. R8 returned to facility at 3:50 a.m. R8's AVS included an order for CT Pelvis Lumbar Spine on [DATE]. R8's physician progress note dated [DATE], indicated that R8 had an emergency room visit over the weekend related to increased confusion after a fall, imaging was negative for an intracranial bleed, there was a new L1 (lumbar region of the spine) compression fracture and some interval healing at S4 (sacral region of the spine). R8's [MEDICATION(S)] (antiparkinsonian drug) was decreased with thoughts that this could be causing R8's [CONDITION(S)]. R8's care plan was not revised to address the new lumbar fracture. R8's progress note dated [DATE], at 11:59 p.m. identified that shortly before supper R8 had been fidgety and busy, was self-transferring, pulling his call light out of the wall and trying to fix things. R8 was also noted to be dragging his furniture around the room, could not explain to staff why he needed to move these things stating it just needed to be done, was also found walking while holding onto his curtain. R8 was found on the floor in his room seated on his bottom. R8's record did not include any other additional information pertaining to the fall, nor evident the physician was notified. R8's rogress note dated [DATE], identified that at 8:45 a.m. R8 was found by a nurse on the floor in his bathroom. R8 was bleeding from a laceration to his left forehead and had a small laceration under his right eye, R8 complained of back pain and was unable to answer questions per his baseline, staff stayed with R8 until emergency services arrived for transport by ambulance to the ED. R8's Minnesota Document of Death was reviewed, and indicated that R8 died at the hospital on [DATE], at 5:42 p.m., causes for death indicated, complications of Lewy Body Dementia and [MEDICATION(S)] force injury to the head and spine from a fall. Date of injury was [DATE], at 8:50 a.m. Injury occurred from a fall at standing height. During an interview on [DATE], at 1:25 p.m. with the clinical manager (CM) and interim director of nursing (IDON) present, CM verified that R8 had 3 falls during his stay from [DATE], to [DATE], with no root cause analysis, and no prevention interventions were put in place. CM was not aware of the second fall that occurred until it was brought to her attention by the surveyor. CM further verified R8 was not assessed for injury, no comprehensive assessment was completed and failed to root cause or place prevention interventions for future falls. CM was aware that R8's last fall had resulted in a neck fracture and had passed away. R5's admission record, identified R5 had diagnoses of psychophysical visual disturbances (visual disturbance in which a person with partial or severe [CONDITION(S)] experiences visual hallucinations), [CONDITION(S)] ([CONDITION(S)] disease that causes muscle pain and stiffness), [CONDITION(S)], [CONDITION(S)] (eye condition that distorts or causes loss of central vision), [CONDITION(S)] (eye diseases that can cause vision loss and [CONDITION(S)]), and [CONDITION(S)]. R5's significant change, MDS, dated [DATE], identified R8 had significant cognitive impairment, exhibited delusions, did not walk, and required extensive assistance of ,d+[DATE] staff with ADL's and used a wheelchair for mobility. R5 was occasionally incontinent of bowel and bladder and had 1 fall with injury. R5's fall care plan dated [DATE], identified R5 was at risk for falls characterized by history of falls/injury, with multiple risk factors related to diagnoses of hypertension, history of fractures, [CONDITION(S)], medication use, required assist with ADL's and the use of an assistive device. Interventions were to: anticipate and meet R5's needs, be sure the call light is within reach, transfer and change positions slowly, wear proper and non-slip footwear, reinforce need to call for assistance, have commonly used articles within easy reach and check R5 frequently to ensure safety. R5's care plan did not identify additional and/or revisions to fall interventions after [DATE]. R5's fall record was reviewed between [DATE], to [DATE]. R5's record identified R5 had falls on [DATE], and [DATE], in which both caused injury. R5's record lacked a comprehensive assessment for causal factors/root cause, was not evident immediate interventions were developed or implemented. R5's Fall Report dated [DATE], at 7:40 a.m. identified R5 was being transferred with an EZ-stand (a type of mechanical lift to assist a patient to and from one area to another) with the help of a nursing assistant (NA) to get to the bathroom. NA stated when she lifted R5 up, R5 lifted her feet up causing her to fall to her knees on the EZ-stand foot plate. This fall resulted in a skin tear to her right lower leg. R5's record did not include a comprehensive transfer assessment before or after the fall to ensure safety during transfers with a standing mechanical lift. R5's physician note dated [DATE], identified that R5 has had ongoing decline since her COVID diagnosis in [DATE], there was noted functional decline prior to this but has since increased. R5 has gone from the use of an EZ-stand for transfers to a Hoyer lift (full body lift). R5's Incident Audit Report, dated [DATE], identified that R5 was found at 3:30 p.m. on the floor lying against the tray table with the power lift chair tipped on top of her, pressure dressing applied to right wrist and 911 was called R5 was transported to the ER. Injury was a skin tear to the back of the right hand and unable to determine the laceration to the face. R5's [DATE] treatment administration record (TAR) identified an order for hourly checks while in the recliner from [DATE], to [DATE]. On [DATE], the order was changed to hourly checks for safety. The record did not identify why the order was changed or identify when the recliner was removed. R5's progress note dated [DATE], identified that the fall from [DATE], at 3:30 p.m. identified R5 sustained a degloving (happens when a large piece of skin and the layer of soft tissue right under it partially or completely ripped from your body) injury to her right hand and an injury to the right side of her face and scalp. Root cause of fall was R5 did not use her call light for assistance and improper use of the lift chair. The intervention that was identified was to remove the recliner and use only the Broda chair, care plan updated. R5's care plan was not updated per the progress note and according to the June TAR documentation, R5 used the recliner on [DATE], [DATE], and [DATE]. During an observation and interview on [DATE], at 3:09 p.m., R5 was seated in her Broda chair in her room. A large L-shaped reddened scar was observed on the top of R5's right hand. R5 stated, Oh, I think it got squashed in something, then they had to wrap it. R5 put her right hand out in front of her and stated, maybe they should rewrap it. R5 indicated she had not had any falls, I have been pretty lucky. R5 stated she did not have pain, but had a problem with her eyes, I am going blind, it's been really hard to deal with and has been going on for a couple of years now, there is nothing they can do about it. During interview on [DATE], at 11:59 a.m. with CM and IDON present. CM verified that R5 had 2 falls that were not appropriately root caused, prevention interventions were inappropriate and not updated to the care plan. CM stated R5 had impaired cognition and sounded like the first fall R5 did not have the leg strap used for the EZ-stand transfer and that may have contributed to the fall. CM indicated R5 was not reassessed by therapy to determine if the leg strap should be used after the fall. R5 was eventually changed to a Hoyer lift for transfers, and thought the date was maybe [DATE]. In regard to R5's second fall on [DATE], CM indicated R5 may have had access to the remote in her recliner which may have caused her last fall and was not sure if the recliner had been removed from R5's room as it was not updated on the care plan. R4's admission record, identified R4 was admitted on [DATE], with diagnoses of history of falling and right femur fracture, dementia with Lewy bodies, bilateral hearing loss, extrapyramidal and movement disorder (involuntary or uncontrollable movements such as tremors or muscle contractions caused by side effects from certain medications), and abnormal involuntary movements. R4's significant change, MDS, dated [DATE], identified R4 had moderate cognitive impairment, and required extensive assistance of one staff with ADL's and used a walker and wheelchair for mobility. R4 was frequently incontinent of bowel and bladder and had 2 or more falls with no injury. Review of R4's, fall risk assessments, identified they were done on the follow dates, [DATE], [DATE], and [DATE], identified R4 was at risk for falls and the clinical suggestions were to utilize a toileting plan. R4's care plan, dated [DATE], identified R4 was at high risk for falls characterized by history pf falls/injury, multiple risk factors that include history of fractures, [CONDITION(S)], medication use, required assist with ADL's and use of an assistive device. Interventions were to: anticipate and meet R4's needs, be sure the call light is within reach, transfer and change positions slowly, wear proper and non-slip footwear, reinforce need to call for assistance, have commonly used articles within easy reach and check R4 frequently to ensure safety. Review of R4's TAR's from [DATE], to [DATE], identified hourly safety checks. Review of R4's care plan identified no new interventions added since [DATE], which was PT/OT consult if needed. R4's record reviewed from [DATE], to [DATE], identified R4 had five falls. Every fall lacked a comprehensive assessment to determine identification of root cause/causal factors for implementation of appropriate immediate interventions to prevent falls and/or mitigate the risk. The last fall on [DATE], resulted in a right pubic fracture, five day hospitalization and a decline in her ADL's with significant pain requiring narcotic medication to keep pain under control. R4's progress note dated [DATE], identified at 7:00 p.m. R4 was found lying on her left side facing the bedroom door with her head towards the bathroom, R4 stated she was trying to get into her wheelchair, lost her balance and fell , intervention was reminder to use her call light. R4's progress note dated [DATE], identified at 3:30 a.m. R4 was found lying on the floor just in front of her door entry, R4 was assessed, brought to the bathroom and assisted back to bed. R4's Fall Follow Up Notation dated [DATE], (follow up fall from [DATE]) identified a root cause of not asking for assistance. R4's Falls Initial Notation dated [DATE], R4 was found on the floor in her room at 10:15 p.m., no root cause identified, prevention intervention was to place her wheelchair next to her bed (intervention was not identified in the care plan). R4's progress note dated [DATE], at 8:00 p.m. identified that R8 fell attempting to get out of her wheelchair. R4's progress note dated [DATE], identified a follow-up for a fall on [DATE], root cause identified as not using her call light for assist. R4's care conference note dated [DATE], identified R4 to have moderate cognitive impairment with noted delusions. R4 liked to be up at 6:00 a.m. and in bed by 10:00 p.m. R4's progress note dated [DATE], identified R4 experienced a bit of dizziness after breakfast and was assisted to lay down in bed. R4's progress note dated [DATE], identified that at 1:30 p.m. R4 was found flat on her back leaning towards the left side of the door. R4 had ,d+[DATE] pain in her head, left hip, lower back and spine. R4 was oriented to self only. At 2:00 p.m. paramedics arrived to transport to the hospital. At 10:55 p.m. the hospital notified the facility that R4 had a pelvic fracture. R4's Incident Audit Report dated [DATE], identified that R4 tripped when she was trying to go to her bed from her wheelchair, (does not identify what R4 tripped over), prevention intervention was to maintain a clear pathway in her room. R4's progress note dated [DATE], identified R4 returned from the hospital on a stretcher at 3:45 p.m. with a pain rating of ,d+[DATE] with movement. R4's care conference note dated [DATE], identified that R4 is now a Hoyer lift for transfers, takes [MEDICATION(S)] for her pain, and on occasion will experience delusions and hallucinations. Will start PT and OT. During an observation on [DATE], at 4:10 p.m. R4 was noted to be lying on her back in bed, covered with a light quilt with her eyes closed. Bed is in low position and had grip tape strips on the floor in front of the bed. R4's soft touch call light was noted to be lying at the bottom of the bed on R4's left hand side out of her reach. During an observation and interview on [DATE], at 3:18 p.m. R4 was noted to be lying in a low bed with the head of the bed slightly elevated. R4 stated she had pain fromy falling; her elbows both ached, her heels both ached, and this all started when her hips started hurting. R4 indicated her hips hurt from the fall, she hurt her pelvis, and her pain was managed pretty well. During an interview on [DATE], at 10:40 a.m. licensed practical nurse (LPN)-A stated the reason for R4's falls was mostly because she self-transferred, she liked to try and get herself into bed, and they try to keep her involved in activities. Her cognition has declined, especially her short-term memory, sometimes she will put her call light on and forget why she put it on. She does not utilize her call light very often since her memory had declined. During an interview on [DATE], at 10:44 a.m. nursing assistant (NA)-A stated R4 was more confused than she used to be. NA-A explained R4 would fall because she self-transferred especially if she has to go to the bathroom or when she tries to get to her bed. For interventions we try and get her in her bed, offer toileting every 2 hours. NA-A indicated an unawareness if scheduled safety checks were in place, stated she would have been notified by a nurse if there was safety checks. As far as R4's cognition goes I would say she is more confused. During an interview on [DATE], at 3:26 p.m. NA-B stated he has worked at the facility for 2 months, was assigned to work as a float (not assigned a specific group of residents) and would assist with R4 as needed. NA-B stated R4 had at least one fall and thought her fall interventions were to make sure her floor was not slippery, keep the bed in low position and do every 15 minute checks. NA-B indicated this was done for all residents who had falls (15-minute checks could not be verified as completed in R4's record). During an interview on [DATE], at 3:27 p.m. registered nurse (RN)-A verified he was the nurse for R4 for the evening shift today and was the nurse working on [DATE], when R4 last fell . RN-A stated R4 was a high fall risk, her fall intervention was every one hour checks which nurses and NA's were responsible for. RN-A was unable to figure out how to access R4's care plan in order to verify the fall interventions in the electronic health record (EHR). RN-A stated R4 was confused and thought staff had to keep reminding R4 to use her call light. During an interview on [DATE], at 3:36 p.m. NA-C stated this was his second day working the floor and was scheduled to work the floor that R4 resided on for the evening shift. NA-C was not aware if R4 ever had any falls and was not able to articulate any of R4's fall interventions. NA-C was able to state R4 was currently upgraded from a Hoyer lift to an EZ-stand for transfers, NA-C thought that R4 maybe had a broken hip. During an interview on [DATE] at 11:37 a.m. CM verified R4 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. CM stated R4's fall on [DATE], resulted in a right pubic fracture resulting in hospitalization for 4 days, the falls were not appropriately root caused and interventions were not put in place, or updated to the care plan. IDON verified R4's care plan interventions had not been updated since [DATE], and stated, we will be having some education on making sure the nurses are more knowledgeable on how to update a care plan. R6's admission record, identified R6 had diagnoses of history of falling, repeated falls, dementia with behavioral disturbance, [CONDITION(S)], ataxic gait, [CONDITION(S)] and collapse, mixed receptive-expressive language disorder, and collapsed vertebra in lumbar region. R6's significant change MDS, dated [DATE], identified moderate cognitive impairment, required supervision with eating, limited assist of 1 with bed mobility, walking and locomotion, required extensive assist of 1 with transfers, dressing, toileting and hygiene. Balance during transitions and walking identified that R6 is not steady but able to stabilize without human assistance with the following: moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet and surface to surface transfer, used a walker for mobility. R6 was frequently incontinent of bowel and bladder and has had 2 or more falls without injury. R6's discharge assessment, dated [DATE], identified R6 had 2 or more falls without injury and had a planned discharge to another nursing home. R6's care plan for [DATE], to [DATE], with accurate revision dates was requested and not received by the facility after multiple requests. The care plan that was provided identified interventions with a revision date of [DATE], after the resident had been discharged . The care plan identified R6 was at high risk for falls related to gait/balance problems due to a history of falls prior to admission, hypertension, history of TIA's, [CONDITION(S)], [CONDITION(S)], diabetes, dementia, depression, weakness, and ataxic gait, in addition R6 had a history of falls with a lumbar fracture, will frequently self-transfer without walker and frequently does not use call light or ask for assist. Interventions dated [DATE] included anticipate and meet needs, assist to keep clutter off the floor in the bathroom, be sure call light is in use and remind R6 to use it, ensure to wear gripper socks when in bed, ensure shoes are within, reach grip strips in front of recliner and on the floor next to bed Intervention that included a discernable implementation date included the following: -Dycem in recliner (start date [DATE]) -Hourly safety checks (start date [DATE]) -half-hour checks (start date [DATE]) -Toilet plan identified to check and change for incontinence every 2 hours, offer to go to the bathroom (start [DATE]) R6's physician visit dated [DATE], was reviewed and indicated that R6 had fallen at least 7 times in 2021, and again on [DATE]. Review of R6's fall risk assessments indicated R6 was at risk for falls and were completed on the following dates, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The clinical suggestions were to utilize, personal/pressure sensor alarms and nonskid footwear for use with ambulation. Review of R6's medical record identified, R6 had seven falls between [DATE], to [DATE]. All falls were unwitnessed and in her room. All falls lacked a comprehensive assessment, lacked identification of accurate root cause/causal factors, was not evident immediate interventions were implemented, and the care plan was not revised. R6 did not sustain any significant injuries. R6's fall record documentation included the following: -[DATE], at 5:56 a.m. R6 was found on her right side on the floor in her room, bump noted to the back of her head and R6 refused to go to the ER, did not have shoes on and stated she was trying to get into the recliner. Root cause was R6 failed to have gripper socks on and failed to use her call light, and no new intervention was provided. -[DATE], at 8:00 p.m. R6 was found on the floor in her bathroom, had told staff she was feeling ill and had an emesis. Root cause identified as R6 failed to use her call light, no intervention provided. -[DATE], at 4:37 p.m. R6 was found on the floor between her bed and recliner. Root cause identified as R6 failed to use her call light, no intervention provided. -[DATE], at 9:00 p.m. R6 was found lying in the middle of her floor, complained of level ,d+[DATE] pain to her right upper arm. R6 was walking from her bathroocm to her closet carrying long pajamas. Root cause identified as R6 failed to use her call light, no intervention provided. -[DATE], at 10:45 p.m. R6 was found on the floor in front of her recliner, R6 stated she slid out of her chair, does not identify if Dycem was used per her care plan. R6 was noted to be incontinent at the time. Root cause identified as R6 failed to use her call light, no intervention provided. -[DATE], at 8:30 p.m. R6 found sitting on the floor of her room in between the closet and her recliner with her back against the wall, stated she was trying to grab something out of the closet. R6 was noted to be oriented to person and situation only per her baseline. Root cause identified as R6 did not ask for assist and was trying to get something out of the closet, no new prevention intervention was identified. -[DATE], at 5:47 p.m. R6 could be heard from the hallway calling for help, was found in her room on the doorway of the bathroom floor, R6 complained of pain in her right upper arm. Root cause identified as R6 failed to use her call light, no intervention provided. During interview on [DATE], at 11:06, a.m. with CM and IDON present. CM indicated after a resident would have a fall, the floor nurse would immediately assess the resident for injury, when safe the resident would be transferred with a Hoyer lift to either the chair or the bed. The floor nurse would be responsible for the documentation in the record, which would include assessment, identification of root cause, and the new intervention. The care plan would then be updated to reflect the new intervention. All department heads meet every morning Monday through Friday to discuss incidents in risk management, this would include falls. CM further stated we don't really discuss the root cause of falls, there is not a section in risk management for that, we never really discuss that. The floor nurse is responsible for that. During an interview on [DATE], at 1:51 p.m. with the CM and IDON present, CM verified that R6 had 7 falls during her stay from [DATE], to [DATE], with no root cause analysis, and no prevention interventions that were put into place. CM further verified this by looking at the dates on R6's care plan with no new interventions noted. CM stated that R6 had a planned discharge to another nursing home that happened on [DATE]. The immediate jeopardy that began on [DATE] was removed on [DATE], at 4:20 p.m. when the facility educated their staff on the policy and procedures related to the fall process, R4 and R5's falls were comprehensively assess and care plans were reviewed and revised with appropriate interventions. In addition residents were identified that were at high risk for falls and assessments were completed with necessary care plan revisions. Noncompliance remained at the lower scope and severity level 2, an E-scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Facility Policy, Fall Prevention and Reduction, reviewed ,d+[DATE], indicated, Individual fall precautions and interventions will be developed for all residents who admit to a facility. All falls will be reviewed, and preventative measures will be taken to decrease falls whenever possible to prevent injury. Interventions will be identified related to the residents' specific risks and causes in order to reduce falling and to try to minimize complications from falling. All residents are assessed for fall risk. All falls will be analyzed to determine the root cause of the fall. Procedure for Resident Fall: 1. A licensed nurse will evaluate resident's pain, range of motion and level on consciousness or change in cognition level before moving or assisting resident to a safer position. 2. Keep resident comfortable and avoid moving if there is suspected fracture. 3. A resident on the floor should not be lifted from the floor. Mechanical lift equipment is to be used to lift a resident to a chair or a bed. 4. Vital signs will be completed after all fall events; if possible, complete orthostatic blood pressure comparison. 5. If resident is diabetic, blood glucose levels should be determined. 6. Perform a skin and wound check. 7. If on anticoagulant and head strike suspected, or falls unwitnessed, note last INR reading and current dose. 8. If fall is unwitnessed or resident hits head, neurological checks will be initiated. 9. Complete post fall huddle with staff working on the unit where the resident fell . 10. Seek immediate medical care if needed: notify provider and seek orders or call 911 if the situation demands the need. 11. Notify the provider immediately for all resident falls. 12. Notify the administrator and DN immediately if the resident has a change in condition after a fall or resident hit their head. 13. Notify the administrator and the DON by office phone and leave message if no injury from the fall, no head strike. 14. Notify the administrator and the DON immediately if the resident requires transport to the hospital within 72 hours of a fall. Includes evenings, nights and weekends. 15. Contact the resident representative on same shift for all resident falls. 16. Document the fall in risk management using appropriate fall progress note. 17. Determine the root cause as to why the resident fell and implement intervention specific to the cause of the fall. 18. Start immediate intervention to attempt to prevent further falls. (See fall intervention list.) 19. Update the care plan and the Kardex with the fall intervention. 20. Hall nurse to complete the fall risk assessment after the fall to identify

Based on interview and document review, the facility failed to ensure staff were aware of resident food allergies for 1 of 3 residents (R3) reviewed for food allergies. R3 was served a Candy Bar Cheesecake dessert which contained chopped Reese's Peanut Butter Cup and Butterfingers candies causing an [MEDICATION(S)] reaction requiring Benadryl and an [MEDICATION(S)] at treatment at the facility, and R3 was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ). The IJ began on 5/18/22, at lunch time when R3 was served a lunch tray which included a Candy Bar Cheesecake dessert containing Reese's Peanut Butter Cup and Butterfingers candies. R3 unknowingly ate approximately half of the dessert which contained peanut allergens and this caused a severe allergic reaction requiring immediate interventions including: 50 milligrams (mg) of Benadryl (antihistamine), use of an [MEDICATION(S)] (an auto-injectable device that delivers the drug [MEDICATION(S)], used when someone is having an allergic reaction) and ultimately R3 was sent to the emergency department (ED) due to progressing [MEDICATION(S)] (a severe, potentially life-threatening allergic reaction). The administrator and director of nursing (DON) were informed of the IJ on 5/19/22, at 5:07 p.m. The IJ was removed on 5/20/22, at 1:20 p.m. but scope and severity remained at a level E, no actual harm with potential for more than minimal harm. Findings include: R3's Diagnosis List printed on 5/20/22, indicated R3 diagnoses included muscle weakness, [CONDITION(S)] fibrilation (an irregular, often rapid heart rate that commonly causes poor blood flow), and [CONDITION(S)] (commonly known as [CONDITION(S)]). R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact. R3's Care Plan printed on 5/20/22, indicated R3's allergies included allergies to nuts and peanut-containing products. Review of R3's progress notes on 5/18/22 revealed the following: -5/18/22, at 1:01 p.m. R3 was served a cream cheesecake for dessert which carried risks of peanut contamination. The progress note indicated R3 was given 50 mg of Benadryl and had his [MEDICATION(S)] in hand. R3 had a tight throat, and frequent checks were to be made to monitor his condition. -5/18/22, at 2:11 p.m. indicated [MEDICATION(S)] ([MEDICATION(S)]) had been given and was ineffective. 911 was called at approximately 1:25 p.m. due to progression of [MEDICATION(S)]. On 5/19/22, at 11:39 a.m. R3 was interviewed and stated on 5/18/22, he was served his lunch which included a dessert cake. R3 stated he ate some of the dessert, and it turned out to have peanut butter in it. R3 stated he had to use his [MEDICATION(S)], but it didn't relieve his symptoms, and he was eventually sent to the hospital via ambulance. On 5/19/22, at 1:16 p.m. C-B and C-C were interviewed. C-B and C-C both stated they were not aware R3 had an allergic reaction on 5/18/22. C-C stated all the desserts were made from scratch, and she would produce the recipe book. On 5/19/22, at 1:20 p.m. C-A was interviewed. C-A stated the meal ticket did not include a list of the menu ingredients on the ticket, it was the dietary aide's (DA) responsibility to look at the ingredients in the recipe book. C-A stated the prep cook dished up the desserts each day. C-A stated a dietary aide dished up the dessert onto R3's tray without knowing it contained peanut butter. C-A provided a copy of the recipe which showed a list of the allergens used in making the candy bar cheesecake and listed peanuts, soy, gluten, wheat, and milk as allergens. On 5/19/22, at 2:02 p.m. C-D was interviewed. C-D stated she was the one who put the dessert on R3's tray. C-D stated meal tickets have residents' allergies typed in red. C-D stated she delivered the meal tray to R3. C-D stated when she was done with the lunch meal service, she went to eat lunch. C-D stated she took a bite of the dessert and knew immediately there was peanut butter in it. C-D stated she ran to stop R3 from eating it, but he had already eaten it; nurses and aides were already there. C-D stated she felt dietary staff should not have to look through the cookbook for allergens in a food, the food should be labeled. On 5/19/22, at 2:30 p.m. the DON stated whoever dished up the cheesecake candy dessert didn't know it contained the peanut allergen. The DON stated staff knew of R3's severe allergy and called 911 immediately. The DON's stated R3 was her son, and she was trying to remain neutral and allow the investigation to move forward without her providing bias. On 5/19/22, at 2:56 p.m. the administrator stated R3 had an allergic reaction to his dessert. The administrator stated staff told him R3 was given a dessert that contained a peanut allergen. Kitchen staff had initially told the administrator the recipe was new which was not true, he knows as he does the food orders himself and knows the ingredients have been ordered for some time. The administrator stated the facility used a Martin Brothers computer system which has the recipes in the computer system which prints the meal tickets. The administrator stated the Martin Brothers computer system should have been set up to automatically remove foods with allergens from R3's meal ticket, or any other residents meal ticket when an allergen is served. R3's meal ticket dated 5/18/22, for the noon meal, included Candy Bar Cheesecake. R3's meal ticket listed R3's food allergies: peanuts, tree nuts, all nuts. The facility Tray Identification Policy revised on 4/2007, directed the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the resident. The facility implemented corrective action to remove the IJ on 5/20/22, when all resident allergies were reviewed by the DON and administrator, staff were educated on food allergies and intolerance, the facility updated their tray identification policy, the facility updated the Martin Brother system to ensure foods containing allergens were removed from the residents food labels, menus, and meal tickets. Food allergy audits were completed and will continue daily for 10 days, weekly for four weeks, and then monthly thereafter. This was verified through interview and document review.

