Every finding on record at Elm Crest Manor

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 15 sampled residents (Resident #16). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 through A-32, stated, .A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . Page M-5 of the RAI Manual, stated, . M0210: Unhealed Pressure Ulcers/Injuries . Coding Instructions: . Code 1, yes: if the resident had any pressure ulcer/injury . in the 7-day look-back period.Page M-24 stated, M0300F: . Enter the number of pressure ulcers that are unstageable related to slough [nonviable yellow, tan, gray, green or brown tissue] and/or eschar [dead or devitalized tissue]. Review of Resident #16's medical record occurred all days of survey. A PASRR, dated 01/24/25, stated, . PASRR Determination: Level II - approved . PASRR Grouping you fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is: A mental health condition . Review of the nurses' notes, dated August 11th, 13th, and 15th, 2025, identified an unstageable pressure ulcer with the wound bed covered by slough and/or eschar to Resident #16's right heel. A significant change MDS, dated [DATE], showed the facility coded A1500 no indicating no mental health condition. The facility coded M0210 as Yes, indicating current pressure ulcers/injuries but failed to code M0300F, the number of unstageable pressure ulcers related to slough and/or eschar. During interviews on 01/21/26 at 10:32 a.m. and 01/22/26 at 9:02 a.m., an administrative nurse (#2) confirmed staff failed to correctly code Resident #16's MDS.

Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure appropriate care and services for 1 of 3 sampled residents (Resident #14) reviewed for edema (fluid retention). Failure to ensure consistent implementation of support stockings and document resident refusals, may result in worsening edema.Findings include:Review of policy, Compression Stockings occurred on 01/22/26. This policy, dated 11/05/19, stated, . Compression stockings are applied appropriately to aid circulation to lower extremities and to help prevent edema. applied by nursing personnel . Chart if resident refuses stockings.Review of Resident #14's medical record occurred on all days of survey. A physician's order, dated 06/27/24, stated, CIRCULATORY TREATMENT: TED Hose [support stockings to control edema] (knee high) ON AM OFF PM [sic] The current care plan stated, . Ineffective tissue perfusion . monitor for edema . Elevate feet/legs. Apply TED hose in am, off at hs [sic] (hour of sleep).- Observation on 01/20/26 at 11:40 a.m. showed Resident #14 seated in the recliner without support stockings or feet elevated, and visible swelling to both lower legs.- Observation on 01/21/26 at 8:51 a.m. showed Resident #14 walking with a walker, with visible swelling to both lower legs, and no support stockings present.- Observation on 01/22/26 at 8:57 a.m. showed Resident #14 seated in a chair in her room, fully dressed without support stockings on, and visible swelling to both legs. A certified nurse aide (CNA) (#4) stated, She usually refuses to wear them [support stockings].Review of Resident #14's treatment administration record (TAR), dated January 20-21, 2026, showed staff documented the support stockings as applied.During an interview on 01/22/2026 at 11:09 a.m., an administrative nurse (#1) confirmed she expected the CNAs to inform the nurse if the resident refused to wear the supportive stockings and document any refusals.

Based on record review, review of the hospice agreement, and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 sampled resident (Resident #2) receiving hospice services. Failure to obtain the hospice election form limits staff's ability to ensure coordination of care between the facility and the hospice agency. Findings include: Review of the facility's Agreement for Hospice Care for Skilled Nursing Facility and Nursing Facility Residents occurred on 01/22/26. This agreement, dated 12/22/25, stated, . Hospice Provider will provide to the facility the following information . Hospice Provider Election Statement . Review of Resident #2's medical record occurred on all days of survey and identified the resident and/or representative chose hospice services on 12/22/25. The medical record lacked the hospice election statement. During an interview on 01/22/26 at 9:44 a.m., an administrative nurse (#1) confirmed Resident #2's medical record failed to include the hospice election statement.

Based on review of the facility reported incident (FRI) and family and staff interviews, the facility failed to ensure alleged violations involving neglect were reported timely to the State Agency (SA) for 1 of 1 sampled resident (Resident #1). Failure to report an elopement in a timely manner placed all residents at risk for neglect and/or elopement. Findings include: Review of the FRI identified Resident #1 eloped from the facility on 01/27/25. The facility failed to report the elopement to the SA until 04/09/25. The facility could not identify how or when the resident left the building. During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member stated the facility contacted her and stated a member of the community found the resident in the town gym about one block from the facility and returned her to the facility. During an interview on 04/14/25 at 5:30 p.m., two administrative staff members (#1 and #2) stated the elopement actually occurred on 02/01/25, and confirmed the facility failed to report the elopement to the SA in a timely manner.

Based on review of the facility report incident (FRI), record review, and family and staff interview, the facility failed to thoroughly investigate an elopement for 1 of 1 sampled resident (Resident #1). Failure to thoroughly investigate an elopement to determine causative factors may limit the facility's ability to put appropriate interventions in place to prevent further elopement episodes. Findings include: Review of the FRI, received by the SA on 04/09/25, indicated Resident #1 eloped from the facility on 01/27/25. Review of Resident #'1's medical record occurred on 04/14/25. A nurses' note dated 02/01/25 at 2:55 p.m., stated the following: * Res. [resident] confusion regarding leaving elm crest and applying a code alert for her safety. Code alert applied to right ankle. The facility could not identify when the resident left the building but stated the elopement occurred on 02/01/25, not 01/27/25, but the medical record showed to staff charting charting between 1:40 p.m. and 2:44 p.m. (over 1 hour). During an interview on 04/14/25 at 5:00 p.m., Resident #1's family member stated the facility contacted her and told her a member of the community found the resident in the town gym about one block away from the facility and returned her to the facility. The facility failed to thoroughly investigate/determine the causative factors of Resident #1's elopement which placed Resident #1 at risk for elopements and limited the facility's ability to put interventions in place.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#3) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services may result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 01/06/25 at 11: 55 a.m., the dietary supervisor (#3) stated she is enrolled in the Certified Dietary Manager (CDM) course, but has not competed the training. During an interview on 01/07/25 at 10:40 a.m., an administrative staff member (#2) confirmed the dietary supervisor (#3) lacked the required training for the position. The facility failed to ensure the dietary manager (#3) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.

