Every finding on record at Episcopal Church Home the Gardens

Based on observation, interview, and document review, the facility failed to ensure foods were stored in a manner to prevent spoilage and freezer burn and failed to ensure food items in 6 out of 6 kitchenettes were sealed, labeled and dated. This had the potential to affect all residents who reside in the facility. Findings include:An observation on 4/7/26 at 3:22 p.m., the 2nd floor kitchenette was reviewed. The freezer had undated, opened packages of bacon, pancakes, waffles, hot dog buns and a container of red and white substance. Nursing assistant (NA)-H verified these items and stated all items should have been sealed, dated and labeled.An observation on 4/8/26 at 8:16 a.m., the 3rd floor kitchenette was reviewed. The freezer had undated, opened packages of french toast, waffles, pepperoni, english muffins, omelets and bacon. NA-G verified these items and stated all items should have been sealed, dated and labeled.An observation on 4/7/26 at 2:29 p.m., the 4th floor kitchenette was reviewed. The freezer had undated, opened packages of omelets, pancakes, french toast, corn dogs, bacon, sausages, Toaster Strudel, and [NAME] Castle burgers. Additionally, the refrigerator had an undated bowl of noodles, undated Tupperware container of beans, and a bag of opened carrots that were expired on 3/25/26 . NA-F verified these items and stated all items should have been sealed, dated and labeled.An observation on 4/7/26 at 2:13 p.m., the 5th floor kitchenette was reviewed. The freezer had undated, opened packages of french toast, waffles, bacon, and omelets. NA-A verified these items and stated all items should have been sealed, dated and labeled.An observation on 4/8/26 at 7:44 a.m., the 6th floor kitchenette was reviewed. The freezer had undated, opened packages of bacon, french toast, bagels and meat patties. NA-E verified these items and stated all items should have been sealed, dated and labeled. An observation on 4/8/26 at 7:27 a.m., the 7th floor kitchenette was reviewed. The freezer had undated, opened packages of bacon, pancakes, waffles and french toast. NA-D verified these items and stated all items should have been sealed, dated and labeled.During interview on 4/8/26 at 12:28 p.m., chef manager (CM) expected any opened food items were sealed, dated and labeled. The kitchenettes had Ziplock bags, markers and deli containers with lids for storage use. CM further stated the kitchenettes were overseen by a multidisciplinary team. The CM oversaw education, ordered, stocked supplies and provided stocking sheets for staff. The nursing department oversaw the NAs. During interview on 4/9/26 at 12:40 p.m., administrator stated they expected all staff to handle and store food properly. Additionally, any opened items were to be labeled, dated and sealed. The rationale for proper food storage decreased the risk of food borne illness.A facility policy titled Episcopal Homes Refrigerator and Food Storage, directed staff to ensure opened freezer foods are sealed to prevent freezer burn and spoilage. Furthermore, all foods must be sealed, labeled and dated.

Based on observation, interview, and document review the facility failed to ensure appropriate glove use and hand hygiene for 1 of 1 resident (R19) during personal cares. The facility further failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R19) who had a nephrostomy tube and for 1 of 1 resident (R4) who had a catheter and was receiving catheter cares. The facility also failed to ensure 1 of 1 resident (R54) on droplet precautions was wearing a mask when out of her room. This had the potential to affect all 10 residents residing on the 3rd floor. Findings include: Hand Hygiene/Glove Use R19's significant change Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, was dependent on staff for toileting and personal hygiene, and was always incontinent of urine and frequently incontinent of bowel. R19's diagnoses included chronic kidney disease, anxiety, and need for assistance with personal care. R19's care plan revised 4/6/26, indicated R19 required assistance of one for personal hygiene and substantial to total assistance for toileting. During observation on 4/7/26 at 10:05 a.m., nursing assistant (NA)-A entered R19's room and offered a brief change. R19 stated that she did need to be changed and cleaned. NA-A donned gloves and put the head of the bed flat, lifted R19's gown and removed her brief which was dirty with bowel movement (BM). NA-A wiped R19's bottom of the BM and completed peri care. Without changing gloves, NA-A placed a new brief, pulled R19's gown down, repositioned her legs by grasping her feet, and adjusted the bed using the bed controls. During interview on 4/7/26 at 10:12 a.m., NA-A stated she did not change gloves after cleaning