Based on observation, interview, and document review, the facility failed to ensure appropriate assessment, monitoring and physician notification were completed for 3 of 3 residents (R48, R36, R44). This resulted in actual harm when R48 required re-hospitalization with fluid overload resulting in [CONDITION(S)] and acute on chronic congestive heart failure. Findings include: R48's facility face sheet identified R48 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's physician visit dated 7/30/21, included R48 had leg swelling and his weight was 333.8 lbs. (pounds). Plan was to continue [MEDICATION(S)] 40 milligrams [mg], will adjust if needed, nursing to monitor weight, Check daily weight notify provider if gain 2 lbs. in a day or 5 lb. in a week. R48's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Daily weights, notify physician for weight gain over 2 lbs. (pounds) in a day OR 5 lbs. in a week (start date 8/2/21) -[MEDICATION(S)] 40 mg (milligrams) one time a day for congestive heart failure (start date 7/31/21) -Occupational therapy wrap bilateral lower extremities Monday through Friday (start date 8/6/21) R48's Admission assessment dated [DATE], indicated R48 had +3 pitting [CONDITION(S)] in both lower extremities; location in the lower extremities was not identified. R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 did not have cognitive impairment, required extensive assistance of two or more staff members for activities of daily living that involved mobility and extensive assist of one staff for personal hygiene and dressing. The MDS indicated R48 was administered diuretic medications. R48's care plan dated 8/6/21, indicated R48 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R48's record indicated on 8/6/21, physician ordered a chest X-ray to rule out [CONDITION(S)]. R48's chest X-ray results on 8/11/21, indicated R48 had patching opacification (air in lungs replaced with other material such as fluid or bacteria) in the right lower lobe, and small pleural effusion (water on the lungs). The report also included Patchy right lower lobe infiltrate is seen, follow up exam recommended). R48's weight record identified over 2 lb. weight gain in a day without evidence of physician notification per physician order. -On 8/3/21, weight was 330.4 lbs. -on 8/4/21, weight was 334.2 lbs. -On 8/5/21, weight was 339.0 lbs. -On 8/7/21, weight was 343.0 lbs. -On 8/9/21, weight was 343.0 lbs. R48's record lacked evidence of daily weights on 8/10/21, 8/11/21, 8/12/21, and 8/13/21. R48's progress note dated 8/13/21, at 7:39 a.m. included, Resident had a sudden onset of shortness of breath around 4:00 a.m. Resident appeared pale/cyanotic. Resident initially had head of bed elevated, and oxygen increased to 3 liters per minute (LPM). Lung sounds clear/diminished. Vital signs: blood pressure 146/85, Pulse of 90, respirations 28, and oxygen saturations 80%. Resident requested to be placed in a tripod position, fell ow nurse assisted to position, and one on one supervision initiated. Resident refused ambulance services. Symptoms resolved approximately 30 minutes after onset. Resident requested to be put back to bed with head of bed elevated. Every one-hour checks initiated, morning staff notified of incident and sent physician notification. R48's progress note dated 8/13/21, at 10:30 a.m. indicated R48 was transferred to the hospital via ambulance related to shortness of breath and low oxygen saturations. R48's discharge summary dated 8/25/21, indicated primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary indicated between hospital discharge on 7/25/21 and hospital admission on 8/13/21, R48 had an 8.8 lb. weight gain. The summary indicated 1.5 liters of fluid was removed from R48's lungs. The discharge summary included new orders to change diuretic from [MEDICATION(S)] to [MEDICATION(S)] and add 2-liter fluid restriction. R48's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Daily weights, notify physician for weight gain over 2 lbs. in a day OR 5 lbs. in a week (start date 8/25/21) -Fluid Restriction: 2 Liter-Document in progress note with total 24-hour fluids consumed (Start Date 8/25/21) -[MEDICATION(S)] 60 mg one time a day related to heart failure (start date 8/25/21) -Compression Stockings: Donn in a.m. prior to getting out of bed. Remove in evening once in bed (start date 8/25/21) R48's weight record was reviewed from 8/25/21 to 9/13/21; record lacked physician notification in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 8/25/21, weight was 303.0 lbs. -On 8/26/21, weight was 308 lbs. -On 8/28/21, weight was 307.2 lbs. -On 9/2/21, weight was 310.0 lbs. -On 9/3/21, weight was 312.6 lbs. -no weight was recorded on 9/4/21 according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 9/5/21, weight was 315.0 lbs. -On 9/7/21, weight was 315.0 lbs. R48's physician notification dated 9/7/21, indicated R48 had a 13 lb. weight increase since 8/31/21 with no other symptoms. The note indicated R48 had +2 pitting [CONDITION(S)] to both lower extremities. The note also included, He does have some complaints of shortness of breath with exertion but is able to catch his breath when at rest. Lungs are clear bilaterally anterior and posterior. R48's fluid intake record was reviewed along with nursing progress notes for the 24-hour fluid intake evaluation. Fluid intake was not consistently documented every shift; with the lack of documented intake on the 24-hour fluid intake it could not be calculated/reviewed in accordance to the fluid restriction. R48's record identified between 9 different shift when R48's fluid was not monitored or documented from 8/25/21 to 9/13/21. During an observation and interview on 9/13/21, at 1:43 p.m. R48 sat up in his wheelchair. R48 stated he was in the hospital a couple of weeks ago for fluid overload and they had removed 24 liters of fluid. R48 stated when he got back from the hospital, he weighed 303 lbs. but was back up again to 315 lbs. R48 stated before he went to the hospital, he had been around 330 to 335 lbs. R48 stated he had felt so much better after all the fluid was removed, and thought it had steadily progressing over time, and indicated he would have to pay closer attention to his weight gains. During an interview on 9/15/21, at 8:24 a.m. medical director stated there were clear expectations nursing notify the physician when there was a weight gain in accordance with physician order. Medical director indicated the most objective measurement for fluid volume monitoring is weight gain. Medical director stated nursing needed to be monitoring/evaluating [CONDITION(S)] for the effectiveness of the treatments and medications. During an interview on 9/15/21, director of nursing (DON) stated she expected the physician be notified of weight gain in accordance with physician orders. DON stated the expectation of monitoring [CONDITION(S)] daily and findings documented accurately. DON stated if there was a weight gain, an evaluation needed to be done to determine if the weight gain was related to fluid, the evaluation should include a complete respiratory assessment, resident interview, and assessing for [CONDITION(S)] in extremities, hips, and abdomen. DON indicated if there was a change the physician needed to be notified. DON stated the episode of shortness of breath should have been documented in its entirety with a complete assessment and passed along in shift report for continual monitoring. R36 R36's face sheet indicated R36 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's hospital discharge summary dated 7/20/21, indicated R36 was admitted in part related to fluid overload with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary included, would recommend short term rehab to allow for closer monitoring of his weights/fluid status to determine appropriate dosing of diuretic in the outpatient setting. The summary indicated R36's dry weight of 303.6 lbs. The discharge summary also included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R36's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Daily weights notify physician for weight gain of over 2 lbs. in a day or over 5 lbs. in a week (start date 7/23/21). -[MEDICATION(S)] (diuretic medication) 10 mg (milligrams) in the morning for fluid retention's (start date 7/23/21). R36's care plan dated 7/25/21, identified R36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a day; neck vein distention; difficulty breathing; increased heart rate; elevated blood pressure; skin temperatures; monitor breath sounds for crackles. R36's physician visit dated 8/27/21, indicated R36's weight was stable on low dose of [MEDICATION(S)]; weight was 299.6 lbs. and on admit on 7/20/21 was 298 lbs. R36's weight record reviewed between 8/27/21 and 9/13/21, identified an increase in weight over 2 lbs. in a day or over 5 lbs in a week; record lacked evidence of physician notification. R36's weights included: -On 8/28/21, weight was 302.2 lbs. -On 8/30/21, weight was 302.8 lbs. -On 8/31/21, weight was 304.2 lbs. -On 9/3/21, weight was 306.6 lbs. -On 9/4/21, weight was 308.0 lbs. -On 9/6/21, weight was 308.4 lbs. -On 9/7/21, weight was 310.0 lbs. -On 9/9/21, weight was 313.4 lbs. -On 9/11/21, weight was 315.0 lbs. -On 9/12/21, weight was 315.4 lbs. -On 9/13/21, weight was 314.2 lbs. During an observation on 9/13/21, at 3:21 p.m. R36 sat in his wheelchair with his feet down on the floor. R36 was wearing regular cotton socks and was observed to have [CONDITION(S)] from ankle to just below the knee. R36 stated he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 9/14/21, at 8:13 a.m. R36 sat in his recliner with his feet elevated. R36 was observed to have [CONDITION(S)] in both legs from ankle to just below the knee. R36 stated that he had not slept very well last night, he woke up short of breath and indicated he called for staff to assist him to his recliner. R36 stated the shortness of breath resolved once he was sitting up. R36 stated, according to my doctor the fluid in my legs is making it hard for me to breath. R36's progress note dated 9/14/21, at 3:56 a.m. did not address R36's episode of shortness of breath and indicated R36 did not have [CONDITION(S)] present. R36's documented oxygen saturations were 90% on room air, which was below R36's average of 93-98%. During an interview on 9/14/21, at 12:05 p.m. licensed practical nurse (LPN)-D was asked, how often do you measure [CONDITION(S)], LPN-D stated he had never measured [CONDITION(S)] while working at this facility, stated he would only measure the [CONDITION(S)] if the resident had ace wraps or if physical therapy had reported concerns of [CONDITION(S)]. During an observation and interview on 9/14/21, at 12:11 p.m. LPN-D entered R36's room, R36 was sitting in his wheelchair with his feet down on the floor. LPN-D requested permission to evaluate [CONDITION(S)]; R36 consented. LPN-D stated R36 had 2+ pitting [CONDITION(S)] around both right and left ankles and 3+ to 4+ [CONDITION(S)] from lower shin to just below the knee on both legs. Although, R36's progress note dated 9/14/21, at 12:32 p.m. entered by LPN-D, reflected R36 had No [CONDITION(S)] present even though LPN-D had evaluated the [CONDITION(S)] at 12:11 p.m. in the presence of the surveyor. R44 According to R44's electronic health record (EHR) admission record/face sheet included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R44's quarterly Minimum Data Set (MDS) assessment dated [DATE], R44's primary medical condition was considered to be a medically complex condition. R44's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The following orders included: 2 L (liters) fluid restriction-document total consumed each shift. NOC (night shift) will total every day shift, Document progress note with total 24 hour fluids consumed; Daily weights-->notify provider if >189 lbs in the morning; Document progress note on [CONDITION(S)] location, pitting [CONDITION(S)] noted, skin intact (fluid weeping) lung sounds, weight, CNP [certified nurse practitioner] followed up on 8/13/21 and increased [MEDICATION(S)] [diuretic]. [CONDITION(S)] to BLE [bilateral lower extremities]. Every evening shift until resolved, Wrap legs daily with ACE bandages on in am and off at HS [bedtime]. R44's orders also included medications to control heart, blood pressure and to relieve [CONDITION(S)]: [MEDICATION(S)] capsule ER 24 hour sprinkle 25 mg, give 12.5 by mouth in the morning, [MEDICATION(S)] tablet, give 50 mg by mouth one time a day, [MEDICATION(S)] tablet 20 mg, give 40 mg by mouth two times a day. R44's [MEDICATION(S)] dose had increased on 8/13/21 from 20 mg to 40 mg and increased again on 8/16/21 to be taken twice a day instead of once per day. A review of R44's daily weight was not recorded on 9/3, 9/5, 9/10 or 9/11. On 9/12, 9/13 and 9/14 his weight exceeded 189 pounds. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R44's record for September identified missing progress notes for 9/9/21-9/11/21 no note related to [CONDITION(S)], weight, or lung sounds 9/12/21-weight was taken after lunch. Will reweight [sic] tomorrow and reassess. Resident is asymptomatic. No additional information related to [CONDITION(S)] or lung sounds. 9/13/21-no note related to [CONDITION(S)], weight, or lung sounds 9/14/21 at 3:42 p.m. assessment conducted: resident is alert and oriented x3, oxygen levels 92-93% on 1 L, wheezing auscultated bilaterally, 4+ [CONDITION(S)] of R and L extremities. Weight for today 190.2 lb. Nurse manger notified of change in weight, ACE wrap applied, resident left building for scheduled appointment. On 9/14/21, at 8:19 a.m. R44 was observed lying in bed in his room, resting. His facial appearance and limbs was red and flushed. A one liter jug of ice water was noted to be sitting at his bedside. An oxygen concentrator was beside the bed and was running, but R44 did not have a nasal cannula in his nose. On 9/14/21, at 8:43 a.m. R44 was observed sitting on the side of his bed. His legs were bare and swollen from the knees down. R44 had difficulty speaking, but was able to communicate through short phrases, gestures, some writing and answering yes, no questions. He indicated he had noticed his legs were swollen and gestured to show they were getting bigger. He also tapped on his abdomen. He indicated his legs should be wrapped. His hands were slightly swollen and he held them up to be seen. On 9/14/21, 12:03 p.m. R44 was observed to be lying in bed with his legs bare. Registered nurse (RN)-C entered the room with two elastic compression wraps and informed R44 he should have his legs wrapped before going out for the day. RN-C started wrapping R44's right leg at the toes and performed a figure eight wrap. He asked, do you like it tight? No, just a little loose? After reaching R44's knee, there was a considerable amount of wrap still on the roll, so RN-C proceeded to wrap the leg back down to the ankle. Following the right leg, RN-C wrapped the left leg in the same manner. RN-C stated the wraps were too long, and that he should have gone to find different wraps; however, RN-C did not go find any other wrap. At 9/14/21, 12:15 p.m. R44 indicated he had not been weighed. RN-C stated R44 was to be weighed every day. RN-C called to a passing nursing assistant (NA-F) who said R44 had not been weighed. Another nursing assistant, NA-C stated daily weights were to be done every morning as soon as possible, before eating and confirmed that R44 had not yet been weighed for unknown reasons. NA-C weighed R44 and reported a weight of 195 lbs. During an interview on 9/14/21 at 12:17p.m. RN-C confirmed that R44 had an order to monitor [CONDITION(S)]. He stated the best way to assess [CONDITION(S)] was to squeeze the feet and watch how much indent would occur and confirmed he had not done this but would do it later. RN-C noted R44's weight should be re-checked because it was more than the day before. RN-C confirmed he had been working the day before and had documented a weight of 191.6, but had not called the medical provider, stating he had not seen the order to call the provider for a weight greater than 189 lbs. RN-C stated an increase in weight and [CONDITION(S)] indicated a possible fluid overload. According to an interview 9/14/21, 12:42 p.m. the nurse manager for the unit, RN-D, said a daily weight was to be done before breakfast, and [CONDITION(S)] monitoring and compression wraps should also be done early in the morning. [CONDITION(S)] monitoring, RN-D confirmed, should be accomplished prior to the application of the compression wraps. RN-D stated a nurse should find a shorter set of compression wraps if the ones they had were too long. RN-D said a nurse should notify medical providers when a resident has a change in condition or when an order was left for notifications to be done. The expectation for notification method would be to write out an SBAR (situation, baseline, assessment, result/request) form and send it to the provider immediately, but any nurse should also be able to call a provider with a report. RN-D was not aware of any guidelines saying it must be the nurse manger to call. RN-D confirmed that R44 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D stated an expectation of nurses to document on R44's condition in a daily progress note as outlined in his orders with lung sounds, [CONDITION(S)], changes in weight, but confirmed that this information was not done daily, saying, it looks like there is no documentation since the 12th. According to an interview 9/14/21, 12:57 p.m. with the director of nursing (DON) the DON stated an expectation that daily weights be done at the same time each day, preferably right away upon rising before breakfast. DON also stated an expectation for compression wraps to be applied before getting up for the day. In relation to monitoring [CONDITION(S)], DON stated some physicians like to have [CONDITION(S)] checked later in the day, such as in the afternoon, to see if the condition progresses when the resident is up, but in general, [CONDITION(S)] monitoring should be done in the morning prior to the application of the compression wraps. DON said that when monitoring a resident for problems with fluid excess it was expected that nurses would do daily weights, monitor lung sounds, vital signs and sometimes abdominal girth if ordered. DON stated any orders should be initialed as being completed in the treatment administration record (TAR), but a progress note should be written as well. During an interview 9/15/21, 8:46 a.m. with the facility medical director (MD-A), he stated he was watching R44's condition closely as he had a perplexing presentation, their interventions had not been fully successful and R44's clinical trajectory continues to decline. MD-A stated unchecked fluid intake would be problematic, although he was currently stable. The primary concern for R44, according to MD-A was an exacerbation of his heart failure. A request was made of the facility for a policy on fluid/[CONDITION(S)] management and monitoring, but this was not provided. The Heart Failure-Clinical Protocol policy revised November 2018 covered only expectations of physicians and did not address nursing care.