Based on record review, review of facility policy, review of facility investigation report, and staff interview, the facility failed to report an incident of potential abuse/neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #7) who experienced a fall from the mechanical lift. Failure to report an event of potential abuse/neglect to the SSA places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy Abuse Policy occurred on 01/07/25. This policy, dated 06/10/20, stated, The resident has the right to be free from . negligence . Investigations must be documented and all findings including the initial report of allegation reported in writing to the administrator as soon as possible but no later than 24 hours following the incident. The Administrator or Designee will notify the State Department of Health of the reported incident. Review of Resident #7's medical record occurred on all days of survey. A fall report, dated 09/20/24, indicated Resident #7 fell from the mechanical lift. Review of the Final Abuse Investigation Report stated, . On Friday September 20th at 0520 [5:20 a.m.] resident stretched her arms over her head and whole body stiffened during a hoyer [full-body mechanical lift] transfer. This movement caused the resident's body to slide out of the sling on the side. Assessment revealed a small open area to L [left] upper thigh and redness above the right eye. The record lacked evidence the facility reported the above incident to the SSA as possible abuse/neglect. During an interview on 01/08/25 at 10:05 a.m., an administrative nurse (#1) confirmed the facility failed to report the above incident to the SSA.

Based on record review and review of the facility reported incident investigation, the facility failed to provide food textures according to the resident's prescribed diet for 1 of 1 sampled resident (Resident #1) who had a choking incident. Failure to ensure Resident #1's diet is followed while serving snacks resulted in a hospital emergency room transfer and treatment for choking. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 06/14/24. The facility implemented corrective action and education on 06/14/24. Review of the facility policy titled Therapeutic Diet Order Policy occurred on 06/25/24. This policy, dated, 02/24/24, stated, . Therapeutic Diet is a diet ordered by a physician or delegated registered dietician, a part of treatment for a disease or clinical condition . dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form as prescribed . NDD1 Level 1 (National Dysphagia Diet) Level 1 . Dysphagia Pureed diet . this diet consists of pureed food . food should be 'pudding-like'. meats . recommended . pureed meats . breads . recommended facility prepared pureed bread . Review of Resident #1's medical record occurred on 06/25/24 and included diagnoses of dementia. Physician orders showed a regular NDD1 Level 1 diet, also known as a Dysphagia-pureed diet with small portions. The resident's current care plan stated, Resident to receive ordered diet NDD1- pureed diet . small portions . Resident #1's progress notes, dated 06/14/24 at 6:44 a.m., stated, Late entry . Resident began choking and unable to breathe . O2 Sats [oxygen saturation rate] was 87-88% . asked if the certified nurse aide [CNA] had done any Heimlich maneuver [abdominal thrusts] . she had and said some of the obstruction came out . resident stated had something in her throat and that it hurt . call to on call provider . said she should be looked at . ambulance called . ER [emergency room ] given report of incident . resident's daughter informed . resident is on a pureed diet . she had snacks that did not meet her diet requirement . Review of physician notes, dated 06/14/24 at 2:53 p.m., . resident was seen today following an emergency room visit for a choking episode . she is currently on a regular diet with pureed consistency . she was given a granola bar and a piece of beef jerky and choked on them . recommend to continue a pureed diet and do not offer foods that are difficult for her to chew or swallow . The facility's investigation report, dated 06/14/24, stated, . resident was given a snack . resident started to cough and was struggling with her airway . asked resident if there was something in her throat . she shook her head yes . was given a couple of back blows . called on call doctor and received orders to send to ER . resident was given a beef jerky stick, milk and a granola bar . the staff member stated they did not look at the resident's diet as they did not think about it at that time . Based on the following information, noncompliance at F684 is considered past noncompliance. The facility implemented corrective actions on 06/14/24 to ensure the deficient practice does not recur by: * The facility completed an investigation with interviews of staff that determined the cause of the incident. Resident #1's morning snack on 06/14/24 consisted of a granola bar and beef jerky. Staff failed to follow the pureed diet order. * The facility provided immediate staff education to the CNA and nurse present during the incident. * The facility provided education to nursing staff through the communication book. * The facility placed binders noting all resident diets in the resident's coffee/snack area and the nurses' station. * On-going education with all staff will continue to occur.

Based on observation and facility policy, the facility failed to assure safe and secure storage of narcotic medications for 2 of 2 medication carts. Failure to store all medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Controlled Drugs occurred on 11/21/23. This policy, dated 03/04/20, stated, . Strict control of narcotics is maintained always. Procedures: . All controlled medications are kept under double-lock and in a separate drawer (also known as the narcotic drawer) from other medications. Observation on 11/20/23 at 2:30 p.m. with two nurses (#2 and #3) showed schedule II-V narcotics/controlled medications ordered as needed (PRN) stored in the bottom drawer of two medication carts with non-controlled medications and not double locked.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 19 sampled residents (Resident #23, #28, and #33). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled RESIDENT CARE PLANNING occurred on 11/21/23. This policy, dated 12/19/20, stated, . Each resident has a resident care plan (RCP) that is current, individualized, and consistent with the medical regimen. Implementation: Times and actions are stated so that caregivers new to the resident can carry out care with complete continuity. - Review of Resident #23's medical record occurred on all days of survey and identified the resident experienced a fall which resulted in a fracture on 08/01/23. Resident #23's care plan failed to identify a risk for falls and lacked specific interventions and measurable goals for falls. - Review of Resident #28's medical record occurred on all days of survey. The Minimum Data Sets (MDSs), dated 05/27/23 and 08/26/23, identified weight loss. Resident #28's care plan failed to identify weight loss. During an interview on 11/21/23 at 1:54 p.m., an administrative nurse (#1) agreed the care plans should include falls and weight loss. - Observation on 11/19/23 at 2:59 p.m. showed Resident #33 wore a continuous glucose monitor (CGM). A physician's order, dated 08/27/23, stated [FreeStyle Libre 2 Sensor] Continuous Blood Gluc [glucose] Sensor . Resident #33's care plan lacked information related to use of a CGM. 40489