Based on observation, interview, and document review the facility failed to comprehensively assess risk for pressure ulcers, and develop and implement interventions to prevent pressure ulcer injuries for 1 of 2 residents (R175). The facility's failures resulted in harm when R175 developed a stage 2 pressure ulcer and a deep tissue pressure ulcer. In addition, the facility failed to complete comprehensive assessments for pressure ulcers and failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include R175's face sheet dated 9/16/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R175's significant change minimum data set (MDS) assessment dated [DATE], indicated R175 had severe cognitive impairment. The MDS identified R175 required extensive assistance from two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated R175 was occasionally incontinent of urine and bowel. The MDS identified R175 was at risk for pressure ulcers and did not have pressure ulcers or moisture associated skin damage at the time of the assessment. The MDS indicated pressure reducing device for chair was not used for chair however a pressure reducing device was used for bed and identified R175 did not have a turning and repositioning program. R175's record lacked a comprehensive assessment for risk of skin breakdown after R175 became dependent on staff for mobility. R175's care plan did not identify the level of assistance in accordance with the MDS. R175's toileting care plan dated 9/1/20, directed staff to toilet R175 upon rising, after breakfast, before and [after] all other meals, at bedtime, on night rounds, and as needed. R175's skin care plan dated 10/17/2019, indicated R175 has the potential for pressure ulcer development r/t [related to] immobility. [R175] has thin, fragile skin prone to bruising, skin tears, and age related petechiae (pinpoint, round spots that appear on the skin as a result of bleeding). Associated interventions included follow facility policies/protocols for the prevention of skin breakdown R175's Skin Only Evaluation dated 9/10/21, at 11:44 p.m. indicated skin warm and dry, normal color, turgor normal, and had a skin tag on right upper abdomen. During an observation on 9/13/21, at 7:40 p.m. R175 laid on her back in bed. R175's room smelled of urine. RN-H and nursing assistant (NA)-H were at bedside encouraging R175 to roll over to allow them to change her saturated incontinent garment. R175's mattress protectors was observed to also be urine soaked. R175's behavior progress note dated 9/13/21, at 10:41 p.m. included tonight nurse and nursing assistant got R175 out of bed. Pain medication was offered at the beginning of the process, she did not understand. It was attempted to roll R175 she yelled out in pain and started hitting. The [MEDICATION(S)] was given and more communication about the process was provided. After several attempts to motivate the patient we rolled her on her side, washed and laid new pads down. During an observation on 9/14/21, at 7:00 a.m. R175 sat in her wheelchair in a hospital gown. At 7:50 a.m. licensed practical nurse (LPN)-D stated R175 had been in the wheelchair all night because she had been restless, stated an unawareness of the last time R175 had been toileted or changed. During an observation on 9/14/21, at 8:50 a.m. R175 was given her breakfast tray. At 9:27 a.m. R175 continued to sit in her wheelchair by the nursing station with her breakfast in front of her. During an observation and interview on 9/14/21, at 12:04 p.m. R175 continued to sit in her wheelchair by the nursing station. Licensed practical nurse (LPN)-D stated R175 had been sitting there since he got there this morning, and stated he was not aware if NAs had checked her incontinent brief or repositioned her. LPN-D stated R175 had nodded off for an hour maybe two in her chair. During an observation on 9/14/21, at 12:20 p.m. R175 remained by the nursing station. At 12:32 NA-A asked LPN-D how R175 transferred. LPN-D stated an unawareness and stated he would call therapy. NA-A was asked when R175 had last been toileted, NA-A stated the last time was between 6:00 a.m. and 7:00 a.m. when she assisted the night shift aide. At 12:49 p.m. R175 was transferred via full body mechanical lift to her bed by NA-A and NA-B. When NAs removed R175's incontinent garment, it was observed to be heavily saturated with urine. When R175 rolled onto her right side, a dark purple/blue area with a small wound that was bleeding was observed on her lower left buttock and small reddened area was observed on her right lower buttock. NA-A exited the room to get registered nurse (RN)-D. RN-D entered the room, RN-D observed the impaired skin integrity, and indicated R175 had a stage 1 pressure ulcer to the right buttock and the left buttock wound was a stage 2 and would have to do further evaluation if the wound was a deep tissue injury. RN-D stated the left buttock had more redness than the right and appeared irritated. R175 was very cooperative with RN-D during the assessment and with application of new brief. During an interview on 9/14/21, at 3:38 p.m. RN-D stated the wound on her left buttock was a deep tissue injury, with an open stage 2 pressure injury. RN-D stated she had conversed with family member who thought that R175 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D stated within the last several weeks R175 had an increased need to for assistance; she used to be independent with bed mobility and positioning herself. RN-D reviewed R175's care plan and verified the care plan was not consistent with the level of care R175 required and the MDS assessment. RN-D confirmed the care plan did not identify how often R175 needed to be turned and repositioned and an assessment to determine tissue response to pressure over time had not been completed after R175's change in condition. RN-D stated the nurse should have questioned/prompted or directed NAs to reposition R175 if there was a question of how long R175 was sitting in her chair next to the nursing desk. RN-D stated if R175 was refusing care then, it was expected the NA's reattempt or get someone else to attempt, report to the nurse on the floor, nurse should then attempt and notify the charge nurse of continued refusals. RN-D indicated, if necessary, the physician should be contacted for further medical management if interventions were unsuccessful. RN-D stated the refusals with interventions and the effectiveness of the interventions needed to be documented. R175's progress note dated 9/14/21, 9:24 p.m. identified R175 had left buttock stage 2 deep tissue injury 2 centimeters (cm) x 0.9 cm. Injury is purple/blue in color, small tear which had fresh red blood around the edges, less than 0.5 cm in diameter of fresh red blood in center of injury. The evaluation indicated dietary would be consulted, and care plan revised to include repositioning schedule and behavior plan for increased need in cares including barrier cream and hydrating lotion for dry skin for comfort. During an interview on 9/15/21, at 8:24 a.m. medical director stated a familiarity with R175 and indicated R175 had worsening heart failure and advancing dementia; goals of care were conservative. Medical director indicated an awareness of R175's behaviors of rejection/refusals of medications and compression management for [CONDITION(S)], however, was not aware of rejection/refusals for repositioning/toileting. Medical director indicated an expectation of routine skin assessments and a repositioning plan be in place for the prevention of pressure ulcers. Medical director stated if a resident demonstrated self-neglecting behaviors the physician (or hospice) needed to be notified; residents can't sit in their own urine, it would need further evaluation. When asked if the duration of time R175 sat in her wheelchair without positioning or changing incontinent brief contributed to the pressure ulcers, medical director stated Yes, that would be the definition of a pressure ulcer. During an interview on 9/15/21, at 11:34 a.m. director of nursing (DON) indicated R175 should have been assessed for a turning and repositioning program after her mobility declined. DON stated the expectation residents were toileted in accordance with their care plan. DON stated if residents refused, the expectation was the nurse be notified, and ultimately the physician if necessary for further medical intervention. R61 R61's hospital discharge summary dated 8/11/21, indicated R61 had a left buttock stage 2 pressure ulcer that had been identified on 7/16/21; plan for treatment included cleanse skin with wound cleanser, pat dry, and cover with foam boarder dressing, change dressing daily and as needed. The discharge summary also identified an unstageable pressure ulcer on a leg with orders for wound care. R61's Admission skin assessment dated [DATE], did not identify presence of pressure ulcers. The note indicated resident refused with no further information or interventions for refusal. R61's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R61's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R61's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If changes, document in skin alterations and wounds progress note. Wound: pressure injury to left lower extremity-unstageable, left buttock pressure stage 2. R61's record identified the left lower extremity pressure ulcer was not comprehensively assessed until 8/16/21, even though there were physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R61's skin evaluation dated 8/16/21, indicated R61 had an unstageable pressure ulcer on the left lower extremity (location on extremity was not identified) that measured 1.5 cm (centimeters) x 0.9 cm. The skin evaluation did not identify the presence of a stage 2 pressure ulcer. R61's admission Minimum Data Set (MDS) assessment dated [DATE], identified R61 had one stage 2 pressure ulcer and one unstageable pressure ulcer. R61's skin evaluation dated 8/23/21 and 8/31/21, did not identify the stage 2 pressure ulcer. R61's record did not indicate why the physician ordered treatment to the left buttock was discontinued on 9/2/21. R61's skin evaluations dated 9/7/21 and 9/8/21, did not identify the left buttock pressure ulcer. R61's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/14/21, at 9:15 a.m. licensed practical nurse (LPN)-D indicated R61 only had one wound treatment to complete; the unstageable ulcer on the left calf. During an observation on 9/14/21, at 9:21 a.m. licensed practical nurse (LPN)-D explained to R61 he was going to complete the dressing change on his left calf; R61 gave consent. LPN-D donned gloves, removed the dressing, disposed of the dressing, then removed gloves. LPN-D then used a pen to write the date on the new dressing and donned new gloves without performing hand hygiene. LPN-D completed the dressing change per physician orders, removed gloves, and washed hands. During an interview on 9/14/21, at 9:26 a.m. LPN-D stated he should have done hand hygiene between glove changes. During an observation on 9/15/21, at 1:16 p.m. RN-B explained to R61 he was going to change the dressings on his left calf and left buttock; R61 gave consent. RN-B washed his hands and donned gloves, RN-B then removed R61's wound dressing from the left calf and through the dressings on the floor. RN-B then removed the cap from the saline bottle, put the ointments for the wound in the cap, opened a tongue depressor, and stirred the ointments together. RN-B then removed scissors from his left pocket and cut the non-stick dressing to the size of the wound. RN-B then used a Q-tip to spread the mixture of ointments onto the wound and applied the cover dressings. RN-B had the same gloves on throughout the procedure, in addition RN-B had not disinfected the scissors prior to or after the completion of the dressing change. RN-B then picked up the soiled dressings from the floor, took off gloves, and sanitized his hands. RN-B then informed R61 of the next dressing change on his left buttock. RN-B donned gloves and undid R61's incontinent brief, R61 was incontinent of stool, RN-B performed incontinent care (a dressing was not observed on R61's left buttock where there was a nickel sized superficial wound that was reddened), used an incontinent wipe to clean his gloves, walked to the bathroom and donned another pair of gloves (without disinfecting) over the gloves he already had on and applied the left buttock dressing per physician order. During an interview on 9/15/21, at 2:13 p.m. RN-B confirmed there was not a dressing to the buttock wound and there should have been, RN-B stated if the wound had been resolved it's not anymore. RN-B stated he should have changed his gloves and performed hand hygiene after taking off the old dressing. RN-B stated an unawareness if double gloving was appropriate for the procedure. During an interview on 9/16/21, at 11:44 p.m. director of nursing (DON) stated an expectation that pressure ulcers were comprehensively assessed upon admission, weekly thereafter and as need, should be monitored for improvement or worsening daily with dressing changes. DON stated the expectation dressings were applied according to physician order. DON indicated appropriate hand hygiene was expected during dressing changes, gloves should be removed after dressing and removal and cleansing the wound, hand hygiene should be performed after each glove change. DON stated soiled dressings need to go into a garbage can and not on the floor, and scissors should be disinfected prior to using on a clean dressing. Facility policy Pressure Injury Risk assessment dated ,d+[DATE], included 1) The purpose of pressure injury risk assessment is to identify all risk factors and then determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. 2) Risk factors that increase a resident's susceptibility to develop or to not heal PU's include b) impaired/decreased mobility and decreased functional ability, the presence of previously healed PU, exposure to urinary and fecal incontinence or other source of moisture, altered skin status over pressure points, and cognitive impairment 6) once the assessment is conducted and risk factors are identified and characterized, a resident centered care plan can be created to address the modifiable risks for pressure injuries. Facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 4/2018, did not identify frequency of monitoring or completing comprehensive wound assessments. The protocol indicated a skin examine would be completed upon admission

Based on observation, interview, and document review the facility failed to ensure safety and protect residents from physical and verbal abuse, during resident to resident altercations. This resulted in an immediate jeopardy (IJ) when resident (R) 1 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy began on 6/5/21, when the facility failed to protect R2 and other residents after R1 aggressively yelled and swung at her. There was 8 other residents (R2, R3, R4, R5, R6, R7, R8, and R9) identified to have had known suffering by either physical abuse, verbal abuse, or physical aggression. The IJ was identified on 7/19/21. The administrator and director of nursing (DON) were notified on 7/19/21, at 5:12 p.m. The IJ was removed on 7/22/21, at 2:58 p.m. after it could be verified the facility had implemented an acceptable removal plan, however, non-compliance remained at E severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's hospital discharge summary dated 10/12/21, indicated R1 had a psychiatric hospital stay related to worsening agitation and behavioral disturbance with aggression in the setting of major neurocognitive disorder (probable Alzheimer's and [CONDITION(S)]). The summary indicated R1 was prescribed medications for behavior/mood management. R1's face sheet dated 7/22/21, indicated R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Behavioral Care Area assessment dated [DATE], included R1 is new to Pine Haven, he is here for respite care, he likes to walk, he is confused and used to be home with his wife. and was not fully completed. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 had severe cognitive impairment, had signs and symptoms of [CONDITION(S)] that was continuously present, had physical and verbal behavioral symptoms directed towards others 1 to 3 days during the assessment period, and rejection of care behaviors 1 to 3 days during the assessment period. R1 also had wandering behaviors daily. The MDS indicated R1 required supervision for transfers, limited assistance from staff to walk in room and in corridor, and supervision for locomotion on and off the unit. R1's behavioral care plan dated 6/24/21, included, R1 had alteration in memory, judgement, decision making and thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ! Let's go! Where are you! Family reports resident becomes agitated when he sees mirrors/his reflection. Interventions included: -Mirrors removed from room [ROOM NUMBER]/21/21. -Give medication as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Break activities into manageable subtasks. Give one instruction at a time to resident (start date 3/5/2021) -Ensure staff introduce themselves and are wearing name tags at initiation of each interaction with resident (start date 3/5/2021) -Use only one staff member for cares, multiple staff around me make me agitated (start date 3/5/2021) -[NAME] responds well to praise. When participating in cares, acknowledge that he is participating well (start date 3/5/2021) -If resident has behaviors, it may be due to not understanding what is being done, use soft gentle tone, soothing words. (start date 3/5/2021) -If I enter other resident's rooms, do not tell me I can't be in there. Tell me See you later [R1] or We should go into this room instead (start date 3/5/2021) -Allow R1 to assist with simple tasks, like carrying his snack back to his room, and say things like Good job [R1] (start date 5/26/2021) -I am easily over stimulated by too much noise or too many people (start date 5/28/2021) -Keep resident away from mirrors when possible to avoid agitation (start date 6/18/2021) R2's quarterly MDS dated [DATE], identified R2 did not have cognitive impairment During observation and interview on 7/19/21, 3:34 p.m. R2's room had a Velcro mesh netting with a STOP sign strung across her doorway. R2 sat up in her chair. When asked what is the stop sign for? R2 replied, it was to stop R1 from entering; he goes up and down the hallways looking for his wife. R2 stated she was aware of R1's behaviors of wandering into residents' rooms and yelling at other residents. R2 stated before the stop sign was placed, (R2 could not recall the date), R1 came in the room, R2 put on her call light right away, she was scared and shaking, she then told R1 he was in the wrong room. R2 stated R1 became hostile, walked over to where she was sitting in her chair and got 2 inches from her face, started yelling back at her but could not recall what his words were. R2 stated she thought he was going to hit her. R2 stated she couldn't get up without assistance from staff. R2 indicated R1 left on his own and shut the door behind him, stated R1 had been in her room for about 5 minutes and staff had not responded while he was in her room. R2 stated she reported the incident and concerns to staff. staff were aware of how scared she is of him. R2 stated R1 had not been back in her room since then but continues to be very frightened, R1 continued to stand behind the stop sign and looks in, I just fall to pieces when I see him, I tremble in fear. R2 stated she didn't know what he would do, one day he was standing out there and he was trying to take the sign down. He just scares me. R2 stated, she did not feel very safe and even though she continues to report fear to staff, she doesn't think they have done anything about his behaviors. R9's admission MDS dated [DATE], identified R9 had moderate cognitive impairment. During an interview on 7/19/21, at 3:44 p.m. R9's room had a Velcro mesh netting with a STOP sign strung across her doorway. When asked what the stop sign was for, R9 stated it was to prevent R1 from entering his room. R9 stated R1 had entered his room recently, (could not recall the date) R1 started going through his drawers, when R9 told him to get out, R9 walked over to him and swatted me in the head. R9 stated R1 hit him with an open hand however, it really hurt. R9 stated he had put on his call light as soon as R1 had entered his room, however, staff did not respond to prevent him from getting hit. R9 indicated after R9 had hit him, he left the room, and soon after staff responded, R9 reported the incident, and staff came back with that stop sign. R9 indicated R1 had not come in his room again, however does linger outside his door, I hope I never get in his way! R1's progress notes included: 5/29/21, at 3:10 p.m. Resident [R1] was wandering into others rooms with another resident. Staff attempted to redirect, resident who became agitated very quickly and was giving a strangling motion to another resident. Resident was given a snack at the nurse's station. 