Based on observation, review of professional literature, and staff interview, facility staff failed to prepare and serve foods under sanitary conditions in 1 of 1 kitchen. Failure to serve food in a sanitary manner may result in forborne illness to residents, staff, and visitors. Findings include: The Food Code, U.S. Public Health Service, Food and Drug Administration, U.S. Department of Health and Human Services, 2017, page 78, stated, . SINGLE-USE gloves shall be used for only one task . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observations during the 11/01/22 and 11/02/22 noon meals showed a dietary staff member (#5) touched multiple surfaces (cupboard, drawer, and microwave handles and dietary meal cards) with gloved hands. With the same gloves, the staff member placed bread into and out of a toaster, and placed sandwiches onto the resident's meal plates. During an interview on 11/03/22 at 4:16 p.m., a dietary manager (#6) stated she expected the dietary staff member (#5) to use a utensil to serve the sandwiches for both meals.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure proper respiratory care for 1 of 1 sampled resident (Resident #1) with orders for continuous oxygen therapy. Failure to provide oxygen as ordered may complicate the resident's respiratory status. Findings include: Review of the facility policy titled OXYGEN THERAPY-MASK AND NASAL CANNULA occurred on 11/03/22. This policy, dated December 2020, stated, . portable liquid tanks or e-cylinders are used for transportation of resident throughout facility . turn oxygen source to the prescribed flow . place cannula in resident's nose . check liter flow . to assure flow is correct and bottle is filled appropriately. Review of Resident #1's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders stated, . Administer oxygen 3.0 liter/min [minute] (per nasal cannula) continuous. Observation on 10/31/22 at 2:42 p.m. showed two certified nurse assistants (CNAs) (#2 and #3) transferred Resident #1 into a wheelchair. The CNA (#3) placed a nasal cannula attached to a portable oxygen tank on the back of the resident's wheelchair and proceeded to push Resident #1 to an activity. Assessment of the the oxygen tank showed it empty. Observation on 11/01/22 at 11:55 a.m. showed Resident #1 seated in the dining room, wearing a nasal cannula attached to a portable oxygen tank on the back of her wheelchair. Assessment of the portable oxygen tank showed the tank empty. The CNA (#4) stated, It [portable oxygen tank] should have been filled before she was brought out to the dining room. During an interview on 11/02/22 at 2:35 p.m., an administrative nurse (#1) stated she expected facility staff to ensure portable oxygen tanks are full prior to resident use.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to prevent skin breakdown and pressure ulcers for 1 of 1 sampled resident (Resident #14) reviewed for pressure ulcers. Failure to turn/reposition residents may result in worsening of existing pressure ulcers and additional skin breakdown/pressure ulcers. Findings include: Review of the facility policy titled Terminal Care occurred on 11/03/22. This policy, dated January 2021, stated, Purpose: To assure residents receive appropriate care through the last stage of life. If resident is immobile, change their position every two to three hours . Review of Resident #14's medical record occurred on all days of survey. Physician's orders stated, . 10/21/2022 SKIN TREATMENT [MEDICATION(S)] [absorbent foam adhesive dressing] to coccyx Change 2 x wk [twice a week] . 10/29/22 SKIN TREATMENT: Apply Protective dressing to mid back change 2 x wk . A significant change Minimum Data Set (MDS), dated [DATE], identified three Stage 2 (partial thickness loss of skin which presents as an abrasion or blister) unhealed pressure ulcers. Resident #14's care plan, stated, . Stage 2 [pressure ulcer] Mid Spine 10/05/22 . Stage 2 coccyx 09/30/22 . 10/14/2022 Potential for End of Life. Disease progression. On Comfort Cares. Resident #14's pressure ulcer risk assessment, dated 10/14/22, stated, . MOBILITY: Very limited-Makes occ. [occasional] slight changes in body/extremity position-can't make freq/signif [frequent/significant] changes alone . ADDITIONAL RISK FACTORS: . history of pressure areas . SCORE:14 . moderate risk for skin breakdown. Observations showed Resident #14 laid in bed in the same position as follows: * On 10/31/22, from 1:19 p.m. to 4:43 p.m. (approximately 3.5 hours), right side. * On 11/01/22, from 12:19 p.m. to 3:43 p.m. (approximately 3.5 hours), left side. * On 11/02/22, from 8:59 a.m. to 2:31 p.m. (approximately 5.5 hours), on back. During an interview on 11/02/22 at 2:35 p.m., an administrative nurse (#1) stated she expected facility staff to reposition Resident #14 every two to three hours.

Based on observation and review of professional literature, facility staff failed to follow standards infection control standards for 1 of 6 sampled residents (Resident #3) and 1 supplemental resident (Resident #41) observed during transfers using a mechanical sit-to-stand lift. Failure to follow infection control standards related to disinfecting patient care equipment has the potential to transmit infections to other residents, staff, and visitors. Findings include: Review of guidelines found at https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf, updated May 2019, page 86, stated, . Ensure that, at a minimum, noncritical patient-care devices are disinfected . after use on each patient . Observations on 10/31/22 showed the following: * 2:39 p.m., Two certified nurse assistants (CNAs) (#2 and #3) transferred Resident #3 to the bathroom and then to a wheelchair using a mechanical sit-to-stand lift. After completion of the transfer, the CNAs failed to sanitize the lift prior to placing it in the hallway. * 2:56 p.m., Two CNAs (#2 and #3) transferred Resident #41 to the bathroom and then into a wheelchair using the same mechanical sit-to-stand lift used for Resident #3. After completion of the transfer, the CNAs again failed to sanitize the lift prior to placing it in the hallway.