6/2/21, at 2:02 p.m. Resident [R1] was wandering halls around 1300 [1:00 p.m.] and walked into [number of a resident's room] room when staff attempted to redirect him and he became aggravated swinging his fists around. Another resident, [initial of a resident] in [room number of that resident], was also walking down that hall and attempted to speak to [R1] and redirect him from entering said room when he grabbed onto her wrist and swung it away from him. Staff unable to remember which wrist. The two were separated by staff and walked their separate ways. 6/5/21, at 10:29 p.m. Resident [R1] was yelling at a female resident very aggressively. Female resident did not say anything to him. He then swung at her quite hard and missed her by less than an inch because she flinched backwards. A resident asked to go to her room because she was scared of that man, he is so angry, he is going to hurt someone Staff had to remove him from other resident's room's multiple times. One time in particular, the other resident, whose room it was, was screaming because she was scared and this resident was screaming back at her to shut up and let's go he was also trying to get over to her in her recliner. This is when he grabbed this nurses arm and squeezed it very hard. He also punched and slapped this nurse trying to get to the scared resident. This resident hit and slapped this nurse and other nurses multiple times when he walked by. For no reason what so ever. 6/6/2021, at 9:40 p.m. Resident [R1] intruding into many residents rooms this shift. Yelling at several residents which has made them afraid to come out of their rooms due to this behavior. Resident went into [room number of a victim] room and [victim] yelled at him to get out. This resident [R1] got very angry and began to yell. Staff was able to redirect him away from the room. [Victim] was told to talk to him calmly if he comes into their room. During an interview on 7/21/21, at 1:08 p.m. DON indicated records did not identify which resident the progress note referred to, DON stated after further investigations were completed on 7/20/21, one of the residents was identified as R2 and the other resident(s) were not able to be identified. DON stated the incident was not reported to the State Agency. 6/7/21, progress note indicated new orders were given to increase R1's antipsychotic medication. 6/8/21, at 11:30 p.m. Resident [R1] entered a female resident's room and would not get out when she asked him and it was difficult to remove him with the help of staff as well. Female resident cannot move herself and was scared and crying. This agitated and angered this resident more. Resident came out of the room and soon was distracted by something else. Female resident is requesting a Velcro stop sign to be placed in her doorway to help prevent this resident from entering again. R1's physician visit note dated 6/9/21, did not address aggressive behaviors toward other residents. The note included, Updates obtained from nursing and patient. He has had some refusal of cares. He has also had behaviors of urinating inappropriate places. To help ensure he is safe in redirectable his [MEDICATION(S)] (antipsychotic) has been titrated. It was noted that he was sleeping more yesterday, but has been up and witnessed ambulating around building again today. He often wonders [sic] throughout the building. The note also included, Difficulty and risks with staff providing cares is indication for this dose being titrated up. Will be monitored closely and adjusted appropriately. R1's progress note dates on 6/13/21, at 2:34 p.m., indicated R1 attempted to elope from the facility. The note then included, This writer and another nurse tried to bring resident inside which agitated him even more and was grabbing and pushing staff members while another resident was watching and crying because she was scared. Staff members were eventually able to bring resident back inside and lie him down in bed. R1's physician visit note dated 6/15/21, did not address the behavior noted 6/13/21. Note included, On 6/7/21 patient was noted to have increased behaviors during bedtime regimen including agitation grabbing at wrists of staff and difficult to redirect. [MEDICATION(S)] medication regimen was readjusted to providing him with a dose of [MEDICATION(S)] at bedtime. The note indicated since then he has been directable with less behaviors. Staff continues to educate numerous staff on approach with [R1] which seems to be the most effective. 6/16/21, at 8:12 p.m. Resident [R1] easily agitated this shift. Resident noted to be restless (wandering halls) throughout the shift. Resident displayed verbal and physical aggression towards staff and verbal aggression towards other residents. Resident would wave fist in air and yell unintelligible sounds/garbled speech at other residents. Resident would attempt to move others in wheel chairs if they were in the path of resident. 6/17/2021, at 12:20 p.m. Resident [R1] has been aggressive towards staff and other residents today. Resident was easily directed at times with food. However, there were situation where he needed to directed away from the scene. Cooperative with mediation administration. 6/17/21, at 12:45 p.m. Resident [R1] walking down to DR [dining room] by the windows. [R4] said hi. [R1 name] went behind her and punched her in the back and called her an[OBSCENITY] . Staff intervened and removed this resident from the scene. Resident remained agitated despite agitation. 6/18/21, at 8:22 a.m., note indicated DON, and administrator aware of the situation between R1 and another resident on 6/17/21. The note indicated the care plan would not be changed and staff would continue to redirect the resident to a more calm environment. 6/26/21, at 2:39 p.m. Resident [R1] wandered into [R5's] room. [R5] asked him to leave in which he started yelling and acting like he was going to hit resident. Staff escorted resident out of room and redirected him into own room. 6/30/21, at 3:15 p.m. At 1515 [3:15 p.m.] on 6/30/21 Resident [R1] slapped another resident on their left arm. Resident had been arguing with another resident moments before and was upset r/t [related to] that. 7/12/21, at 3:15 p.m. Resident [R1] asked another resident [R7] a question and the other resident didn't hear him and said, what did you say. This angered resident and he hit the other resident twice with the back of his right hand on the side of the other resident's upper left arm. This nurse got in between the two residents and took the other resident down the hall to use the bathroom. 7/13/21, at 4:30 p.m. Resident [R1] was walking up and down the halls and passed in front of a couple of ladies watching a program on TV One of the ladies [victim not identified] who has dementia yelled, Why don't you get out of the way. This resulted in an argument and resident 2 [R1] grabbed resident 1 [victim] by her right forearm with his left hand squeezing and twisting. He let go of her arm as this writer ran toward the situation. Resident one [sic] walked away. Resident 2 [sic] started crying and saying, He twisted my arm. Both resident's forgot about this altercation shortly after it happened. 7/16/21, at 3:55 p.m. progress note indicated leadership team discussed resident's continued behaviors and agitation. Indicated increased agitation typically in afternoon beginning at 1:30 p.m. and continuing until 5:00 p.m. He becomes agitated easily and at times hits staff members and has hit residents. Area of concern is the common area on 200/300/400 units. Resident is having acute visit on 7/19/2021 to addressed continued and increased behaviors. Updated care plan and kardex for staff to walk with resident on 500/600 units as he previously enjoyed this when his room was on the 600 unit. Writer updated hall nurse and communication page. Observations on 7/19/21: -At 11:30 a.m. during the initial facility tour, multiple resident rooms were observed to have mesh netting with a stop sign strung between the door frames. -At 12:06 p.m. R1 walked out of the dining room. Registered nurse (RN)-A assisted R1 back into the dining room. -At 12:21 p.m. R1 was wandering in and out of the dining room calling out for his wife. An unidentified staff member informed R1 his wife was not here and walked away. -At 12:27 p.m. R1 was sitting at the dining room table and began walking out of dining room, unidentified nursing assistant (NA) asked if he wanted a cookie and returned R1 to the dining room table. -At 1:20 p.m. R1 wandered up and down the hallway in front of the nursing station, residents were in the vicinity. -At 3:15 p.m. R1 sat in the front entry way eating a snack, other residents were near R1. Observation on 7/21/21: -At 7:55 a.m. it was observed that some rooms that had stop signs up on 7/20/21, were not in place. -At 9:32 a.m. R1 sat in a chair down the 200 hallway. At 9:34 a.m. R1 was wandering in the hallway without supervision. The stop signs continued to be down. -At 11:21 a.m. multiple stop signs continued to be down. -At 12:25 p.m. multiple stop signs continue to be down in most resident rooms -At 12:35 p.m. administrator stated stop signs were supposed to be up at all times whether residents were in their rooms or not. Administrator was informed stop signs had not been up since first observation made. -At 1:08 p.m. stop signs continued to not be in place. -At 4:25 p.m. stop signs continued to not be in place. R1 was observed wandering down the 300-hallway unsupervised, R1 entered 2 residents rooms that previously had stop signs on them, one resident was in her bed sleeping. An unidentified nursing assistant was walking with another resident in front of R1. NA asked R1 to follow them, R1 stated no, dietary assistant (DA)-1 attempted to redirect R1 to follow her to the dining room several times, however R1 became agitated and slapped DA-1 on the shoulder. -At 4:35 p.m. administrator was made aware of the observations. Observations on 7/22/21: -At 7:25 a.m. stop signs were not up on residents rooms. -At 7:41 a.m. R1 came out of his room and urinated on the doors that lead to the 500/600 unit, after several minutes licensed practical nurse (LPN)-A responded to the scene. -At 8:44 a.m. stop signs to resident's rooms continued to be not in place. Administrator inquired with LPN-A where the stop signs were. Administrator supervised R1 until other staff were nearby to supervise resident. -At 9:24 a.m. R1 finished his snack and wandered unsupervised down the 200 hallways, R1 stopped and entrances to resident rooms and looked inside. At 9:25 a.m. a staff member walked passed him and said hi and kept walking. -At 11:11 a.m. director of nursing (DON) indicated an awareness that staff were not monitoring/supervising R1 when R1 was wandering in order to keep residents safe. -at 12:29 p.m. all stop signs to resident rooms were observed to be in place. During an interview on 7/19/21, at 11:37 a.m. licensed practical nurse (LPN)-A stated R1 had aggressive behaviors and got agitated with redirection. LPN-A stated R1 would hit you, indicated when R1 demonstrated aggressive behaviors, staff were supposed to leave him alone and reproach him, offer him food, or toilet him. LPN-A stated if a resident tried to tell him something he didn't want to do, R1 would get agitated/aggressive toward them too. LPN-A stated R1's behaviors of aggression were unpredictable. During an interview on 7/19/21, at 11:41 a.m. LPN-C indicated she was not aware of all of the R1's incidents of physical/verbal abuse against residents. LPN-C stated if R1 was agitated we would remove him away from other residents and offer a snack. LPN-C indicated R1 had very short-term memory loss, he would forget what he was doing in seconds. LPN-C stated R1 would get agitated with noise and a lot of people, behaviors started to increase around 1:30 p.m., staff were supposed to take him to a different unit when he got agitated. LPN-C stated R1 calms down as fast as he got agitated, no rhyme or reason for his behaviors, and his aggression was very unpredictable. During an interview on 7/19/21, at 12:05 p.m. LPN-B stated R1 wandered a lot. LPN-B stated R1 got agitated and aggressive, he didn't always comprehend what staff are telling him. LPN-B stated R1 has pretended to take a swing at her. LPN-B indicated R1 was not always supervised when he wandered, residents would tell him to get out and he would get frustrated. When asked how residents are protected from R1 if he wandered into a residents room and became frustrated, LPN-B stated I like to keep a close eye on him LPN-B stated R1 didn't have a lot of behaviors on the day shift, R1 had more behaviors on the evening shift, around shift change is when behaviors started. LPN-B stated R1 was triggered by a lot of commotion and visitors coming into the building. During an interview on 7/19/21 at 1:52 p.m. medical doctor (MD)-A stated an awareness of R1 history of aggressive behaviors. MD-A indicated nurse practitioner had increased his antipsychotic medications on 6/7/21, for an increase in behaviors; at the follow-up visit around 6/15/21, there had been an improvement. MD-A stated an unawareness of increase of physical/verbal aggressive behaviors after the NP had evaluated him. MD-A stated staff should have notified him/NP when R1 demonstrated physical/verbal/threatening behaviors toward other residents and/or with increase in behaviors after the medication dose adjustment. MD-A indicated an expectation non-pharmacological behavioral intervention be utilized and evaluated for effectiveness. MD-A indicated because R1 was ambulatory, difficult to redirect, limited successful non-pharmacological approaches, elements of behavioral unpredictability, and concerns with stress on residents and their safety, medication management was warranted in addition to good behavioral approaches. During an interview on 7/20/21, 7:51 a.m. nursing assistant (NA)-A stated R1 had aggressive behaviors toward staff and residents. NA-A stated his behaviors are unpredictable and doesn't like to be told what to do. NA-A stated when he is agitated we offer him something to eat, bathroom, or take him for a walk to the other unit where it is quieter, and he likes being told he does a good job. During an interview on 7/20/21 at 8:11 a.m. registered nurse (RN)-A indicated she was the nurse manager of the unit in which R1 resided. RN-A reviewed R1's progress notes that identified incidents of physical/verbal abuse and threatening behaviors towards residents. RN-A verified immediate interventions to protect residents were not developed and/or implemented after each occurrence and the care plan had not been revised. RN-A stated any incidents of abuse or threatening behaviors toward other residents should be immediately reported to the administrator or the DON. RN-A stated it should have been made clear who those residents were and that they were safe, and immediately protected from R1. RN-A confirmed R1's physician was not notified of the physical/verbal abuse inflicted on other residents, confirmed physicians of the residents who suffered abuse were not notified, and confirmed psychosocial assessments, monitoring, or services were offered to those victims. During an interview on 7/21/21, at 11:10 a.m. NA-C indicated R1 had aggressive behaviors and he had good days and bad days. NA-C stated he would get agitated when he was not ready to be helped with something or if there was too much commotion. Staff could tell if he was agitated if he wandered around looking for his wife. NA-C stated when R1 was agitated, staff offered him food, or take him away from the commotion. NA-C indicated R1 wandered around the unit. When asked how were staff aware if R1 had wandered into a residents' room, NA-C responded the resident would put on their call light. NA-C stated R1's behaviors were sometimes unpredictable, if R1 was having a bad day and a resident told him to get out, he would not leave unless directed by staff. NA-C stated recently she had to step in-between him and R3 because they were having words back and forth and he looked like he was going to hit her. NA-C stated she redirected R1, and removed him from the location. NA-C stated R1 has grabbed and hit her before, and R1 would probably have the same aggressive behaviors towards residents. During an interview on 7/21/21, at 11:56 a.m. licensed social worker (LSW) indicated her assistant covered the unit in which R1 resided however, had awareness of R1's aggressive behaviors towards residents because every morning the leadership team had a meeting to review/discuss progress notes/events from the previous day. R1's record was reviewed with LSW, when asked how the facility was protecting residents from R1, LSW stated residents were provided with stop signs, I know staff don't always do that, we have provided education on ensuring they were up. LSW indicated all residents who resided on the same unit had not been interviewed and/or evaluated after R1's documented abusive incidents. LSW indicated the facility had not completed a comprehensive assessments and/or monitoring of residents who suffered R1's abusive behaviors, indicated the residents were checked on, but the checks were not documented or evaluated. LSW indicated nursing was supposed to be documenting behaviors, however the documentation did not reflect how may occurrences of each behavior occurred on each shift and the effectiveness of the intervention used. During an interview on 7/21/21, at 1:08 p.m. DON confirmed the lack of documentation and/or incident report completion. DON stated that the notes that indicated verbal aggression were not reported to the State agency because they were deemed as arguments between residents even though the documentation indicated residents were fearful of R1. DON indicated after further investigation on 7/20-7/21, residents who were affected were identified after further investigation and vulnerable adult reports were submitted to the state agency for those that were not previously reported. When asked how residents were being protected from R1, DON indicated residents that resided on the same unit were protected by putting stop signs up that prevented R1 from entering and staff were supposed to take R1 for a walk to the 500/600 hallway when he demonstrated agitation, however, could not articulate how long R1 was supposed to be walked and if R1 was supposed to be monitored after the walk. DON stated R1's agitation was unpredictable. DON stated as of 7/21/21, all residents who resided on R1's unit had not been interviewed in order to determine if R1 had demonstrated verbal/physical aggression towards them. DON indicated that interventions including medication should be monitored and evaluated for effectiveness, confirmed the record lacked analysis of the effectiveness of interventions. DON stated stop signs on resident rooms should be up at all times and staff had been provided education. Facility policy Pine Haven Abuse and Neglect Policy and Reporting dated 1/2021, included the following definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical charm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the policy of Pine Haven Care Center, that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The policy also outlined reporting and investigation requirements including the protection of the vulnerable adults during the investigation. The immediate Jeopardy was removed on 7/22/21, at 2:58 p.m. when it could be determined the facility had completed the following: 1) All staff were educated on the abuse policy, monitoring interventions for effectiveness, completing a comprehensive abuse assessment, and completing root cause analysis leading to the alleged abuse, and implementing immediate interventions to protect residents from abuse. 2) R1's behaviors and interventions were comprehensively assessed, and interventions were developed, care planned, and implemented to protect facility residents from further abuse. 3) Facility residents who sustained alleged abuse were evaluated for any impact on mental well-being and facility residents. 4) Facility conducted abuse investigations to determine root cause analysis including interviewing all residents residing on same unit in order to determine if any other residents were affected. 5) An auditing system for compliance with the abuse policy, comprehensive assessments, root cause analysis, and implementation of interventions was developed and implemented.