Based on record review and review of facility policy, the facility failed to evaluate nutrition status for 2 of 4 sampled residents (Resident #2 and #10) with weight changes. Failure to adequately monitor and evaluate weights may contribute to unrecognized weight loss/gain and delay interventions. Findings include: Review of a facility policy titled Resident Weights occurred on 07/08/21. This policy, dated 01/20/21, stated, . If there is a variation to the weekly weight of the resident then there should be a reason for the variance. (ie, done with clothing on, done after dinner, done on a different scale than routinely used, etc) . - Review of Resident #2's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's weight record identified the following: * 06/07/21: 189 pounds (lbs.) * 06/14/21: 161 lbs. [14.81% weight loss with no reweigh or documentation of variance] * 06/21/21: 171 lbs. [5.59% weight gain with no reweigh or documentation of variance] * 07/05/21: 169.3 pounds lbs. - Review of Resident #10's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's weight record identified the following: * 06/25/21: 103 lbs. [21.36% weight loss with no reweigh or documentation of variance] * 06/29/21: 81 lbs. During an interview on 07/08/21 at 12:55 p.m., a dietary manager (#1) confirmed staff should have reweighed.

Based on observation, review of facility policy, review of manufacturer's labeling, and staff interview, the facility failed to store and serve food under sanitary conditions in 2 of 2 food storage refrigerators (main kitchen and nurse station nourishment area). Failure to label food to identify the expiration date and discard expired food has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Review of the facility's policy titled Date Marking for Food Safety occurred on [DATE]. This policy, dated [DATE], stated, The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 degrees or less for a maximum of 7 days. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. The discard day or date may not exceed the manufacturer's use-by date, or four days whichever is earliest. The date of opening or preparation counts as day 1 (one). The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Manufacturer's labeling for all the thickened juice drinks and water stated, Use in seven days and Do Not Freeze. A dietary tour occurred on [DATE] at 8:30 a.m. with a dietary staff member (#5). Observation in the main kitchen storage refrigerator showed an half-gallon container of skim milk with an open date of [DATE] and the manufacturer's use-by date of [DATE] six days beyond the open date and eight days beyond the use-by date. During an interview at the time of the tour, the dietary staff member (#5), agreed the container of milk was beyond the discard and use-by dates. During a dietary tour the afternoon of [DATE] a supervisory dietary staff member (#6) stated the nursing staff are responsible for monitoring the food storage refrigerator at the nurse's station. Observation of the food storage refrigerator at the nurse station showed the following items opened and not labeled with a discard date: * One 46-ounce bottle of honey thickened water * One 46-ounce bottle of nectar thickened orange juice * One 46-ounce bottle of honey thickened orange juice * One 64-ounce bottle of clamato tomato cocktail juice, which contained a resident name. During an interview on [DATE] at 1:50 p.m. an administrative staff member (#1) stated dietary staff are responsible for dating the food items placed in the nurse station nourishment area. The facility failed to follow their policy related to date marking for food safety.

Based on observation and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records (MARs) on 1 of 3 days of survey. Failure to promote resident privacy may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff. Findings include: Observation on 9/24/19 from 11:38 a.m. to 11:59 a.m. showed the nurse (#2) left a medication cart unattended and the MAR indicated [REDACTED]. Observation on 9/24/19 at 4:21 p.m. showed the nurse (#3) left a medication cart unattended and the MAR indicated [REDACTED]. Observation on 9/24/19 at 4:24 p.m. showed the nurse (#4) left a medication cart unattended and the MAR indicated [REDACTED]. During an interview on the afternoon of 9/25/19, an administrative nurse (#1) confirmed she would expect staff to lock computer screens when unattended.

Based on review of the facility's Quality Assurance and Performance Improvement (QAPI) program and staff interview, the facility failed to ensure the Medical Director (physician) actively participated on the Quality Assurance (QA) committee for 2 of 4 quarters (January-March 2019 and July-September 2019). Failure to ensure the medical director participates in the facility's QA activities deprived the committee of the physician's unique contributions for analyzing and correcting problems with identified resident care areas. Findings include: Review of the facility QAPI program titled Quality Assurance/Assessment and Performance Improvement Plan occurred on 09/25/19. The plan, established 10/05/17, stated, . The Quality Assessent and Assurance (QAA) Committee consists of the Director of Nursing, the Medical Director, the Administrator, the Infection Control and Prevention Officer and interdisciplinary team. The QAA Committee meets monthly, and the Medical Director and Pharmacy Consultant participation (sic) at least quarterly to coordinate and evaluate the activities under the QAPI program. The facility provided documentation showing the QA committee met on a quarterly basis between (MONTH) (YEAR) and (MONTH) 2019. The documentation showed the Medical Director failed to attend meetings January-March 2019 and July-September 2019. During an interview on 09/25/19 at 12:54 p.m., a managerial nurse (#7) confirmed the Medical Director failed to attend two of the four required quarterly QA committee meetings.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure the correct concentration of sanitizer solution in 1 of 1 kitchen. Failure to correctly prepare sanitizing solutions in a three compartment sink and a sanitizer bucket according to the facility's policy may result in a sanitizer concentration that is either too weak to sanitize kitchen surfaces or too strong, which may be unsafe or toxic. Findings include: Review of the facility policy, SANITIZER IN TRIPLE SINK occurred on 09/06/18. This undated policy, stated, . The sink should be no less than 200 ppm's or more than 400 ppm's. Sanitizer solution should be changed every 2 hours. Staff is to write ppm's on triple sink sanitizer. Dietary manager will check chart to ensure this is being completed. Dietary manager will follow-up with staff who have not completed chart to ensure the procedure is followed. A tour of the kitchen occurred on 09/05/18 at 4:20 p.m. with a supervisory dietary staff member (#6). Observation showed a filled three compartment sink which utilized an automatic sanitizer dispenser. Upon request, the staff member (#6) checked the sanitizing concentration in the three compartment sink with a result of 100 ppm. The staff member stated the solution should be between 200 and 400 ppms. Review of the sanitizer log showed the facility staff failed to document the concentration in accordance to facility policy every two hours (1:00 p.m. and 3:00 p.m.) on 09/05/18. Another dietary staff member emptied and refilled the sink and re-tested the solution, with a result of 300 ppm. A return tour of the kitchen occurred on 09/05/18 at 4:50 p.m. Observation showed a supervisory staff member (#6) tested the concentration of a bucket of sanitizing solution with a result of 100 ppm. The staff member (#6) stated the solution needed to be changed to meet the 200-400 ppm requirement. Facility staff failed to ensure the sanitizer measured between 200 and 400 ppms, change the sanitizer every two hours, and document the ppms result.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide respiratory care consistent with physician's orders for 1 of 1 sampled resident receiving oxygen (Resident #25). Failure to ensure oxygen is administered as ordered may complicate a resident's respiratory status. Findings: Review of the facility policy titled OXYGEN THERAPY-----MASK AND NASAL CANNULA occurred on 09/06/18. This policy, revised (MONTH) 2012, stated, . turn on oxygen source to the prescribed flow. An observation on 09/04/18 at 11:48 a.m. showed Resident #25 seated in his wheelchair in the dining room and receiving oxygen via nasal cannula. Observation showed the portable oxygen tank set at 2 liters per minute (lpm). An observation on 09/04/18 at 3:01 p.m. showed two certified nursing assistants (CNAs) (#2 and #3) transferred Resident #25 to his wheelchair and set his portable oxygen tank at 2 lpm. An observation on 09/05/18 at 9:47 a.m. showed two CNAs (#4 and #5) transferred Resident #25 to his wheelchair and set his portable oxygen tank at 2 lpm. The CNA (#4) stated the kardex is used to determine a resident's oxygen settings, and the kardex identified Resident #25 received oxygen at two lpm. Review of Resident #25's medical record occurred all days of survey. Current physician's orders included continuous oxygen at 3 lpm. The current kardex stated, . SPECIAL INSTRUCTIONS . Oxygen at 3 liters per nasal cannula continuously. The current care plan stated, . Other Special Instructions: Oxygen at 3 liters per nasal cannula continuously. The current physician's orders, kardex, and care plan all stated Resident #25 is to receive oxygen at 3 lpm. During an interview on 09/06/18 at 1:35 p.m., an administrative nurse (#1) stated she expected CNAs to utilize the kardex to determine oxygen delivery for a resident.