Based on observation, interview, and document review, the facility failed to comprehensively assess each fall and identify casual factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate the effectiveness of fall interventions for 2 of 3 residents (R1, R2) reviewed for accidents. R1 had history of falls with fractures and sustained another left ulnar fracture. These deficient practices resulted in immediate jeopardy (IJ) for R1. In addition, R2 had multiple falls that resulted in minor injuries. The IJ began on 6/25/21, when R1 sustained a fracture to the left arm after the facility failed to ensure safety checks and toileting scheduled were not provided in accordance with R1's individualized fall care plan, failed to adequately assess and monitor interventions for effectiveness, failed to adequately educate staff and supervise direct care staff on following the care plan, and failed to ensure accurate concise documentation was completed. The administrator and director of nursing (DON) were notified of the immediate Jeopardy at 4:44 p.m. on 7/7/21. The immediate jeopardy was removed on 7/8/21, at 6:40 p.m. after it could be verified the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1 was observed on 7/7/21, at 9:36 a.m. sitting in her wheelchair in front of the nursing station with a purple cast on her left arm that extended from just below her elbow to her wrist. R1's face sheet dated 7/8/21, included diagnoses of dementia without behavioral disturbance, Alzheimer's disease, [CONDITION(S)], anxiety disorder, constipation, and bilateral [CONDITION(S)]. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, signs and symptoms of [CONDITION(S)], and did not have rejection of care behaviors. The MDS identified R1 required extensive assistance from one staff member for bed mobility, transfers, and toilet use. The MDS indicated R1 was frequently incontinent of urine and occasionally incontinent of bowel and had two or more falls since previous assessment completed on 2/12/21. R1's fall risk assessment dated [DATE] indicated at risk for falls with clinical suggestions: Rubber-soled shoes or nonskid slippers worn for ambulation and utilize toileting program. R1's care plan dated 4/4/21, indicated R1 was at risk for falls characterized by history of falls/injury, multiple risk factors related to: incontinence, use of opioid medications, deconditioning, dementia, attempts to be independent, is not always aware of physical limitations, and impaired safety judgment. Has history of falling resulting in fractures and other minor injuries. Care plan interventions included: -Analyze previous falls to determine whether pattern/trend can be addressed (date 9/28/21). -Staff to anticipate needs (5/30/18) -Review toileting schedule to see if trends in falls related to toileting (6/8/2020). -Toilet every 2 hours (start date 12/22/21, stop date 6/25/21) -Toilet every 1 hour (start date 6/25/21, stop date 7/7/21) -Toilet every 2 hours (start date 7 /7/21, stop date 7/8/21) -Toilet every 1 hour (start date 7/8/21) -Hourly safety checks (3/23/21, changed to 30 minute safety checks on 4/2/21) R1's progress note for 6/25/21 were reviewed and included R1 had an unwitnessed fall in her bathroom at 5:45 a.m. after self-transferring to the toilet to have a bowel movement. The note indicated R1 had an abrasion and bruising to her right 4th finger, abnormal areas to both her wrists, and reddened area to left hip area. R1 had said ouch when touched anywhere. Note at 8:55 a.m. indicated an X-ray was ordered to both wrist. Note at 9:53 a.m. indicated the X-ray results identified left arm fracture and the family was going to take her to the emergency room in the morning for further evaluation. R1's progress notes for 6/26/21, indicated R1 was transported to the emergency room , a cast was applied, however, R1 became very agitated, R1 was then sedated to remove the cast, and because of sedation was kept overnight for further observation because of the sedation. The note indicated a hard cast would be applied in the next couple of days. R1's progress note for 6/27/21, indicated R1 returned from the hospital at 11:40 a.m. with a soft cast to left arm. R1's progress notes from 7/1/21, to 7/5/21 did not identify when the hard cast was reapplied (note on 7/4/21 identified it was on), however, did indicate R1 had an increase amount of pain to left arm; physician was contacted with elevation of pain and one time doses of narcotic pain medication were administered on the evening on 7/1, evening of 7/4, and afternoon of 7/6/21. According to a Vulnerable adult report submitted to the State Agency on 7/2/21, at 5:08 a.m. identified R1 had falls on 4/2/21, 5/5/21, and 6/25/21. The report indicated on 6/25/21, at 5:45 a.m. R1 had an unwitnessed fall in her bathroom that resulted in a left ulnar fracture, abrasion and bruising to her right 4th finger, and reddened area to her left hip area. R1's care plan included toilet every two hours and she had last been toileted at 3:40 a.m. according to a nursing assistant (NA), however through video surveillance review, it was identified every 30-minute safety checks were not followed in accordance with the care plan. The root cause of the fall determined to be resident self-transferred due to need to use the bathroom; R1's care plan was revised to toilet every one-hour to prevent further falls. On 7/7/21, facility provided outline of video surveillance from the overnight shift on 6/24 into 6/25/21. The outline identified staff members did not enter R1's room after 1:00 a.m. staff members did not perform every 30-minute safety checks or every 2 hour toileting according to the care plan. Staff members were not observed to enter R1's room until 5:46 a.m. During an interview on 7/7/21, at 9:00 a.m. administrator and director of nursing confirmed video surveillance identified staff NA-A and NA-B did not follow the care plan for every 30-minute safety checks or R1's toileting schedule. DON indicated because of the fall, the care plan was revised to an every one-hour toileting schedule and education was provided pertaining to bowel medication administration as the record indicated a suppository was administered at 11:30 p.m. on 6/24/21. During a continuous observation on 7/7/21, from 9:36 a.m. to 11:14 a.m. R1 was not offered and/or assisted to the bathroom in accordance with the care plan. -At 9:36 a.m. R1 was observed self-propelling in her wheelchair in the hallway; she had a hard purple cast on her right arm. -At 9:56 a.m. R1 continued to self-propel up and down the hallways surrounding the nursing station. -At 10:20 a.m. R1 self-propelled to the dinning room. -At 10:29 a.m. R1 was in her wheelchair in the 400 hallway, NA-C walked past R1 without stopping. -At 10:44 a.m. R1 was in her wheelchair in 300 hallway, NA-C took R1's temperature and walked into an adjacent room. At 10:49 a.m. NA-C again walked up to R1 and took her oxygen saturations. During an interview at 10:50 a.m. NA-C indicated she did not offer/attempt to take R1 to the bathroom. -At 11:14 a.m. NA-A pushed R1 into her bathroom and assisted R1 to the toilet; R1 voided a large amount of urine. During an interview on 7/7/21, at 11:17 a.m. NA-D stated R1 was on 30-minute safety checks; the nurses or the trained medication assistants (TMA's) were responsible for completing the checks. When asked how often was R1 supposed to be toileted, NA-D responded, I think she is every 2 hours. NA-D stated an unawareness of when R1 had last been toileted, stated She was probably toileted after breakfast, I didn't get report from [NA-E] before she left this morning. During an interview on 7/7/21, at 2:15 p.m. DON stated NA's should be aware of the care plan they all have access. During a meeting with staff on 6/29/21, R1's updated care plan interventions were discussed. DON stated the staff who worked the overnight shift on 6/24/21 had been provided education. DON verified not all nursing staff to date had not been provided with fall re-education, however the information was on the home page of the electronic health record (EHR) system. DON stated after the fall, audits were being completed three times a week to ensure R1's care plan was being followed. During an interview on 7/7/21, at 3:18 p.m. NA-E stated R1 was supposed to be on every 30 minute safety checks and toileted every 2 hours and was not aware R1's toileting plan had changed to every one-hour. NA-E stated NA-C had toileted her before breakfast at around 7:30 a.m. NA-E indicated she think she offered her toileting before she left but did not recall the time. NA-E stated she did not go to the nursing meeting on 6/29/21, and did not receive any education pertaining to R1's falls. During an interview on 7/8/21, at 8:14 a.m. registered nurse (RN)-A stated she was the nurse manager of the unit. RN-A stated after R1's fall occurred there was a 72-hour review to determine the root cause, if appropriate interventions were developed and if interventions needed to be added to the care plan. RN-A indicated it was identified the toileting documentation was not being consistently completed by NA's. RN-A provided education but found documentation was not being done and not consistent. RN-A indicated an awareness of how to identify if the documentation the NA's were documenting were accurate, and indicated NA's were not specifically observed in person providing cares in accordance to the care plan rather the monitoring consisted of a review of the documentation entered into the record. R2's During an observation on 7/7/2021, at 10:16 a.m. R2 was observing sitting in his broda chair slightly reclined in front of his television in his room. R2's face sheet dated 7/8/21, included diagnoses of [CONDITION(S)] disease, dementia without behavioral disturbance, cognitive communication deficit, gait and mobility abnormalities, and weakness. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment, had hallucinations and delusions, and rejection of care behaviors. The MDS indicated R2 required extensive assistance from two or more staff members for bed mobility, transfers and toilet use and was frequently incontinent of bladder and bowel. The MDS also indicated R2 had two or more falls with minor injury since the previous assessment. R2's fall care plan, indicated R2 had a history of falls with multiple risk factors including impaired balance, involuntary movement related to [CONDITION(S)], poor judgment, poor coordination, hallucinations, abnormal gait, dementia, and cognitive communication deficit. R2's fall interventions included: -Offer toileting every one- hour, not to be left alone in bathroom. -Hourly checks do to fall risk. -30-minute checks due to fall risk. R2's fall record last 30 days included: R2 sustained an unwitnessed falls on 6/9/21, 6/15/21, and 7/7/21. R2's fall progress note dated 6/9/21, at 1:55 a.m. indicated R2 fell from his wheelchair at the end of the hallway by nurse's station at 1:55 a.m. that resulted in a skin tear to his left inner arm. The note indicated the trained medication assistant (TMA) reported R2 had been toileted recently, resident's brief was wet at the time of the fall. Immediate Fall Intervention: toilet q [every 2 hours]. The note indicated the care plan was updated with the new intervention. R2's Fall Follow Up progress note dated 6/9/21,included the additional information, R2 was last toileted at 9:12 p.m. The note included, Falls initial notation states toileting had been done recently. Current toileting plan is to offer every hour. and At the time of the resident's fall, care plan was being followed. The note identified the root cause was determined as confusion, impaired memory, gait imbalance, not asking for help, self-transferring. Intervention placed in attempt to prevent further falls: 30-minute safety checks. R2's every hour toileting documentation and urinary continence documentation was reviewed for 6/8 and 6/9 prior to the fall, documentation indicated R2 was not toileted every one-hour in accordance with the care plan. The continence documentation and hourly toileting documentation identified prior to the fall at 1:55 a.m., R2 was only offered or assisted to the bathroom at 9:12 p.m. and was incontinent. R2's Incident report for falls dated 6/15/21, at 7:04 p.m. indicated R2 had an unwitnessed fall in his room. R2 was found by an aide sitting on the floor by the side of his television stand and did not have any injury and R2 stated he was looking for his car keys inside his drawer to drive home. The immediate action in the report indicated R1 was brought to the common area and to ensure proper utilization of as needed medications. The report indicated the care plan was updated. R2's bladder incontinence record for 6/15/21 indicated R2 was last toileted at 2:19 p.m. at which time he was continent of urine. R2's progress note dated 7/7/21, at 2:45 p.m. indicated R2 had an unwitnessed fall in his room at 2:45 p.m. The note included: nurse was called into resident's room where he was sitting on his left side, with his weight on his left arm, hip and hand on floor holding him upright. His knees were slightly bent and half on the floor half on the wheelchair footrest. His wheelchair was tipped forward. Resident stated that he was trying to get up to go to the bathroom. Resident stated that he landed on his knees and tried to crawl. He denied pain. There was no visible injury anywhere on his body r/t [related to] this fall. The note indicated the immediate intervention to prevent reoccurrence was Therapy to evaluation safety of wheelchair. R2's documentation for hourly toileting and continence identified 9 separate entries for a toileting time of 2:19 p.m. During an interview on 7/7/21, at 10:20 a.m. licensed practical nurse (LPN)-B stated NA's were supposed to document in real time when they toileted and/or offered toileting to residents. LPN-B stated if there was no documentation, she would have to ask NA's every hour if toileting was completed according to the care plan. During an interview on 7/7/21, at 11:42 a.m. LPN-A stated R2 was supposed to be toileted every 2 hours; however then referenced the care plan and stated R2 was supposed to be toileted every hour. During an interview on 7/7/21, at 2:15 p.m. DON and administrator stated staff should be aware of what is in the care plan and if they were not, they should know where to get information and/or access to get familiar with the care plan. DON indicated after a resident fall, the nurse is supposed to determine root cause, determine an immediate intervention, and revise the care plan. DON indicated a 72-hour review was then completed which consisted of review of fall, causal factors, and evaluation of the care plan interventions to determine appropriateness. When asked how it was determined documentation of toileting was accurate, DON indicated if a resident was a two assist both persons would be interviewed and toileting documentation would be reviewed. DON stated surveillance video was not always used to determine root cause and/or if staff were following the care plan. During an interview on 7/8/21, at 8:14 a.m. registered nurse (RN)-A stated she was the nurse manager of the unit. RN-A reviewed R2's fall record, confirmed the record lacked documentation of the fall on 6/15/21, lacked care plan revision and implementation of an immediate intervention to prevent and/or reduce risk of falls. RN-A reviewed R2's toileting documentation and confirmed the documentation was inconsistent and conflicting. RN-A stated documentation should be done in real time and should be accurate. The immediate Jeopardy was removed on 7/8/21, at 6:40 a.m. when it could be determined the facility had completed the following: 1) R1's and R2's care plan was revised. 2) All staff were provided with education and found competent on the facility's fall policy which included; a) Determination of root cause analysis of falls b) Development of implementation of immediate fall interventions c) Importance of following individualized fall care plan interventions d) Concise and accurate documentation of fall interventions utilized in real time 3) All staff were provided with education on communication and a sustainable means of communication when care plan fall interventions were revised. 4) All licensed nurses were provided with education on the implementation, assessments, monitoring and effectiveness of interventions. 5) An auditing system was developed that included direct supervision to ensure all fall care plan interventions were being providing in accordance with the care plan and the corresponding documentation was accurate and completed in real time. In addition, all resident fall care plans were audited for accuracy, appropriateness, and individualization. Facility policy Fall Prevention and Reduction dated 7/2020, included: Individualized falls precautions and interventions will be developed for all residents who admit to the facility. All falls will be reviewed and preventative measures will be taken to decrease falls whenever possible and prevent injury. Interventions will be identified related to resident's specific risks and causes in order to reduce falling and to try to minimize complications from falling. All falls will be analyzed to determine root cause of the fall. Determine Root Cause as to why resident fell and implement interventions specific to the cause of the fall. Start immediate intervention to prevent further falls. Update Care Plan and Kardex with fall interventions. Hall nurse to complete Fall Risk Assessment after fall to identify new or changing risk factors for resident fall.

Based on observation, interview, and document review, the facility failed to assess, evaluate and monitor for the reoccurrences of resident to resident abuse for 1 of 1 residents (R1). The facility's failures resulted in a past non-compliance Immediate Jeopardy (IJ). The IJ that was identified on 7/30/2020, began on 6/18/2020, when the facility failed to prevent another occurrence and/or manage R1's continual physical aggression towards other residents. R1 had an altercation with an unknown resident on 7/13/20, and two subsequent altercations with R2 on 7/14/20 and 7/16/20. The IJ was removed on 7/16/2020, when R1's medical team was working to adjust medications, R1 was sent to the emergency room for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A Facility Reported Incident submitted to the State Agency (SA) on 6/18/20, indicated alleged physical abuse occurred when R1 and R2 were both in the dining room. The report indicated R1 began to yell at R2 and both residents started yelling at each other. R2 was removed from the dining room and R1 refused to leave and then hit and bit a nursing assistant. Both residents had bruises on their hands. The facility's investigative summary submitted to the SA on 6/23/20, indicated R1 had 3 prior resident to resident altercations since 6/8/20. The summary indicated changes to policy and procedures were not needed and to prevent reoccurrence the facility would offer R1 distraction activities, redirect other residents away from her, and inquired with a geriatric psychiatric hospital for criteria for admission (for admission R1 would have to be referred from the emergency room ). Interventions added to R1's care plan included: distract and carry on conversation prior to attempting cares and use language such as why don't we try going to the bathroom after developing a conversation with her. The summary also indicated the physician increased R1's [MEDICATION(S)] (antipsychotic medication), wrote and ordered to send to emergency room (ER) if there were additional physical altercations that put staff or other residents at risk. During an interview on 7/29/20, at 4:39 p.m. director of nursing (DON) indicated prior to 6/18/20, R1 had been physically aggressive towards R2 three times since 6/1/20, and an incident occurred on 6/12/20. The DON indicated R1's physical/verbal behaviors seemed to increase in the afternoon. The DON stated R1 liked to sit in the hallway, not in her room, therefore staff implemented 1:1 activities in the afternoon and tried to serve her meals first in her room. During an interview on 7/29/20, at 5:24 p.m. registered nurse (RN)-A stated R1 had physical and verbal behaviors towards staff, and verbal behaviors towards a couple of residents. RN-A stated an awareness of R1's physical aggressiveness towards R2 however, was not aware of the number of occurrences. RN-A stated on 6/18/20, R1 had been in the dining room eating at the same table as R2. RN-A verified R1 was not supposed to be in the dining room. RN-A stated, [R1] grabbed [R2's] arm or hit her or something. RN-A stated the NA's separated both of the residents, R1 was very difficult to redirect, and R1 hit and bit the NA's. RN-A stated she called the physician and got an order to increase R1's [MEDICATION(S)] and to send the resident to the ER if R1 continued to be aggressive and/or a danger to herself and others. During a subsequent interview at 5:56 p.m. on 7/29/20, the DON confirmed R1 should not have been in the dining room during meal time due to history of behaviors. During an interview on 7/30/20, at 2:53 p.m. NA-A stated she witnessed the altercation between R1 and R2 on 6/18/20. NA-A stated R1 was in the dining room for dinner that night but was not sure if someone took her in or R1 took herself in; R1 sat a table with R2 sitting on her right side and a male resident sitting on her left side. NA-A stated R1 had been served a dinner tray. NA-A stated she had to leave the dining room to get another resident, and when she was walking back, from the nurse's station she could see R2 crying at the table while R2 punched her repeatedly in the shoulders and upper arms. NA-A stated she ran in and yelled for NA-B who was on the other side of the dining room for help and at the same time pulled R2 away and took her into the hallway and got the nurse to assess R2. NA-A stated she then went back into the dining room, NA-B was trying to de-escalate R1, R1 continued to yell and curse and threw things at other residents. NA-A stated is was very difficult to get R1 out of the dining room and in the process, R1 bit her hand and hit NA-B. NA-A stated she had been aware of R1's verbal aggression towards a couple of the residents, however, was not aware R1 had 3 previous incidents prior to the one on 6/18 and had she known there would have been more of an effort to keep her out of the dining room and away from R2. NA-A stated R1 was very social, however, would get frustrated with residents when she could not hear them or if they did not make sense to her. During an interview on 7/30/20, at 4:50 p.m. NA-B verified on 6/18/20, R1 was sitting at the dining room table next to R2. NA-B stated she was in the dining room towards the end of the meal service to assist residents back to their room. NA-B said she had been attempting to stop a resident from self-transferring when she heard NA-A yell her name. NA-B said she turned around and saw R1 hit R2 in the face twice so she ran over to try and de-escalate R1, while NA-A removed R2 from R1. NA-B stated R1 continued to yell, was very difficult to redirect and remove from the dining room, bit NA-A and hit her. NA-B stated, [R1] and [ R2] should not be seated next to each other. NA-B also stated R1 did not always like R2 because R2 had dementia and was often confused which frustrated R1. R1's Admission Record, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment and had continuous disorganized thinking and delusions. The MDS also indicated R1 had physical and verbal behaviors directed towards others as well as other behavioral symptoms not directed towards others. The MDS also indicated R1 required limited assistance from one staff member for transfers, locomotion on and off the unit, and to walk in room, however required supervision to walk in the corridor. R1's behavior care plan dated 6/19/20, included R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The associated interventions included: -Acknowledge resident moods in 1:1 interactions. Remove resident to quiet room and spend time with her to reassure (start date 4/18/19) -Encourage resident to attend group activities (start date 4/18/19) -Discuss feelings of anger and options of appropriate channeling of these feelings with resident (start date 4/18/19) -Provide emotional support to resident/ family as needed (start date 10/17/19) -Medications as ordered (start date 6/7/20) -Observe mental status/ mood state changes when new medication is added (start date 6/7/20) -Offer activities of which resident has shown interest (start date 6/7/20) -Just prior to meal tray delivery to the 500/600 wings, please assist resident to her room, provide diversional activity such as music, tv, etc., to help decrease her anxiety prior to meal (start date 6/8/20) -Using language like why don't we try going to the bathroom? after developing a conversation with her (start date 6/19/20) -Distract and carry on conversation 1st before attempting any cares, she likes to talk her jewelry, her beads in particular (start date 6/19/20) -R1 likes to be in the hallway at intersection of 200 & 300 hall. She calls this her spot. (start date 6/19/20) -Referral to ER as needed (start date 6/19/20) R2's Admission Record dated 7/30/20, included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly MDS dated [DATE], indicated R2 had severe cognitive impairment, had continuous disorganized thinking, hallucinations, delusions, and had wandering behaviors. The MDS also indicated R2 required extensive physical assistants from one staff member for activities of daily living including bed mobility, transfers, locomotion on and off the unit. R2's vulnerable adult care plan dated 6/9/20, included, Potential for Susceptibility and Vulnerability r/t [related to] impaired cognition secondary to dementia with delusions and SNF [skilled nursing facility] placement, recipient of resident to resident physical aggression. Corresponding interventions included: -Inform family of personal needs -Social service intervention as needed -Staff to be aware of resident vulnerability -Staff to meet resident's needs per plan of care. R1's physician visit note dated 6/19/20, indicated the facility nurse had reported R1 had another significant event last night. She had in [sic] altercation with another resident, she also bit a staff member breaking the skin. [R1] has had increasing difficulties with agitation and disruptive behaviors, likely exacerbated to some degree due to COVID-19 pandemic limitations. She is on [MEDICATION(S)] currently 12.5 mg at 10:00 a.m., 25 mg at 2:00 p.m. and 12.5 mg at 6:00 p.m. The note also included, Discussed in the event of the episode yesterday, if it is not felt safe for the patient to be in the facility that should be directed to the emergency department for the evaluation of Grace Unit, versus inpatient psychiatric unit [name of location], versus inpatient medicine service at [name of facility] with psychiatry following is appropriate. Orders included: 1) Continue to maximize non pharmacological interventions 2) increase [MEDICATION(S)] to 50 mg at 2:00 p.m. and 25 mg at 6 p.m. 3) Follow up visit to review behaviors in 1 week. 4) If additional altercations putting staff or residents at risk, referral to ER (emergency room ) would be needed. R1's physician visit on 6/24/20, indicated reason for visit was behavior problem and per the director of nursing R1 had increased aggressive behaviors since 5/26/20. The note included history of aggressive incidents. 