Immediate jeopardy identified at 3:20 p.m. on 07/02/13 related to door security alarm system not functioning properly. During the standard recertification survey on July 01-03, 2013, it was determined the facility failed to thoroughly monitor and evaluate the status of the Code Alert alarm system after Resident #8 eloped from the facility's Willow exit door on three separate occasions. The survey team contacted management staff at the State Agency (SA) on 07/02/13 at 3:20 p.m. to discuss a potential immediate jeopardy situation. From 3:25 p.m. to 4:05 p.m., all the residents with code alert bracelets (nine), either on their ankle or on their wheelchair, were escorted out and back into the facility through the Willow exit door. Three of the nine resident's code alert bracelets failed to activate the alarm system. At 4:30 p.m., the survey team (in concurrence with management staff at the SA) determined an immediate jeopardy situation existed. At 4:34 p.m., the survey team notified the facility administrator (#6) and the director of nursing (DON) (#1) of the immediate jeopardy situation. Between 4:45 p.m. and 5:15 p.m., the maintenance supervisor (#3) changed the antenna on the Willow door Code Alert system, facility staff escorted Resident #8 and #11 through the Willow exit door and the alarm sounded, which confirmed for facility staff members the alarm system failed to activate due to placement of the sensors on the doorways. The administrator contacted the company who installed the Code Alert system to send out a service person to perform maintenance on the system. At 5:40 p.m., the DON removed the code alert bracelets from Resident #8 and #11 ankles. The DON applied new bracelets on Resident #8 and #11 and facility staff members placed the bracelets, which they had removed from the residents, on their own ankles for testing purposes on the other five exit doors. Two of these doors (Spruce and one in the Great Room) did not alarm when staff members walked through while wearing the Code Alert device (as identified below). At 6:00 p.m., it was determined the Code Alert system on the Spruce exit door failed. The maintenance supervisor replaced the antenna and the system functioned properly. At 6:30 p.m., it was determined the Code Alert system on the right side exit door (double doors) of the Great Room failed. The facility did not have a replacement antenna for this door alarm. The administrator stated she would contact the company and order an antenna the next morning. At 6:40 p.m., the facility administrator and DON placed a sign on the right side exit door in the Great Room, which stated to use the left door, placed two heavy cones in front of the door, and placed "caution" tape on the door. The administrator and DON developed a plan to check the Code Alert system on all exit doors twice a day until the company sent out a service person. At 6:50 p.m., the administrator provided the survey team with a plan of correction. The survey team determined the immediate jeopardy situation was reduced, and lowered the scope and severity to an "E." 1. Based on observation, record review, and staff interview, the facility failed to ensure the safety of wandering residents at 3 of 6 outside exits (Willow, Spruce, and the Great Room) equipped with a Code Alert system. Failure to ensure the functionality of the system after a resident equipped with a code alert left the building without setting off the alarm on three occasions placed this resident and all residents who have a Code Alert device at risk of injury when leaving the building without staff knowledge. Findings include: - Review of Resident #8's medical record occurred July 1-3, 2013. This facility admitted Resident #8 on 03/20/2013 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident had moderately impaired cognition; experienced fluctuating behaviors of inattention and disorganized thinking; wandered one to three days in the last seven; walked independently in her room; and required one person setup help for walking in the corridor and locomotion on and off the unit. Review of Resident #8's care plan, dated 04/01/13, stated, "Problem: Alteration in ADLs (Activities of Daily Living) R/T (related to) . . . needs cues reminders and supervision. . . . Approaches. . . . 19. Code Alert on left ankle/right wrist. . . . Problem: Alzheimer's, dementia, anxiety, depression, and agitation. Looking for a way home. . . . Problem: . . . Also resident occasionally eloping from facility and packing clothes. . . . Approaches: . . . 4. Elopement log started 05/07/12 (sic). . . ." A nurse's note showed facility staff applied a Code Alert to Resident #8's left ankle on 03/21/13 when she talked about going home. Nurse's notes identified the following incidents when Resident #8 eloped from the building without the Code Alert system alarming: * 04/28/13, 8:30 p.m., " . . . Res (resident) attempted to go out Cedar door staff brought res away from door. Moments later went out Willow door. Alarm didn't sound. Res slid through rails on guardrail et (and) slid down enbankment (sic) into parking lot. Did not fall. Staff brought res back into facility et took res to Rm (room). Res did get ready for bed. . . " * 05/05/13, 10:00 a.m. "Res. had been in Church and when left Chapel was looking for her car. Staff noticed Res. going to Willow door. Res was able to get out door before staff member got to her Res has code alert on ankle, but alarm did not go off. Staff member walked with Res to main door & (and) then came in, and that door alarm did go off. . . . Nurse did go and checked (sic) Willow door with different alarm & alarm did go off." * 05/10/13, 2:45 p.m. "Attempted to leave out of Cedar door. Staff brought her away from door (sic) Res crying. Wanting to go home. Went to Great Rm then out Willow exit, alarm didn't sound. Was out to end of ramp et returned (with) staff. Sat (with) staff at NS (Nurses' Station)." An "Elopement Incident Report," dated 04/28/13, identified "maintenance is aware that code alert did not sound and are checking on this." After the elopement on 05/10/13, when the alarm failed, the "Elopement Incident Report" identified "second alarm (code alert) placed on Res." The report failed to identify the effectiveness of the code alert in relation to the door alarm. During an observation, on 07/02/13 at 1:55 p.m., an administrative nurse (#1) walked with Resident #8 out the Willow door. The alarm failed to sound. The nurse confirmed Resident #8 had a code alert on her left ankle under the fold in her sock. The nurse (#1) continued to walk with Resident #8 around to the main entrance. Upon entering the building, the code alert sounded. Prior to an observation on 07/02/13 at 3:45 p.m., an administrative nurse (#1) identified staff placed a new code alert on Resident #8's left ankle. The nurse (#1) and Resident #8 walked out the Willow door, and the alarm failed to sound. Resident #8 stated, "I found a way to walk to not set off the noise." The nurse (#1) and the resident walked around the parking lot and came in the Willow door. Again the alarm failed to sound. The nurse (#1) pulled the code alert out of the fold of Resident #8's sock, walked out Willow door, and again the alarm did not sound. The nurse (#1) and Resident #8 continued to walk around the building to enter through the main entrance, where the alarm sounded. Following this observation, an interview with a maintenance staff member (#3) and an administrative staff member (#6) identified the facility had previously changed the position of the alarms at the Willow exit in order to prevent further elopements by Resident #8. The maintenance staff member (#3) could not recall the specific date the alarm was moved. These staff members (#3 and #6) could not verify the facility tested Resident #8's code alert after moving the alarms. 2. Based on observation, record review, review of facility job description, review of professional reference, and staff interview, the facility failed to ensure transport staff were adequately trained to prevent accidents for 1 of 1 sampled resident (Resident #3) who experienced a fall/injury while being transported in the facility van. Failure to ensure adequate training and to investigate a fall placed Resident #3 and other residents at risk for an injury when riding in the facility van. Findings include: Review of the facility job description titled " EMPLOYEE JOB DESCRIPTION" occurred on 07/03/13. This undated job description, stated, "Position Title: Van Driver . . . ESSENTIAL JOB FUNCTIONS: . . . 2. Transports residents and tenants to appointments and activities as scheduled. This will include operating the mechanical lift for wheelchairs, . . . and securing passengers' wheelchairs to restraining devices in order to stabilize them during the trip. . . ." Information obtained from an administrative staff member (#6) identified the facility used Q' Straint wheelchair tie-downs in the facility van. Review of the Internet website www. amsvans.com/mobility-equipment/wheelchair-tie-downs/qstraints stated, ". . . All Q'Straint systems include four (4) tie-downs. When securing a wheelchair passenger, be sure to follow the safety procedures outlined in the user manual for the Q' Straint system you purchased. . . ." The facility failed to provide a manufacturer's user manual, including instructions for securing a wheelchair, in the facility van. Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set), dated 05/02/13, identified Resident #3 required extensive assistance of one for locomotion off the unit. Resident #3's Incident Report identified the following: " . . . Date of incident: 04/08/13; Time of incident: 10:20; Incident: Fall; . . . Other: sitting in van; . . . Describe the incident: On way back from Dr. (doctor) appt. (appointment) in van res. (resident) attempted to adjust self in w/c (wheelchair) et (and) tipped w/c into back seat, hitting back of head. Chair uprighted (sic) by driver - Res denies pain to back of head. Neuro (neurological) checks started on return to facility. . . . Functional Status: Wheelchair dependent; Contributing Medical Conditions: recent double amputation to lower legs . . ." Nurse's Notes, dated 04/08/13, stated, "C/O (complain of) pain to both stumps #10 (worst possible pain). Hydrocodone (one) po (by mouth) given, Stated while in w/c in van, w/c tipped backward onto back seat causing res. to hit back of head. (No) marks noted to back of head. States didn't hurt his head. Neurochecks started. . . ." Observation on 07/03/13 at 12:23 p.m., showed an administrative nurse (#1) demonstrated the procedure to secure a w/c into the facility van. The nurse positioned the wheelchair against the back seat of the van and locked the brakes. The nurse secured two "S" hook Q' straint tie-downs to the back of the w/c, but none to the front. The w/c did not tip backwards in this position. Moving the w/c approximately 3 inches away from the backseat and unlocking the w/c brakes allowed the w/c to tip backwards. During an interview on the morning of 07/03/13, an administrative nurse (#1) was unable to locate documentation indicating the van driver, CNA (#7) had received training on proper use of the van equipment. The facility failed to complete an investigation related to this incident, failed to ensure the manufacturer's instructions were available for staff to reference, and failed to ensure staff were trained in the use of van equipment.

Based on observation, record review, review of professional reference, facility policy, family interview, and staff interview, the facility failed to implement interventions to prevent accidents for 2 of 10 sampled residents (Resident #4 and #5) identified by the facility as experiencing falls. This failure resulted in Resident #4 and #5 experiencing injuries related to falls. Findings include: The Food and Drug Administration (FDA) Center for Devices and Radiological Health publication titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" issued on 03/10/06, stated, ". . . FDA has received reports in which . . . patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term 'entrapment' describes an event in which a patient is caught, trapped or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries . . . The current International Electrotechnical Commission (IEC) standard recognizes that the bed frame, deck, and rails are the major elements involved in entrapment . . ." Safety Alert: Entrapment Hazards with Hospital Bed Side Rails, August 23, 1995, and Joint Commission on Accreditation of Healthcare Organization: Sentinel Event Alert, Issue 27, September 6, 2002, have identified bed rail- related entrapment deaths and injuries can occur in the elderly population, who are often at risk due to limited mobility, psychoactive or sedative medications, confusion, sedation, restlessness, lack of muscle control, size and physical deformities. Death by asphyxiation or injuries to the resident's extremities can occur when the resident becomes caught between the mattress and the bed rail; the headboard and the bed rail; or getting his or her head/extremity stuck in the bed rail. Both split and full rails have the potential to cause fall-related injuries as well as entrapment. Additionally fall-related injuries or injuries to extremities can occur when confused/ disoriented residents climb over the top of side rails or get an arm or leg entrapped. Review of the facility "Policy for the use of side rails" occurred on 07/27/11. The policy, dated 05/17/06, stated, "Purpose: 1. If the resident has difficulty turning themselves in bed, the side rails may be used to enable him/her to do this on their own or to assist aides in this procedure. 2. Resident is restless in his/her sleep and has a tendency to roll out of bed. 3. Resident lies very close to the edge of the bed and will roll out easily. 4. Side rails will be used per family and/or resident request. Procedure: . . . 3. Resident should be checked at least every two to three hours and prn (as needed) to assure he/she is not attempting to crawl through or over the rails. . . ." - Resident #4's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. Resident #4's medication regimen included Remeron (an antidepressant with sedative effects) 45 milligrams (mg) daily at bedtime, Buspar (an antianxiety) 10 mg twice a day, Zyprexa (an antipsychotic) 15 mg daily and 45 mg at bedtime, and lorazepam 0.5 (an antianxiety) mg four times a day. The record identified Resident #4 experienced a fracture of the right femur on 01/17/11 without surgical repair. Minimum Data Sets (MDSs), dated 01/31/11 and 04/24/11, identified the resident required extensive assistance with bed mobility, had frequent urinary incontinence, not on a toileting program, experienced falls since the prior assessment, and used a bed rail daily. A physician's orders [REDACTED]." Resident #4's care plan, dated 12/29/09, identified a problem, "Alteration in ADLs (Activities of Daily Living) R/T (related to) unstable moods . . . Tardive Dyskinesia . . . hospitalized ,[DATE] for R) (right) femoral neck fx (fracture) . . . Returned without surgical repair. Fall Assessment high risk . . ." Approaches to the problem included, "Transfer with extensive assist of one or two 4/28/11 . . . 2-1-11 Foam padded 1/2 siderail for repositioning et (and) safety. Bed alarm on bed . . ." Review of "Care Plan Update" notes identified the following: * 04/26/11: "4-19-11 p (after) x-ray of (R) hip showed it was healed. Res (resident) continues to require extensive assist (with) ADLs due to weakness. Res able to sit on edge of bed per self at times. Res bed in lowest position. Has half siderails (with) padding due to attempts to get up per self. Also has fall mat beside bed. . . ." * 07/27/11: "Res needs assist . . . in & (and) out of bed, is at times able to sit up in bed per self . . . Res transfers (with) assist of 1 or 2 . . . is walking in room (with) assist of 2 at this time. . . ." Review of nurse's notes identified the following: * 03/20/11 at 1 p.m.: "Has sm (small) open areas on knees - does become restless & rubs knees on bed rails or walls." * 03/22/11 at 6:50 p.m.: "Staff found Res sitting on floor mate (sic) beside her bed. Denies any injuries. Has a skin abrasion (with) faint puffness (sic) . . . Ice pack applied to R) FA (forearm). * 03/22/11 at 10 a.m. "R) forarm (sic) with increased discoloration & puffyness (sic)." * 03/23/11 at 6 a.m."Ace Wrap rewrapped - cont (continues) to have 4 cm (centimeter) long abrasion (with ) hematoma." * 04/02/11 at 12 noon: "Bruise (R) arm yellow et (and) fading." * 04/05/11 at 1:55 a.m.: "Res had been very anxious & restless for the past 1/2 hr (hour). Res sitting up & trying to crawl out of bed 4 to 5 times in past 1/2 hour . . ." * 04/09/11: 6:30 a.m.: "Bed Alarm Sounding - found Res laying on R) side beside bed . . ." * 04/15/11 at 3:45 a.m.: "Nurse found res laying on her bedroom floor on her (L) (left) side next to her fall mat . . . Observed 3.4 cm wide x 3.6 cm long light purple bruise to (R) knee. . . ." * 04/29/11 at 9:15 a.m.: "Res rose from bed unassisted. Found on floor off floor mat - stated she hit the back of her head during the fall on the floor . . ." * 05/08/11 at 10:22 p.m.: "CNAs (certified nursing assistants) report res had had (increased) restlessness . . . has attempted to climb out of bed x 5 in the last 10 minutes . . ." * 05/26/11 at 11:30 p.m.: "(increased) restlessness climing (sic) out of bed . . . 