1) 5/26/20 at 9:00 p.m., R1 became aggressive with another resident and sat up over the resident while yelling. 2) On 6/1/20 at 9:30 p.m., R1 hit another resident in a wheelchair on the right hand in front of the 200/400 nurses' station, did not appear to have injuries but was verbally aggressive towards staff. 3) On 6/2/20 resident to resident aggression reported to Office of Health Facility Complaints. 4) On 6/3/20, R1 hit another resident in a wheelchair while they were in the hallway, R1 was swearing and yelling at other residents. R1's progress note dated 7/13/20, at 1:47 p.m. included; While residents were being brought to the dining room this resident grabbed another resident by the wrist. Resident was easily directed and is currently in a pleasant mood. R1's physician note dated 7/13/20, indicated nurse reported R1 had increased behaviors, and had a little bit more of a difficult day in general, but this evening she had increased aggression. She was up in the hallway and when trying to be redirected TMA [trained medication assistant] she hit TMA. [R1] was able to be directed back to her room and while still mildly agitated is not showing aggression towards others at this time. We had discussed the past if she is in the immediate threat to others that would need to be directed to the emergency department for assessment and consideration of inpatient psychiatry verses alternative options such as the Grace Unit. Well she did hit in [sic] individual earlier today, she is not expressing immediate threat to others at this time. Will work on medication adjustments today and continue to work on approach and monitor behaviors. Verbal orders given evening 7/13, 1) [MEDICATION(S)] 25 mg given once. 2) [MEDICATION(S)] dose change to 50 mg at 6:pm. time (keeping AM and 2:00 p.m. dose the same. A subsequent progress note on 7/14/20, at 12:10 p.m. indicated R1's power of attorney (POA) was notified of the increase in [MEDICATION(S)]. Progress note at 12:19 p.m. indicated a fax was received from the physician due to R1's increased behaviors last evening; new order for increased [MEDICATION(S)] to 50 milligrams (mg) at 6:00 p.m. and continue with the same morning and 2:00 p.m. dose, and one time dose of 25 mg at time of the phone call. R1's record lacked evidence staff review of R1 behaviors leading to and including the 7/13/20 incident. Further, R1 had not received an assessment or evaluation of her behavior to determine causative factor of her aggressive behaviors. In addition, no new interventions implemented. During an interview on 7/29/20, at 4:39 p.m. DON referenced R1's record and stated she was not aware of the incident on 7/13/20, it had not been reported to her and verified R1's record did not identify implementation of interventions or persistent behaviors. DON stated RN-A had called her that evening and reported R1's was having verbal and physical behaviors towards staff and she directed RN-A to call the physician to see if R1 should be transferred to the ER for behavioral management. DON confirmed the physician had given orders to increase [MEDICATION(S)] and for the Stat dose, however, indicated R1's record did not have supporting documentation for the stat dose or the increase. Facility Reported Incident submitted to the SA on 7/14/20, alleged physical abuse occurred on 7/14/20, at 7:00 p.m. after R2 backed into R1 with her wheelchair; R1 then yelled at R2, grabbed her wrist and wouldn't let go. The report indicated a nurse separated the residents and R1 was given a PRN (as needed) antipsychotic medication, the physician was notified and directed the nurse to continue to provide R1 with 1:1 supervision for the remainder of the evening. The investigative summary submitted to the SA on 7/21/20, indicated [R1] was witnessed yelling, grabbing the residents [R2] right wrist and hitting the resident. The summary indicated R2 had severe cognitive impairment, was evaluated by the physician on 7/17/20 and a change was made to her mood stabilizing medication and R1 was given PRN [MEDICATION(S)] 50 mg for agitation on 7/14/20. The summary indicated both residents had dementia, a mood assessment and cognitive assessment were attempted for R1 however, R1 did not complete them. R1's care plan was updated to show interventions of medication adjustment, provider visits related to agitation. R1's corresponding progress note dated 7/14/20, at 8:16 p.m. included 7:00 p.m. R1 was in the 300 hallway wing near nurses station, the nurse had their back turned to the situation. The resident began to yell and was witnessed grabbing and hitting another resident [R2]. It is unclear at this time what started the altercation. The resident [R1] was brought back to her room by the writer to ensure other resident safety. The resident again became violent hitting the writer numerous times leaving red marks on the writers right arm and torso. Once in their room another staff member not involved in the initial altercation was brought to do a 1:1 with the resident and ensure safety. Ten minutes later the resident couldn't be more pleasant. Provider contacted and informed of the situation as well as nursing management. At 8:00 p.m. physician was contacted and informed nursing staff to go ahead and stop the 1:1 with the resident and also gave orders for 1 time prn [MEDICATION(S)] 50 mg for agitation to help mitigate future aggression. R1's physician note dated 7/14/20, indicated a facility nurse reported R1 had an altercation with another resident tonight and was able to separate them, and R1 was 1:1 supervision. R1 has been aggressive with others when she is out of her room. [MEDICATION(S)] was increased from 12.5-50.0-25.0 mg (morning/afternoon/evening) to 12.5-50-50 mg today. The note also included, She [R1] has limited insight and understanding. We have limited management options in the setting of COVID-19 and unfortunately pharmacological management continues to be part of the plan given her physical aggression. [MEDICATION(S)] does not appear to be effective and will change to [MEDICATION(S)]. If she poses a threat to others and cannot be redirected, then we would need to send to the ER for additional intervention and safety. During an interview on 7/29/20, at 4:39 p.m. the DON referenced R1's record. In response to the question, what interventions were implemented after this incident to protect R2 and other residents from R1, the DON stated a mood and cognitive assessment were attempted but not completed because R1 was not willing. The DON stated the intent of the assessments was to evaluate for changes and implement any needed interventions based on the outcome of the assessments. The DON confirmed no other interventions were implemented after the incident including ongoing 1:1 supervision and/or increase in supervision. A facility reported incident submitted to the SA on 7/16/20, alleged physical abuse occurred on 7/16/20, at 7:00 p.m. after R2 ran over R1's foot with her wheelchair, R1 reacted and punched R2 in the right arm. The residents were separated, R1 was brought back to her room where she continued to hit staff, called staff [OBSCENITY] es and refused to stay in her room. R1 was given her scheduled [MEDICATION(S)] (antipsychotic) that evening but continued to be aggressive with staff and not follow directions, and NA provided 1:1 supervision to monitor behavior. R1 would not calm down, physician was notified and gave order to send to the emergency for further evaluation. The investigative summary submitted to the SA on 7/24/20, indicated R2 had been evaluated by the physician and had medication changes. The summary included, Care plan updated to offer individualized activities in afternoon as resident allows as resident's agitation, wandering, and restlessness occur typically in the afternoon. Resident continues to be on monitoring for behaviors and change in mood. 7/16/20 [R1] was sent to ED [emergency department] for evaluation r/t incident with [R2] and physical behaviors toward staff. She returned later that evening [CONDITION(S)] medication adjustments made for R1 on 7/16 and 7/21. R1's emergency room physician visit note dated 7/16/20, indicated reason for visit was psychiatric evaluation and cognitive changes. The note indicated R1 had history of major neurocognitive disorder due to multiple etiology with behavioral disturbance. R1 presented to the ER for evaluation of behavioral problem and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . At approximately 2000 [8:00 p.m.], a resident at the nursing home accidentally wheeled over the patient's sensitive toe. The patient then wheeled around and punched the offending resident in the face. EMS [emergency medical service] provided the patient [MEDICATION(S)] and she was transferred to the ED after some escalation in behaviors and the involvement of Rochester Sheriff's Department. The note identified that R1 had recent [CONDITION(S)] medication changes, was observed for extended period of time in the ED, and had returned to baseline. After this observation in the emergency department, I think reasonable to return home .We will give instructions for return for any worsening or worrisome signs or symptoms. During an observations on 7/29/20, from 11:28 a.m. to 3:00 p.m. R1 was observed to be in her bed with her eyes closed. During an observation on 7/29/20, at 7:42 p.m. R1 sat in her wheelchair at the end of the hallway, RN-C accidentally bumped her foot and stated, sorry, I didn't see you. R1 look down and said something not audible. R1 did not demonstrate verbal/physical aggression towards the nurse. During an observation at on 7/29/20, at 8:12 p.m. R1 continued to sit in the same spot, R3 sat in her wheelchair directly in front of R1, R3 was talking to R1, R1 stated what? a couple of times, rolled her eyes, however, R1 did not demonstrate verbal/physical behaviors towards R3. At 8:14 an activities staff member started conversing with R1. During an observation on 7/29/20, at 8:42 p.m. R1 and R2 were sitting in their wheelchairs in the middle of a hallway, heading in opposite directions conversing, R2 was within arm's reach of R1. R1 did not display physical or verbal behaviors towards R2. During an interview on 7/29/20, at 4:39 p.m. the DON stated R1 had an increase and worsening in physical aggression towards residents and staff since around the end of May with increased difficulty in de-escalation and redirection; explained husband used to be here every day and R1's increased behaviors were probably related. DON indicated R1 had multiple changes to her antipsychotic medications between 6/18 and 7/14, last dose of [MEDICATION(S)] and first dose of [MEDICATION(S)] was given on 7/16. DON indicated they were starting to see some improvement in her behaviors, there had not been any further physical aggression towards other residents. DON indicated on 6/18/20, the physician had ordered if R1 had behaviors that jeopardized safety of residents, staff and herself they were supposed to send her to the ER for further evaluation and possibly psychiatric treatment. DON confirmed R1 had not been sent to the hospital until 7/16/20. During an interview on 7/30/20, at 10:59 a.m. R1's doctor (MD)-A stated an awareness of R1's physical and verbal aggressive behaviors directed at staff and other residents, namely R2. MD-A indicated the simplest way to prevent the incidents from occurring is to keep those two separated. MD-A stated R1 had an increase in behaviors since around beginning of June, and R1 had multiple medication changes within that time. MD-A indicated he had discussions with facility nurses in which he directed them that if R1 demonstrated behaviors that put other resident and staff at risk to send her to the emergency room . MD-A stated on 7/13/20, a nurse called to report physical aggression toward staff, and it was decided to give R1 a PRN [MEDICATION(S)] and increase the dose instead of sending to the ER because although agitated was not showing physical aggression towards others. MD-A indicated R1 was sent to the emergency room for further evaluation of increased behaviors on 7/16/20 because staff could not de-escalate R1. The facility's Abuse and Neglect Reporting policy dated 5/2020, included; It is the policy of Pine Haven Care Center, that each resident will be free from Abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing in the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator and wait for further instruction from administration, if possible. If the situation is an emergent danger to the other residents or staff, dial 911 for immediate assistance.

Based on observation, interview and document review, the facility failed to comprehensively assess each fall and identify causative factors to determine the reason for falls and identify potential effective interventions to decrease the risk for future falls for 3 of 3 residents (R1, R2, R3) reviewed for accidents. R1 had two falls from her specialized wheelchair and sustained a brain bleed. R2 had multiple falls resulting in a right [CONDITION(S)]. R3 had multiple falls and sustained right and left wrist fractures. These deficient practices resulted in immediate jeopardy (IJ). The IJ began on 4/15/2020, when R3 sustained a fracture to the right wrist and failed to adequately assess interventions to prevent future falls. The director of nursing (DON) and registered nurse (RN)-A were notified of the immediate jeopardy at 4:50 p.m. on 7/20/20. The immediate jeopardy was removed on 7/21/20, at 4:33 p.m. after it could be verified the facility had implemented an acceptable removal plan however; noncompliance remained at a G - isolated scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings Include: R1 was observed on 7/21/2020, at 9:13 a.m. sitting in her wheelchair in the doorway to her room, right foot pedal, flip away tray with lambs wool in place on her wheelchair and her call light was on. R1's call light was answered at 9:15 a.m. R1 had her call light on to go to the bathroom. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE]; identified R1 was cognitively intact and had no rejection in cares. R1 did not walk in her room or the corridor. R1 required extensive assist of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. R1 had impaired range of motion to the upper and lower extremities on one side. R1 had one fall with no injury. Diagnoses included [CONDITION(S)] and [CONDITION(S)] (one-half of the body has weakness/ paralysis) following a stroke affecting right dominant side. R1's fall risk assessment dated [DATE] had a score of four indicating R1 was at low risk for falls. R1's fall care plan printed 7/17/2020 included, Risk for falls characterized by history of falls/ injury, multiple risk factors related to: impaired balance, impaired mobility, visual field cut, right sided [CONDITION(S)], hx [history] of seizures, and use of antiepileptic and hypoglycemic medications. Goals include, R1will have no injury from falls. Interventions through the next review period included, Ensure environment is free of clutter. Have commonly used articles within easy reach. Reinforce need to call for assistance. Resident to wear proper and non slip footwear. Transfer and Change positions slowly. R1's Kardex Report (nursing assistant care plan) printed 7/17/2020 included, Safety: Right flip away tray in w/c (wheelchair) for right arm positioning, splint to right arm and leg as ordered. Uses foot pedals and w/c (wheelchair). R1's initial state agency report dated 7/3/2020, at 7:05 a.m. indicated R1 had a fall in her room and sustained a head injury, the allegation was for neglect/falls. Description of incident: Resident was in her wheelchair and fell , found on floor. Reported pain in right hip, head and neck. Gave order for resident to be seen in ED (emergency department). CT completed and showed a new left sided subdural hematoma (brain bleed). R1's facility five day investigation report to the state agency included, Care plan at the time of the fall was not followed, resident is to have flip away tray on w/c [wheelchair] to assist with right arm and hand positioning, flip away tray was not on resident's w/c [wheelchair] at the time of the fall. Investigation summary included, .7/4/2020 returned from hospital to care center. 7/8/2020 pharmacy consult review of medications found no irregularities. 7/9/2020 resident was seen for telehealth visit, family request Hospice care at this time. Hospice referral made per family's wishes to Mayo Hospice . Description of harm: left sided subdural hematoma. R1's medical record lacked documentation of a root cause analysis, fall investigation or an interdisciplinary team meeting review of this fall. R1's falls were reviewed from 2/2020 to present and revealed R1had a fall out of her wheelchair on 6/3/2020 and sustained a bump to the right side of her head. R1's progress note dated 6/3/2020 included, Description of Incident: was found laying [sic] on her side on the floor. She had a bump on the right side of her head. Resident fell in her room. Vitals and neuros were stable and WNL [within normal limits]. Neuro checks: LOC, Speech, pupil response, grasp, CWMS of extremities: Alert, speech clear but vocabulary limited per baseline, pupil response normal on right side but sluggish on left per baseline. Color is normal, warmth is appropriate, movement is limited per baseline, and sensation is intact .Skin check completed. Resident has a bump on the right side of her head. No abrasions noted and no bruising noted at this time .Safety Devices in Use?: Call light not in reach. Suspected Head Injury?: Bump on head but neuros and vitals are stable and WNL. R1's medical record lacked documentation of a root cause analysis, fall investigation or an interdisciplinary team meeting review of this fall. During an interview on 7/17/2020, at 9:51 a.m. the director of nursing (DON) stated the facility did not do fall investigations reports. The DON stated she thought the reason R1 fell was she was leaning forward and did not have the lap tray on her wheelchair and could not stop herself and fell forward hitting her head. The DON stated we have an initial fall note, a dicussion the next morning at our morning reports, an IDT (interdisciplinary) team discusses resident's falls. At the IDT meeting they discuss what the team feels is appropriate interventions and would be added to the chart and care plan. The DON verified there was no documentation from IDT meeting in the progress notes for R1's falls. The DON said R1's was found on the floor 7/3/20 and was unable to tell staff what she had been doing. The DON stated she spoke with the nurse that morning who reported she did not have her flip away tray on the wheelchair. R1 uses the tray for positioning for her right arm and hand. The DON stated the nurse completed education with the nursing assistant who cared for R1 and stated this education was not documented. The DON stated she would have expected the education to be documented. The DON verified R1's medical record lacked documentation of a root cause analysis, fall investigation or an interdisciplinary team meeting review of this fall. For the fall on 6/3/2020, the DON verified by looking at the facility documentation and said one cannot tell if R1 fell from bed or the wheelchair. The DON stated the facility would not be able to implement appropriate interventions to prevent further fall if the documentation did not reflect what happened. The DON verified the fall documentation did not indicate if staff were following the care plan. The DON stated there was a lack of documentation related to fall and the facility contributed her fall to her being ill. During an interview on 7/17/2020, at 10:47 a.m. nursing assistant (NA)-E stated R1 was not a frequent [NAME] and stated R1 was paralyzed on her right side and had no control. NA-E stated R1 had a tray for her wheelchair and stated she could slide the tray to the side with her left arm. NA-E stated the purpose of the tray was to support R1's arm so it did not hang and dangle. NA-E stated the staff member did not have her wheelchair tray on the chair when R1 fell on [DATE],. During an interview on 7/17/2020, at 11:10 a.m. licensed practical nurse (LPN)-A stated R1 had to have her flip table on her wheelchair, as she was weak on her right side. Stated she was here for the 7/3/2020 fall and R1 did not have her flip tray on her wheelchair and from what she was able to gather she fell right forward out of her wheelchair. During an interview on 7/17/2020, at 11:51 a.m. NA-F stated he got R1 up and in the wheelchair on 7/3/2020 and stated he did not put her armrest on the wheelchair. NA-F stated he sat her in front of the television and placed her room tray table in front of her and call light was in reach. NA-F stated when he came back the room tray table was to the side and she had fallen straight out of her chair and was to the left of the tray table. NA-F stated he knew of the flip tray/arm rest and he forgot about it. NA-F stated, I forgot about it and she seemed to be sitting fine. I was not aware the tray needed to be on the wheelchair at all time. I think I have been in there before when the tray was not on there and she was fine. NA-F stated the nurse did talk to me and told me, I needed to make sure I followed the care plan, but nothing was specifically said to me about the tray. NA-F stated the Kardex on the tablets includes care plan interventions are in place. NA-F stated, I am not even sure if the tray was supposed to be mandatory to be honest. NA-F stated he got R1 up in her wheelchair and somebody else was going into the bathroom that joined in her room and he helped the other resident. NA-F stated he went to go answer the light real quick, he thought R1 was trying to reach for something and fell to the floor. NA-F stated he would not have left the room if he did not think she was safe. During an interview on 7/17/2020, at 1:17 p.m. NA-A stated on 6/3/2020 she had gotten R1 in her wheelchair as it was her bath day, she was in her jammies, and stated she told her she would come back for her bath. NA-A stated she went to get a lunch order for another resident down the hall and she heard over the walkie that R1 was on the floor. NA-A stated she put the flip table on her wheelchair when she put her into the wheelchair and stated she does not usually work as an aide but stated when she was down there she put the flip tray on R1's wheelchair. NR-A stated she talked to RN-A that day (6/3/2020) regarding the fall and she remembered NA-A bringing her in and talked me about the flip table and we looked to make sure it was in the care plan. NA-A stated they have had a kardex on the tablets and pocket care plan was on the kardex. During an interview with DON and registered nurse (RN)-A. on 7/17/2020, at 1:59 p.m. RN-A verified R1's documentation from fall on 6/3/2020 did not indicate if the facility staff were following the care plan. RN-A stated she wrote nursing assistant (NA)-A up [disciplinary] on that day. RN-A stated she could not recall what she wrote NA-A up for and stated she would need to get the form from human resources. RN-A provided the form titled Employee Discussion Record, which indicated, tray/foot pedal to right side of wheelchair. Lap tray not on and resident fell . Reviewed CP [care plan] with CNA. The DON stated we felt the root cause analysis for both of her falls was because she did not have the lap tray on. The DON stated for the fall on 6/3/2020 R1 bumped her head and stated family did not want her sent in to the emergency room . The DON stated a vulnerable adult report was not made because her understanding was you only needed to report when there was a major injury, R1 had no changes to her cognition, and she was alert. During an interview on 7/17/2020, at 2:40 p.m. family member (FM)-A stated when she was updated of the fall, she asked the nurse if the flip tray was on at the time of her fall on 6/3/2020. The nurse told her they did not believe it was. FM-A stated they called me about the second unwitnessed fall (7/3/2020). FM-A said she asked them how did R1 fall out of her wheelchair when she has not for [AGE] years. FM-A stated the facility staff member would not commit if the flip tray was open on her wheelchair when R1 fell . FM-A stated the facility needed to be diligent in making sure the flip tray was on and stated R1 cannot be left alone with that thing (flip tray) open. During an interview on 7/20/20, at 9:47 a.m. NA-H stated R1 was wobbly, did not have any right side support and her arm will hang over the side of the wheelchair, arm rest and foot pedal must be on the wheelchair to keep her from falling out of her chair. During an interview on 7/20/20, at 10:15 a.m. trained medication aid (TMA)-A said lately R1 had been a frequent [NAME]. TMA-A stated there was a lot of new staff, with new people training new people and did not think they (new staff) were educated enough on the kardex (nursing assistant care plan). TMA-A said R1 required a foot pedal on the right side of her wheelchair and had a flip tray/arm rest for her right side (of the wheelchair). TMA-A stated R1 does not have control, stated if the tray was not on her wheelchair, the armrest was not in place and stated the whole right side of the wheelchair would be open and there would be no support for her. TMA-A said staff take off the whole piece (flip tray/arm rest) off the right side of wheelchair. The right side was completely open on her chair. TMA-A stated it was to be on at all times when R1 was in her wheelchair. During an interview on 7/20/2020, at 10:30 a.m. LPN-B stated when a resident falls staff are called down to the room to make sure the resident is safe, complete range of motion, vital signs and neuro checks and once considered safe, they are able to get them up. LPN-B said they could initiate 15-minute vital checks and neuros. LPN-B said they started a new huddle about a month ago after a fall. LPN-B stated they look at what they doing, when did you see them last, when were they last toileted and this was documented in progress note related to fall. LPN-B stated in our huddle we are to be trying to see what we can do to prevent falls and try to come up with something new that would be appropriate for them. LPN-B stated she believed we are suppose to be doing an intervention and adding them to the care plan. LPN-B stated she was trained on this in the middle of June. During an observation and interview with the DON on 7/20/2020, at 11:05 a.m. The DON demonstrated on R1's wheelchair, the whole right side of the wheelchair comes off and the flip tray is attached to the side of the armrest. During an follow-up observation and interview with the DON on 7/21/2020, at 4:00 p.m. the DON said you can take the flip tray off the side of the wheelchair, but verified what would remain on the right side of the wheelchair would not provide enough support to keep R1 from falling from the wheelchair if the flip tray/arm rest was not attached to the wheelchair. R2 R2 was observed on 7/17/2020, at 10:45 a.m. in her bed resting on her side, oxygen in place, walker by the bed and call light in reach. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE]; identified R2 had moderate cognitive impairment and had no rejection in cares. R2 required limited assist of one for bed mobility, personal hygiene and to walk in her room and corridor and limited assist of two for transfers and extensive assist of one for toileting. The MDS further indicated R2 had two or more falls with no injury. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery (stroke), Alzheimer's disease, muscle wasting and atrophy. R2's fall risk assessment dated [DATE] had a score of fourteen indicating R2 was at high risk for falls. R2's fall care plan with a print date of 7/17/2020 included, At risk for falls characterized by history of falls/ injury, multiple risk factors related to: dementia, History of falls, visual deficit. Fall with fx [fracture] of right greater trochanter 5/26/2020. XR [x-ray] & CT [CAT scan] could not definitely show if fx [fracture] is acute vs [versus] chronic. Goal: [R2] will not have multiple falls with major injury through the next review period. Interventions: Analyze previous resident falls to determine whether pattern/ trend can be addressed. Call light within reach at all times when resident is in their room. Ensure environment is free of clutter. Have commonly used articles within easy reach. Resident to wear proper and non-slip footwear. Staff to anticipate resident's needs. TRANSFER: per therapy, transfer with assist of 2 and walker. R2's Kardex Report (nursing assistant care plan) printed 7/17/2020 did not address resident safety or fall prevention interventions. R2 had six falls from 2/2020 to present and revealed the following: 1. R2's Initial fall Notation- progress note 2/3/2020 included R2 was calling out for help at 11:15 p.m. and was found lying on floor facing window on her left side. Noted to have a bloody nose, resident stated it had started before she got up. No injury. 2. R2's Initial fall Notation- progress note 2/7/2020 included resident self-transferred in room without any assistance from staff without call light. She denied any pain and no observable signs of injury witnessed on behalf of the registered nurse. Risk management documentation indicated the fall was at 7:13 a.m. 3. R2's Initial fall Notation- progress note 4/20/2020 included resident was found on floor by staff between her bed and rocker. Resident was sitting on her buttock. No injuries are noted. Resident was last seen with Hospice nurse 10 minutes prior. Resident stated she was trying to move chairs. Resident was re-educated about how important it is for her to use the call light even if it is something small. Risk management documentation indicated the fall was at 12:31 p.m. 4. R2's Initial fall Notation- progress note 5/19/2020 included resident was found sitting on ground next to her rocker with peanuts spilt around her. Resident has no injuries and denies pain. Risk management documentation indicated the fall was at 12:31p.m. 5. R2's Initial fall Notation- progress note 5/26/2020 included resident lowered themselves on one knee while ambulating independently. Risk management documentation indicated the fall was at 5:40 p.m 6. R2's Initial fall Notation- progress note 5/27/2020 heard resident calling out from room. Resident was found lying on her back on the floor near the bed. Resident had large goose egg on right side forehead. Risk management documentation indicated the fall was at 10:20 p.m. R2's medical record lacked documentation of a root cause analysis, fall investigation or an interdisciplinary team meeting review after each fall for the falls listed above. R2's IDT (interdisciplinary) progress note dated 6/3/2020 included, .Falls (review last quarter): 5/19/20; 5/26/20; 5/27/20. On 5/27/20, resident did sustain an injury due to the fall - 5/27 hematoma on head. Analysis of recent falls to be completed including pharmacy review of current medications . During an interview on 7/17/2020, at 10:58 a.m. nursing assistant (NA)-E stated R2 was not a frequent [NAME]. NA-E stated R2 required a two assist for transfers and stated the facility took away her lift chair remote. NA-E stated she believed R2's falls were from the recliner. NA-E stated for fall interventions the only thing we are doing was a two-person assist or an easy stand if no one was available to help. During an interview on 7/17/2020, at 11:20 a.m. licensed practical nurse (LPN)-A stated R2 has had a couple of falls since she has been here, her cognition varies and sometimes she was alert and orientated and at times confused. LPN-A stated R2 required an assist of one, she was not sure of any fall interventions for her and stated R2 did not have a fall mat or anything. The DON reported during interview on 7/17/2020, at 4:38 p.m. R2 started having hip pain on 5/27/2020. An x-ray was completed and showed a possible fracture, but they could not determine if it was chronic or acute. The DON stated since the CT was inconclusive, R2 was encouraged to have an MRI. However, when the NP spoke with R2's family, they declined to do any further testing instead requesting to have them manage her with comfort measures since she was on hospice. The DON stated there was not enough information from facility documentation, verified a root cause analysis or fall investigations were not completed and stated no new interventions were implemented following R2's falls that she could see. The DON stated her expectation was root cause analysis and falls investigations were to be completed to attempt to prevent further falls and further injuries. During an interview on 7/22/2020, at 9:20 a.m. family member (FM)-B stated he told registered nurse (RN)-A that they were going to have R2 transferred from the facility if this (falls) keeps happening. FM-B stated, I do not think very highly of their responsibility to take care of their patients. I am just not happy with them I guess. During an interview on 7/20/20, at 9:29 a.m. NA-I stated when R2 came into the nursing home it did not seem like she was a frequent [NAME]. NA-I stated that recently, R2 had a couple of falls. NA-I stated R2 did not use her call light and stated staff can hear her from her room stating, Can I get some help in here. NA-I stated R2 fell because she usually needed to go to the bathroom and would self-transfer. NA-I stated for fall interventions toilet upon rising and before and after meals, just making sure you are checking on her, make sure call light was near her and ask her if she needs to use the toilet. R2 stated those are all preventative things (for falls). NA-I also stated R2 would pick up walker when walking to go over oxygen tubing. During an interview on 7/20/20, at 9:44 a.m. NA-G stated for fall interventions R2 had a call light and a bell, staff also check on her a lot and toilet upon rising and before and after meals. NA-G stated staff try to keep her oxygen tubing away from her feet as that was an issue for her and stated she played around with her tubing and can tangle it around her feet. NA-G stated R2 also has poor eyesight and that did not help. During an interview on 7/20/20, at 9:58 a.m. NA-H stated for fall interventions staff try to take R2 to the bathroom before and after meals and before we leave her rooms. NA-H stated most of the falls have been related to R2 trying to get to the bathroom. NA-H stated sometimes R2 used her call light and other times she would holler. During an interview on 7/21/2020, at 9:44 a.m. RN-A stated the analysis of falls or the pharmacy review was not completed per the IDT note written on 6/3/2020. RN-A stated she remembered specifically she had not followed up on the IDT recommendations. RN-A stated she, as the nurse manager would have been responsible to follow up to ensure the falls analysis and pharmacy review were completed. RN-A verified she did not have a system to ensure IDT recommendations were completed and stated she was searching for a way to keep more organized and to keep track. R3 On 7/21/20, at 9:13 a.m. R3 was observed with her eyes closed sitting in a wheelchair near the nurses' station. R3's left arm was in an orange cast and she was holding her left fingers with her right hand. R3 was observed using her feet to propel her wheelchair and down the hallway about 10 feet before turning around and returning towards the nurses' station. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had cognitive impairment. Further, R3 required one-person physical assist with activities of daily living, had impairment on one side, and used a wheelchair and walker. The MDS also identified R3 is frequently incontinent of urine. According to the diagnosis list, R3's diagnoses include: pain, generalized anxiety disorder, [CONDITION(S)] (loss of ability to understand or express speech caused by brain damage), repeated falls, Alzheimer's disease, hypertension, right artificial hip joint, [CONDITION(S)], fracture of left hip, displaced fracture of surgical neck of left humerus, fracture of sacrum. R3's care plan printed 7/17/20, indicated R3 required assistance for mobility related to fall history and deconditioning, with interventions to reinforce use of assistive device and weight bearing as tolerated for bilateral lower extremities but no left shoulder range of motion. The care plan also included a fall risk characterized by history of falls, deconditioning, dementia, attempts to be independent and not always aware of physical limitations. Fall interventions included; analyze previous resident falls to determine whether pattern/trend can be addressed, anticipate needs, assist resident to be in hallway/near staff when not in bed. The interventions indicated R3 shut doors, and that staff were to encourage and open door as often as possible, call light within reach at all times when resident in room, encourage resident to remain in common areas, encourage resident to use handrails or assistive devices properly, ensure environment is free of clutter, have commonly used articles within easy reach, low bed, medication review and recommendation by medical doctor (MD)/nurse practitioner (NP), medication review by pharmacy consultant, OT (occupational therapy) to evaluate wheelchair, reinforce need to call for assistance, resident to wear proper and non-slip footwear, review medications, review toileting schedule to see if trends in falls related to toileting, staff to anticipate resident needs, and transfer and change positions slowly. R3's bedside kardex (used by nursing assistants) printed 7/17/20, included under the Safety Section; assist resident to be in hallway near staff when not in bed, resident shuts door, staff to encourage and open door as often as possible, and encourage resident to remain in common areas. Review of R3's progress notes (PN) for falls from 3/2020 to 7/22/20 included: -PN 3/1/20 at 6:25 a.m., indicated R3 had suffered an unwitnessed fall with skin tear on left hand first finger with right upper arm pain. R3's Discharge/Transfer PN dated 3/1/2020 at 12:30 p.m. indicated resident was sent to the emergency room by ambulance at 0845 and returned at 1230 with no new orders and x-ray of right shoulder was negative. R3's Falls Initial Notoation PN dated 3/1/20 at 12:40 p.m., indicated staff heard a yell and a loud noise come from R3's room and resident was found on the floor in front of the bathroom with the walker on its side next to resident. R3 had a skin tear on the left hand first finger that was cleansed and covered. Neuro checks were within normal limits. R3 did not have a strong grasp on the right hand when asked to squeeze. R3 favored that arm and complained of pain 30 minutes after the fall. No bruising was noted. -PN dated 4/15/2020 at 6:56 a.m. indicated at 6:00 a.m. R3 resident was found on her back on the floor holding her wrist and crying, and had an abrasion noted on right outer wrist. The PN indicated R3 denied hitting her head and was incontinent at the time of the fall. R3's neuro checks were within normal limits for the resident and vital signs were recorded. However, R3 was in pain and guarded the right wrist, but had no other injury besides an abraision noted upon inspection. The PN indicated safety devices had been in use and indicated no suspected head injury. Family notified first, MD [medical doctor] ordered transfer to hospital, and DON [director of nursing] and ADMIN [administrator] later notified. -In a PN dated 4/17/20 at 3:27 p.m., the DON documented the pharmacy consultant was contacted for medication review, and the fall was reported to the State Agency. -6/6/20 at 3:14 p.m., unwitnessed fall with broken left wrist. Facility risk management report included, R3 was heard screaming in room, staff found resident on floor. 911 was called due to obvious deformity of left wrist and resident expression of severe pain in area. Vital signs stable. R3 unable to tell what happened. -PN dated 6/6/20 at 3:23 p.m. indicated resident had obvious deformity to left wrist and hematoma to temporal area with no signs of neuro complications at time of incident. R3 was sent to emergency room via ambulance. -PN dated 6/8/20 at 11:51 a.m. included a fall IDT (interdisciplinary team) review of R3's last quarter indicating fall risk assessment completed on that day identified a score of 20, and noted fall risk assessment score trending up. R3's toilet plan was updated to include: toilet resident upon rising, after breakfast, before and after lunch and supper meals, bedtime, and as needed. In addition, it noted the resident was to be encouraged to be in view of staff when not in bed related to safety, and for the nurse manager to contact OT to evaluate wheelchair for comfort. -6/19/20 1:00 a.m., resident fall with no injury indicated. R3 facility risk management report included the nurse instituted 15 minute checks after notifying family, DON, and administrator. -PN dated 6/19/20 at 2:50 a.m. R3 was heard calling out at 1:00 a.m. and the nurse and 2 aides rushed to room and observed resident next to bed in supine position, with wet pajamas and a wet floor. Nurse assessed R3 who was deemed to be alright, and indicated nursing staff had followed policies for falls. -7/2/20 at 10:45 p.m., unwitnessed fall with skin tear on finger: -PN dated 7/3/20 at 12:01 a.m. indicated R3 fell in room self-transferring from bed to wheelchair and was heard crying by nursing. R3's left hand pointer finger had a large, deep skin tear with bleeding, the wound was cleaned with normal saline and a dry dressing applied. R3 did not want to move fingers due to pain. R3 bed in low position and call light was within reach. R3 had no suspected head injury. -PN dated 7/3/20 at 12:27 a.m. indicated physician gave verbal order to send resident to emergency room via ambulance to have left hand pointer finger assessed. -PN dated 7/3/20 at 8:25 a.m. included resident was seen in emergency department (ED) related to fall with laceration to left index finger. R3 had a urinalysis, x-ray of left hand, right elbow, and right shoulder with negative results. CT scan of head and cervical spine showed no acute findings. The PN indicated R3 was in bed at time of fall and had a long history of falls resulting in major injury. The PN also indicated, R3's exhibited poor judgement related to diagnoses of dementia. R3's fall risk assessment was completed with a score of 16, indicating R3 was at risk for falls. The PN also referenced R3's BIMS (brief interview for mental status) completed 5/14/20, with a score of 3 indicating severe cognitive impairment, and indicated R3's care plan was updated. Occupational therapy notes were reviewed and did not include an evaluation of the wheelchair after IDT meeting on 6/8/20. During an interview on 7/17/20, at 11:03 a.m. nursing assistant (NA)-E stated R3 was a frequent [NAME] and was constantly transferring on her own. NA-E stated R3 had a low bed, no alarms were used, stated she was like a two year old and her attention span was twenty seconds. NA-E stated she was unfamiliar with R3's care plan interventions for falls. NA-E stated she was constantly checking on R3 to be aware of where she was and what she was doing. During an interview on 7/17/20, at 11:17 a.m. licensed practical nurse (LPN)-A stated R3 was a frequent [NAME]. LPN-A stated for fall interventions R3 had a fall mat when on the floor while in bed, was on 15-minute checks and stated these interventions would be on a paper copy in the chart. LPN-A stated, We try to keep her in vision most of the time and stated R3 was by the nurses' station alot tooling around. LPN-A verified R3 had had fractured both of her wrist from falls while at the facility and stated R3 liked to self-transfer a lot. During an interview on 7/20/20, at 9:52 a.m. NA-G stated, I cannot even count the times when she has fallen, we've tried everything with her. NA-G stated R3 does not listen, does not call for help and added, she may ask for help if she was in the hallway and we happen to be there at the right time. NA-G stated R3 was very difficult to prevent from falls. NA-G stated R3 does not wait for staff to assist her; She sees you and thinks she can get up. She is a challenge for many people. During an interview on 7/20/20, at 11:11 a.m. [TRUNCATED]

Based on observation, interview and document review, the facility failed to comprehensively reassess falls to determine possible causative factors in order to develop resident centered interventions to minimize the risk of further falls for 4 of 4 residents (R17, R52, R34 and R61) who had a history of [REDACTED]. Findings include: R17's [DIAGNOSES REDACTED]. A Care Area Assessment (CAA) dated 9/26/16, identified R17 to be at risk for falls. The corresponding problem statement indicated R17 had experienced delirium with suspected underlying dementia. A re-admission Minimum (MDS) data set [DATE], indicated R17 had cognitive deficits as evidenced by scoring 6 out of 15 on a BIMS (brief interview for mental status) assessment. The CAA further indicated R17 required a need for supervision, direction and cues related to memory loss and impairment. R17 was also identified as having difficulty maintaining sitting balance and balance during transitions. R17's care plan last revised on 2/2/17, indicated the resident was at risk for falls characterized by history of falls/injury, multiple risk factors related to impaired balance, lack of safety awareness/judgment. Interventions for care included: call light within reach at all times when in room (initiated 10/17/16), gripper socks on when shoes are not worn (initiated 1/9/17), periodic fall risk assessment by a licensed nurse, reinforce need to call for assistance (initiated 10/17/16), wear proper and non-slip footwear (initiated 10/17/16), and tabs alarm on while in wheelchair or chair in room (initiated 1/19/17). Review of progress notes from December 2016 through March 2017. Progress notes completed daily for acute charting indicated R17 had demonstrated increased confusion and multiple self-transferring attempts when in bedroom. The 4/4/17 nursing assistant's Pocket Care Plan (PCP) (included specific care information for nursing assistants to provide for individual resident), indicated R17 was to have gripper socks on at all times, wheelchair, walker, and a fall mat on both sides of the bed. The PCP also indicated R17 was alert and oriented times three, and included direction for staff to remove the fall mats when R17 was not in bed. To ensure a low bed was used and anti-lock brakes utilized on the wheelchair. Review of fall incident reports from December 2016 through March 2017 with the following findings: A fall on 12/19/16, at 1:25 p.m. occurred outside of R17's bedroom. R17 had been self-transferring to say goodbye to another resident. There were no injuries as a result of the fall. No immediate interventions were implemented at the time of the fall. The incident report indicated the Interdisciplinary Team (IDT) had reviewed the fall on an unknown date, had implemented physical and occupational therapy to re-evaluate, zip-tie glider chair in room or remove chair, and for R17 to wear gripper socks. (The gripper socks were not added as an intervention on the care plan until 1/9/17). A fall on 12/22/16, at 7:40 a.m. occurred in R17's bedroom. R17 had been self-transferring from chair to bathroom. R17 had been found not wearing shoes or gripper socks at the time of the fall. No injuries had occurred. Immediate interventions identified after the fall included for R17 to have shoes on when out of bed (which had been previously initiated 10/17/16). An IDT review had also been completed on 1/5/17 (two weeks after the fall), with no new fall interventions having been implemented. A fall on 12/25/16, at 4:15 p.m. occurred in R17's bedroom. At the time, R17 had been self-transferring from bed to reach the dresser. No injuries had occurred as a result of the fall. Documentation indicated that at the time of the fall, R17 had not been wearing shoes or gripper socks. No immediate interventions were implemented to prevent further falls. The documentation further indicated the IDT had reviewed the fall on 12/29/16, and had determined that R17's care plan had been followed leading up to the fall, except for R17 not having proper foot wear on. No new interventions had been identified or implemented. A fall on 12/31/16, at 3:00 p.m. occurred in R17's bedroom. At the time, R17 had been self-transferring from chair to access the closet. At the time of the fall, R17 had been found not to be wearing shoes or gripper socks. No injuries had occurred as a result of the fall. Immediate interventions identified to be implemented included for R17 to have proper footwear, which was an existing intervention from the care plan dated 10/17/16. The IDT had reviewed the fall on 1/5/17, and had not implemented any additional fall interventions. A fall on 1/2/17, at 1:05 p.m. occurred in R17's bedroom due to self-transferring. The fall note indicated R17 had been found lying face down on the floor of her bedroom in a pool of blood. R17 was observed to have had bleeding from lacerations on her forehead and mouth. Subsequently R17 was transferred to the emergency room for possible stitches as a result of the fall. A tab alarm had been initiated as an immediate intervention upon R17's return from the hospital. However, the tab alarm intervention was not added to the care plan until 1/19/17 (17 days after fall with injury). An IDT review following the fall on 1/5/17 included; additional fluids three times daily, tab alarm and acute charting. A fall on 1/27/17, at 6:50 p.m. occurred in R17's bedroom due to self-transferring from wheelchair to bed. No injuries had occurred as a result of the fall. Immediate interventions implemented included to ensure the resident's call light was within reach (which was an existing intervention from the care plan dated 10/17/16). The IDT also reviewed the fall on 1/30/17 and at that time, implemented an evaluation of wheelchair fit/cushion needed. A fall on 2/13/17, at 3:35 p.m. occurred in R17's bedroom due to self-transferring from bed. Documentation indicated that at the time of the fall, R17 was found to not have shoes or gripper socks on. The fall had resulted in an abrasion to R17's lower back. An immediate intervention included for non-skid footwear to be worn at all times which was an existing intervention from the care plan dated 10/17/16. IDT reviewed fall on 2/14/17, with no new fall interventions implemented. A fall on 3/23/17, at 2:09 p.m. occurred in R17's bedroom due to self-transferring from bed. At the time of the fall R17 was found to not be wearing gripper socks or shoes. No injuries were identified as a result of the fall. The immediate intervention identified was to apply gripper socks (an existing intervention from the care plan dated 1/9/17). The IDT conducted their review on 4/3/17 (11 days after fall), and had identified no new fall interventions to be implemented. During an interview with the director of nursing (DON) on 4/5/17 at 8:26 a.m., the DON verified the following information: No immediate interventions had been implemented following R17's fall on 12/19/16. The DON also verified there was no date documented for when the IDT had reviewed the fall. The DON stated R17 had been seen by the medical provider on 12/20/16. Review of progress notes indicates R17 was seen by the medical provider for a 60 day recertification visit. The medical provider note indicated review of R17's current medication list, vital signs and weights, and indicated R17 had no pain or skin issues and no new orders were written. The provider note included: she did slip out of her chair on 11/18, 11/19 and 12/3, and thankfully, these were without significant injury. As for R17's fall on 12/22/16, the immediate intervention was for R17 to have shoes on when up and out of bed. The DON addressed the fact the IDT hadn't reviewed the fall until 1/5/17, and stated the IDT usually meets one to two times weekly to review falls. However, the DON stated that in this instance the incident form was likely missing necessary information and their facility process was to return the form to the person responsible. The DON said the delay in getting the form back was likely what cause the delay in review by the IDT. The DON further verified the IDT had not implemented any new fall interventions as a result of the 12/22/16 fall. The DON stated regarding R17's fall on 12/25/16, R17 had not been wearing appropriate foot wear at the time of the fall, and as such the care plan had not been followed. The DON verified no immediate fall interventions were implemented at the time of the fall, and verified after IDT review, no new fall interventions had been implemented. The DON stated the glider chair was zip tied at this time, despite being recommended after the fall on 12/19/16. As to R17's fall on 12/31/16, the DON verified R17 had not been wearing appropriate foot wear at the time of the fall. The DON verified the immediate intervention was restated to apply proper foot wear, despite this being an existing intervention. The DON verified the IDT had not implemented any new fall interventions after review. Regarding R17's fall on 1/2/17, the DON verified R17 was transferred to the emergency room for possible stitches for a laceration to the left eyebrow, and bleeding from the mouth. The DON stated after the IDT had reviewed the fall on 1/5/17, they had implemented an increase in fluids. This had been as a result of conversation with R17's family who had indicated [REDACTED]. In addition, notes from the Internal Medicine physician dated 1/3/17, indicated R17's medications had been reviewed due to frequent falls in the facility, and indicated laboratory values from a recent emergency room visit had been reviewed and appeared stable. The note included, (R17) not currently taking any opioid, anticholinergic or benzodiazepine medication. Medication list is minimal and not suspicious for a contributing factor to falls. Primary reason for falling appears to be dementia as she frequently forgets to call for assistance prior to ambulating. The DON verified immediate intervention for the fall 1/27/17 was use of the call light. However, the DON verified the call light is not an effective intervention as R17 is unable to remember to use the call light or ask for help. Regarding R17's fall on 2/13/17, the DON verified R17 was not wearing appropriate foot wear at the time of the fall and the care plan was not followed. The DON verified R17 suffered an abrasion to the lower back as a result of the fall, and again stated the immediate intervention was to remind R17 to use the call light. The DON further verified IDT review had not identified any new fall interventions as implemented. The Internal Medicine physician notes documented 2/16/17, again indicated R17 had frequent falls and that recent labs had been appropriate/non-contributory. The notes included: Primary reason for falling appears to be dementia as she frequently forgets to call for assistance prior to ambulating. Continue working with therapy as have seen a decrease in falls. The DON stated review of the fall on 3/23/17, indicated R17 had not been wearing appropriate foot wear at the time of the fall. The DON confirmed the care plan was not followed and the immediate intervention was to apply gripper socks, even though it was an existing intervention. Finally, the DON verified after IDT review no new fall interventions had been implemented. Registered nurse (RN)-B was interviewed on 4/4/17, at 10:38 a.m. RN-B identified R17's fall interventions to include: assistance with toileting, alarm when in chair and bed, try and keep close to staff, gripper socks and shoes. During continuous observation from 3:34 p.m. - 4:04 p.m. on 4/4/17, R17 was observed to be sitting in a wheelchair in her room watching television. The light was not on, making the room appear dark. R17 had foot pedals on in the wheelchair and was observed to self-propel herself in the wheelchair through her room despite the foot pedals being present. R17 was observed to propel herself towards her walker which was located across her room, and began pushing the walker through the room while still sitting in the wheelchair. At 3:40 p.m. R17 pushed the walker in front of the closet doors and attempted to stand from her wheelchair. R17 made no attempt to utilize the call light. At that time, the surveyor intervened and directed staff to R17's room. Nursing assistant (NA)-B entered the room and R17 explained she was trying to get her pajamas from the closet. NA-B attempted to redirect R17 with a snack which R17 declined, removed the foot pedals from the wheelchair, and then exited the room. At 3:43 p.m. on 4/4/17, NA-B stated he didn't know what fall interventions were in place for R17. NA-B checked the pocket care plan (PCP) and stated there were no interventions. NA-B stated he checks on R17 frequently because she's always moving around. At 3:45 p.m. on 4/4/17, R17 continued to self-propel in wheelchair throughout her room and attempted to shut the bedroom door. NA-B instructed R17 to leave the door open. At 3:47 p.m. R17 continued to self-propel in wheelchair throughout her room and moved towards the bed and began fixing the blanket. R17 was observed to be rocking back and forth in the wheelchair, reaching for the side table, reaching for the blanket and removing her shoes. As R17 was removing her shoes the Tab alarm began to sound. NA-B entered the room at 3:52 p.m. and offered to assist R17 to bed. NA-B assisted R17 to bed. Although R17 had removed her shoes, NA-B did not apply gripper socks before exiting R17's room as indicated in R17's care plan. Instead, the gripper socks were observed to be folded and lying in the glider chair next to R17's bed at 4:01 p.m. At 4:04 p.m. on 4/4/17, the DON also observed R17 with the surveyor. At that time, the DON verified R17 was not wearing appropriate foot wear to prevent a potential fall. The DON stated according to the care plan, R17 was supposed to have gripper socks on if she was not wearing her shoes. The DON stated she was aware R17 removes her shoes at times and that she'd discussed with staff the importance of having R17 have proper foot wear on at all times. During interview with the DON on 4/5/17 at 9:05 a.m., the DON stated the staff had not been completing a root cause analysis of each fall(s) for some time. When asked how they determine resident centered interventions without having conducted a root cause analysis, the DON stated, during IDT meetings we look for any interventions from different departments, we try and look for patterns, we try and review multiple falls. However, the DON verified there wasn't good documentation of the plans or discussions from the IDT meetings. The DON added that it wasn't clear what interventions had been implemented or determined to prevent future falls. The DON indicated for example that the pocket care plan (PCP) identified floor mats to be used, however verified R17 doesn't have floor mats. The DON stated fall interventions should be placed on the PCP by the nurse managers after any updates or changes. NA-A was interviewed on 4/5/17, at 9:45 a.m. NA-A stated R17's fall interventions included keeping the call light in reach, trying to keep her busy, applying the alarm when in she was in bed or in the wheelchair, and applying gripper socks when in bed. NA-A checked the PCP and stated she didn't think R17 had floor mats. During interview with NA-C on 4/5/17 at 2:06 p.m., NA-C stated R17's fall interventions included: tab alarm in bed and wheelchair, to try and keep an eye on her, and to keep her occupied. Registered nurse (RN)- C was interviewed on 4/6/17, at 8:03 a.m. RN-C stated R17's fall interventions included: gripper socks when shoes aren't on, or when in bed, and a low bed. RN-C also stated the PCP should include all fall interventions and should be updated with any changes. RN-C stated she was unsure when the last time R17's PCP had been updated to reflect current fall interventions. RN-C verified outdated and unused interventions including floor mats were still on the PCP and shouldn't be. R52 was observed on 4/3/17 at 2:29 p.m. in bed, with the bed in the low position, and the call light within his reach. On 4/3/17 at 5:23 p.m., R52 was observed in his room sitting in a Rock and Go wheel chair, leaning forward with his hands within a few inches of the floor, holding onto his call light. One of R52's shoes was off and the call light had been activated and was on. At that time, the surveyor notified staff, so immediate interventions could be implemented to prevent a fall from the wheelchair due to R52's position (leaning forward in wheel chair). R52's current care plan printed 4/4/17, identified his [DIAGNOSES REDACTED]. The care plan also indicated R52 had been admitted to the facility on [DATE], and currently lived in the facility. The care plan further indicated R52 was at risk for falls, characterized by history of falls/ injury and multiple risk factors related to use of psychotropic medications and dementia. The care plan indicated, the medical doctor documents that resident has no insight into his fall risk, history of orthostatic hypotension. The care plan goal was that R52 would not be injured due to a fall, and fall interventions directed staff to: keep call light within reach at all times when resident is in room, ensure environment is free of clutter, evaluate effectiveness and side effects of psychotropic drugs with physician for possible decrease in dosage/elimination of medication periodically, has lack of safety judgment into falls, staff to observe frequently for safety, periodic fall risk assessment by a licensed nurse, resident to wear proper and non slip footwear, see use of wheelchair activity tray under mobility care plan for times when he is making attempts to self transfer multiple times, family (F)-A declines to continue with hipsters, risk and benefits reviewed with F-A, chance of breaking a hip or soft tissue injury if he falls without them on, F-A verbalizes understanding and declines to have them on him any longer. R52's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R52 had severe cognitive impairment, and required extensive staff assistance with bed mobility, transferring, locomotion on and off unit and activities of daily living. In addition, the MDS indicated R52 had sustained 0 falls with injury within the MDS reference period. During interview with RN-C on 4/6/17 at 11:30 a.m., RN-C stated the quarterly MDS completed on 1/24/17, had been inaccurate and should have indicated R52 had two or more falls with injuries. A Fall Risk Assessment (tool used to determine falls risk) dated 3/27/17, identified R52 as being at high risk for falls. Documentation indicated R52 had experienced 8 falls since 12/9/16 as follows: On 3/26/17, at 4:15 p.m. R52 found on floor in his bathroom. Description of the incident indicated, Resident was sitting on toilet. Slid off the toilet landing on his left side, holding onto his trousers. The fall scene investigation worksheet completed after the fall on 3/26/17, indicated R52 had an unwitnessed fall, staff were alerted to the fall as the staff member, went back to see if he was finished on the toilet. Resident was trying to pull up his pants. Vital signs at the time of the fall were lying 202/108 and sitting 189/98. The fall huddle indicated resident cannot be left on the toilet because of fluctuating blood pressures. New fall intervention on 3/27/17, care plan not to be left alone on the toilet related to fluctuating blood pressures. R52's neuro sheet revealed vital signs were monitored after the fall for 48 hours starting on 3/26/17. R52's blood pressures met the parameters to have the PRN hydralazine administered nine times with the blood pressures ranging from 211/101 to 160/84. At 4/5/17 at 9:03 a.m., registered nurse (RN)-C verified R52 had not received the PRN hydralazine during the month of March 2017 per physician order [REDACTED]. On 3/20/17, at 3:02 p.m. R52 found on the floor by staff while doing round at approximately 3:02 p.m. R52 was observed to be lying next to bed with head against the wall parallel to head of the bed, and a blood spot noticed on the wall. R52 was actively bleeding (small amount) on the occipital (back of head) section and a small cut was noticed under the bleeding. Pressure applied on the area with a gauze, and bleeding slowed down. Gauze applied on the area and a roll gauze applied around the head for pressure. Vital signs at the time of the fall were lying 145/71 and sitting 203/91. R52 was found with non-skid shoes on, and call light was within reach. The fall scene investigation worksheet completed after the fall on 3/20/17, indicated R52 had unwitnessed fall. Resident stated he was trying to, go to his car to drive or something. The fall huddle indicated regular checks on resident, remind resident on use of call light, and low bed always while in bed. No new interventions were implemented. In addition, no root cause analysis was completed and no actual causal factors were identified. R52's neuro sheet revealed vital signs were monitored after the fall for 48 hours starting on 3/20/17. R52's blood pressures met the parameters to have the PRN hydralazine administered nine times with the blood pressures ranging from 201/93 to 156/80. However, none was administered. At 4/5/17 at 9:13 a.m., RN-C stated R52 had not received the PRN hydralazine during the month of March 2017 per physician order [REDACTED]. RN-C verified no new interventions were implemented and no actual causal factors were identified for this fall. RN-C stated R52 fell at 3:00 p.m. and R52 administered sinemet late this day. The 11:00 a.m. dose was given at 12:43 p.m. and the 4:00 p.m. dose was given at 5:59 p.m. The sinemet is given to reduce the symptoms of motor dysfunction due to Parkinson's disease. On 2/6/17 at 9:15 p.m., R52 was found in room by aide during rounds. R52 was on the floor next to wheelchair located at the center of room approximately 5 feet from bed, and 8 feet from bathroom. Wheelchair observed to have rolled over. Vital signs at the time of fall included blood pressure of 200/88. R52 observed to have had a small skin tear to his right cheek measuring 0.6 centimeters (CM) by 0.3 cm, and 3 tears on his right shin measuring 3.6 cm x 1.8 cm, 1.9 cm x 0.8 cm, 1.3 cm x 0.8 cm respectively from top to bottom (head to toe direction). Resident also observed to have an abrasion to his left knee that is closed. Wheelchair (W/C) observed to have rolled over, and it could be possible that resident may have rolled from W/C as resident often tries to pick up things from floor. Call light observed to be within reach; W/C brakes unlocked, and had non-slide shoes on. The fall scene investigation worksheet completed after the fall on 2/6//17, indicated R52 had unwitnessed fall. The fall huddle indicated more frequent checks on R52 as well as reminders to use the call light. On 4/5/17, at 9:18 a.m. RN-C stated at times R52 would put the call light on. RN-C stated call light on was not on at time of this fall. RN-C stated R52's rocking Broda chair had broken and R52 was in a regular wheelchair at the time of the fall. RN-C stated she called on 4/5/17 to Midwest Respiratory to have them come out right away that day to repair R52's wheelchair. On 1/24/17 fall note read, Resident had been layed (sic) down in bed at 1:30 pm for a nap after being toileted and brief changed. Resident was in his room in his bed when CNA (certified nursing assistant) left room with call light within reach. CNA went across the hall to answer a call light and when she came out of the room noted that resident was lying on the floor with his head at the head of the bed and feet and legs stretched out at foot of bed. Information was requested in regards to the fall and none was provided. On 4/5/17 at 9:21 a.m., RN-C stated she would need to look for the post fall investigation report for the fall on 2/6/17. RN-C was unable to recall if any new fall interventions were implemented to prevent further falls. Surveyor was later provided a sticky note that indicated the facility was unable to find the incident report from the fall on 1/24/17. On 1/7/17, at 2:20 p.m. fall note said R52 was found on the floor on his back. This was an unwitnessed fall. Resident stated he was lying in bed and wanted to get up. It is unknown when the resident was laid down and by whom. Resident had no bruising, no redness, no swelling anywhere but did say his right side of buttock and right side of head hurt. Once patient was toileted and up in the wheel chair, resident reported no pain. The fall scene investigation worksheet completed after the fall on 1/7/17, indicated R52 had an unwitnessed fall. R52 said he was trying to walk and fell . The call light was on at time of the fall. The fall huddle notes indicated reinforced R52 to call for help. New intervention was to have medication regimen review completed. On 4/5/17, at 9:24 a.m. RN-C stated R52 fell at 2:15 p.m. and R52 was administered sinemet late this day. The 11:00 a.m. dose was given at 12:02 p.m., RN-C verified there was not a root cause analysis of this fall completed and only causative factor reviewed was the possibility of receiving the sinemet late which affects gait/steadiness. On 12/27/16, at 5:25 p.m. fall report said that a nursing assistant had walked by R52's room and noted that resident was on the floor sitting on his buttocks with his back against his wall dresser and his feet facing the head of the bed. No injuries noted at this time. Resident asked what he was going to do and resident stated, I wanted to get back in that corner. Resident was referring to the corner of the head of the bed. When resident was asked why he stated, cuz (because) I wanted to. Resident had been sitting in his wheelchair. The fall scene investigation worksheet completed after the fall on 12/27//16, indicated R52 had an unwitnessed fall. The fall huddle report indicated it worked well when we had environmental services monitoring at risk fall residents. Immediate intervention were to keep resident within sight of staff with activities such as coloring. A referral was made for physical and occupational therapy. On 4/5/17, 9:32 a.m. RN-C said they referred him to physical and occupational therapy. RN-C verified there was not a root cause analysis completed of this fall completed and no actual causal factors were identified. 12/25/16 fall notes said that R52 received a left knee skin tear from fall at 3:00 p.m. Mepilex applied with no bleeding and minimal tenderness. The resident incident reporting form completed after the fall on 12/25//16, indicated R52 had an unwitnessed fall. R52 was laying on ground by his bed. R52 sustained a left knee skin tear and staff member indicated, I think he tried to get up and walk around the room. R52 attempted to self-transfer and fell . Call light near resident and frequent observations done by nursing assistant and nurse. No new interventions were implemented. On 4/5/17 at 9:35 a.m., RN-C stated no new interventions were implemented for the fall on 12/25/16. RN-C verified there was not a root cause analysis completed of this fall and no actual causal factors were identified. RN-C stated facility did not complete root cause analysis of falls at this time. RN-C stated we talked about the falls, the interventions and different things we want to try. RN-C stated they have identified for the most part his falls are in the afternoon and evening. RN-C stated they try to keep him busy with different things. RN-C stated he liked to paint, build and color. RN-C stated they try to keep him occupied. On 12/13/16, at 1:55 p.m. fall notes said that R52 was found on the floor facing the foot of the recliner. His posterior head was against the dresser. He complained that he had hit his head on the dresser but not that hard. He said his left arm was tender at the forearm, and across the elbow, (a 1.5 cm diameter abrasion without bleeding or exudate is present-was covered with a Band-Aid). He said his hip hurt yet there was no tenderness nor any discomfort expressed when the resident was Hoyer lifted off the floor. There were no bruises or other abrasions other than the elbow. Resident was alert and stated he had been daydreaming in the recliner about rounding up horses. Potential exists for a head injury. Resident states he didn't hit his head hard enough to see stars and landed with the left side and top of head against the dresser. There are no marks present initially and he will be monitored per protocol. The fall scene investigation worksheet completed after the fall on 12/13/16, indicated R52 had an unwitnessed fall. R52 had been in the recliner in his room. R52 was wearing Ted hose as shoes had been removed when put into recliner. Staff member found R52 when they walked in his room. R52 stated he was daydreaming about rounding up horses. The fall huddle notes indicated closely monitor R52 when in hall during quiet time rather than resting in his room, in recliner or bed. R52 now seated in hall interacting with staff. New intervention gripper socks on when shoes are not on. On 4/5/17 at 9:39 a.m., RN-C verified the fall on 12/13/17 did not have an IDT review until 12/27/16, 14 days after fall. RN-C stated sometimes the fall reports were turned in uncompleted and this could have happened in this case, where I returned the worksheet to the nurse for completion and I did not receive it back timely for review. Also, RN-C stated the new intervention implemented at the time of this fall was gripper socks were to be on when R52 was not wearing shoes. RN-C verified the care plan included indicated R52 was to wear proper and non-slip footwear with an implementation date of the intervention of 3/6/14. RN-C verified there was not a root cause analysis of this fall completed and no actual causal factors were identified. On 12/9/16, at 4:20 p.m. fall notes indicated R52 was in an upright position on the floor. R52's family (F)-B stated R52 wanted to rest in his recliner after F-B had left. Resident was toileted prior to fall and transferred to the recliner to rest as requested. R52 first stated he may have bumped his head when asked and later stated he did not bump his head. No bruising or skin tear were noted. The fall scene investigation worksheet completed after the fall on 12/9/16, indicated R52 had an unwitnessed fall. R52 had been sitting in the recliner in his room. R52 was putting something together. The fall huddle indicated R52 was toileted prior to fall, F-B had just left and requested R52 to rest in recliner (where he self-transferred from) all interventions were put into place. Immediate intervention: Transferred R52 to w/c and set up the side table with coloring books and crayons to give him something to focus on in the hallway so staff has eyes on him at all times. Seroquel PRN administered at 4:40 p.m. for restlessness. No new interventions were implemented. In addition, no root cause analysis was completed and no actual causal factors were identified. On 4/5/17, 9:43 a.m. RN-C stated according to the fall scene investigation worksheet an interdisciplinary team review was not completed for this fall. RN-C stated she was unable to recall if any new interventions were implemented after this fall. RN-C verified there was not a root cause analysis of this fall completed and no actual causal factors were identified. R52's physician order [REDACTED]. The medication administration record (MAR) rev