0500 (5 a.m.) Cont (continues) to try to climb out of bed per self . . ." * 07/13/11 at 2 a.m.: Awake (with) legs over side rail. Did return to bed (after) being told the time of day." * 07/17/11 at 12 a.m.: "CNA Reports old bruising to L) outer knee area also questioned possible swelling. Assessment shows old bruise. Resident is Restless @ (at) times and does bump knees on side rails. No swelling felt to area." Observation during the initial tour of the facility, on 07/25/11 at approximately 9:30 a.m., identified Resident #4 resting in a low bed with one side of the bed next to the wall and a 1/2 padded side rail elevated on the exit side of the bed. On 07/26/11 at 9:05 a.m. observation showed two CNAs (#6 and #7) assisted Resident #4 into bed. The CNAs lowered the bed and elevated the siderail on the exit side of the bed. A CNA (#7) placed the padding on the outside of the side rail, not between the resident and the siderail. Observations on 07/27/11 at 9:35 a.m. and 2:25 p.m. showed Resident #4 in bed with one side of the bed next to the wall and a padded 1/2 rail elevated on the exit side of the bed. Review of Resident #4's Restraint Consent, Side Rail Assessments, Physical Restraint Elimination Assessments, and Resident Incident Reports (from the falls on 03/22/11, 04/15/11 and 04/29/11) lacked evidence the facility reconsidered continued use of the side rail when the resident experienced injuries when crawling out of bed with the 1/2 rail elevated. All three incident reports identified "Rising unassisted" as a contributor to the falls. During an interview on 07/27/11 at 11:30 a.m. administrative nurses (#2, #3, and #4) stated they expect staff to place the padding between the resident and the side rail. When asked about the Resident #4's side rail, the nurses stated staff elevate the side rail to prevent Resident #4 from getting out of bed without assistance. The facility failed to consider alternatives to the side rail when Resident #4 repeatedly attempted to get out of bed with the rail elevated. The resident developed open areas related to the side rail, hit her head, and experienced an abrasion and bruises when she exited the bed with the side rail elevated. Failure to attempt alternatives to the 1/2 side rail resulted in Resident #4 experiencing the above injuries and placed the resident at risk for further injuries related to use of the side rail. - Review of the facility "Chair Alarm Policy" occurred on 07/27/11. The policy, dated October 2001, stated, "Purpose: To assure the safety of a resident with confusion or dementia and/or with a fall alert. Procedure: 1. Place wheelchair alarm on chair to alert staff if resident attempts to get out of wheelchair without assist. . . ." Resident #5's medical record, reviewed on all days of survey, identified [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified the resident with moderate cognitive impairment, and required extensive assistance of one person with transfers and walking in the room. A nurse's note, dated 12/04/10 at 4:15 p.m., identified staff responded to the chair alarm and found Resident #5 on the floor in her room. The facility transferred Resident #5 to the hospital where she was was diagnosed with [REDACTED]. Resident #5's care plan, dated 12/16/10, identified a problem, "Alteration in ADLs . . . Fall Assessment: High Risk. . . ." Approaches to the problem included, "Transfer with ext (extensive) assist of one or two 2/10/11 . . . Chair alarm on chair . . ." A nurse's note, dated 07/06/11 at 9 p.m., stated, "Res fell off toilet - scraping right knee - Res did not pull call light . . ." A right rib X-ray report, dated 07/07/11, identified "Minimally displaced fractures of the anterior ribs of the eighth, ninth, and tenth ribs. Decreased lung volumes are noted on the right." An incident report, dated 07/06/11 at 9 p.m., stated, "Res was sitting on toilet - turned to get something and fell off, bruise and 2 cm (centimeter) scrape to right knee." The incident identified "Contributors to Incident" as "Confusion, Forgets to use call light, and Rising unassisted." The incident report failed to identify interventions to prevent falls in the bathroom. Observation, on 07/25/11 at 3:10 p.m. identified a CNA (#5) entered Resident #5's room in response to the call light. The CNA (#5) stated the resident's husband (who shares her room) usually puts on the call light. The CNA assisted Resident #5 out of bed. During the transfer, the resident stated, "Every time I move yesterday and today I get dizzy." The CNA assisted Resident #5 to walk to the bathroom. After assisting the resident to sit on the toilet, the CNA (#5) closed the bathroom door and left the room. At 3:22 p.m. observation identified Resident #5's husband activated the call light and at 3:24 p.m. the CNA (#5) arrived to assist Resident #5 out of the bathroom. Observation showed the CNA left the resident unattended in the bathroom for approximately 12 minutes. An interview with Resident #5's family member (#1) occurred on 07/25/11 at 3:12 p.m. The family member stated, when Resident #5 fell on [DATE], staff had assisted her to the bathroom and left the room. The family member (#1) stated the resident "hollered for help" and he (the family member) activated the call light. He stated staff returned to the room and found Resident #5 had fallen in the bathroom. Resident #5 experienced fractured ribs when she fell from the toilet while unattended on 07/06/11. The resident complained of feeling dizzy during her transfer to the bathroom on 07/25/11 at 3:30 p.m. The facility failed to ensure Resident #5's safety when staff left her alone in the bathroom. This failure placed Resident #5 at risk of experiencing another fall and/or injury.