the BM and was not aware she needed to do so. During interview on 4/7/26 at 1:55 p.m., registered nurse (RN)-A stated gloves should be removed and hand hygiene completed after performing peri care. During interview on 4/8/26 at 10:23 a.m., licensed practical nurse (LPN)-A stated expectation for staff to change gloves and perform hand hygiene after performing peri care and before moving on to other resident care. During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) stated staff were expected to change gloves and perform hand hygiene when going from dirty to clean areas during resident care. EBP R19 R19's significant change MDS dated [DATE], indicated R19 had intact cognition, was dependent on staff for most activities of daily living (ADLs), and had an indwelling catheter (nephrostomy tube). R19's diagnoses included chronic kidney disease, obstructive uropathy (blockage in the urinary system that impedes urine flow), and need for assistance with personal care. R19's care plan focus initiated on 9/5/25, indicated R19 had a nephrostomy tube for right kidney and instructed staff to perform nephrostomy tube care as ordered. R19's need for EBP related to the presence of a nephrostomy tube was added on 4/7/26. During observation on 4/6/26 at 2:54 p.m., R19's doorway lacked signage indicating R19 required any infection control precautions. During observation and interview on 4/7/26 at 9:10 a.m., R19's doorway lacked signage indicating R19 required any infection control precautions. R19's full nephrostomy bag was visible and lying on top of her sheet. R19 stated staff were responsible for emptying the nephrostomy bag. During observation on 4/7/26 at 10:05 a.m., NA-A entered R19's room, donned gloves but did not don a gown. NA-A performed personal cares; a brief change, peri care, and resident repositioning without using EBP. During observation and interview on 4/7/26 at 12:04 p.m., R19's room had a sign indicating EBP and there was an isolation cart outside her room containing gloves. The sign instructed staff to perform hand hygiene, and don gloves and gown when entering to perform any high-contact resident care activities. NA-A stated while looking at the sign that a gown was only required when there was contact with the resident. NA-A stated was not aware R19 required EBB before now, and stated should have been wearing a gown this morning while preforming cares. During interview on 4/7/26 at 1:55 p.m.,RN--A stated residents with indwelling devices such as nephrostomy tube should be on EBP. RN-A further stated staff should wear gown and gloves when emptying nephrostomy bag, changing the dressing around the tube, and during any high contact care. During interview on 4/8/26 at 10:23 a.m.,LPN-A stated EBP should be in place for any resident with a nephrostomy tube. LPN-A could not explain why R19 had not been on EBP prior to yesterday (4/7/26). LPN-A further stated staff should follow EBP when working with R19 during nephrostomy care and all other high-contact care. During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) stated residents with a nephrostomy tube should be on EBP and could not explain why R19 was not on EBP prior to yesterday. R4 R4'a quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of quadriplegia (paralysis of all four limbs), flaccid neuropathic bladder (type of bladder dysfunction characterized by an inability to contract properly, leading to urinary retention and overflow incontinence), and a need for assistance with personal care. It further indicated R4 had an indwelling catheter and was dependent on staff for toileting. During interview on 4/6/25 at 5:50 p.m., R4 stated some staff wear personal protective equipment (PPE) when they perform catheter cares and some don't. This concerned her as she had been having a lot more urinary tract infections (UTI) recently. During observation on 4/8/26 at 9:59 a.m., R4 put on her call light and nursing assistant (NA)-C answered it. R4 and NA-C went into the bathroom where NA-C was emptying R4's catheter bag into a graduated cylinder and then emptied the graduated cylinder into the toilet. NA-C was wearing gloves but wasn't wearing a gown. During interview on 4/8/26 at 10:10 a.m., NA-C verified R4 was on EBP and the sign on the door indicated they should have been wearing a gown when performing catheter cares, stating they forgot to put one on but should have. R54 R54's quarterly MDS dated [DATE], indicated intact cognition and diagnoses of dementia and chronic obstructive pulmonary disease (COPD). It further indicated R54 required staff assistance with mobility. R54's physician's order, indicated ok for polymerase chain reaction test (test to determine if a certain virus is present) one time only for respiratory symptoms until 4/7/26. R54's progress note dated 4/6/2026, indicated R54 continues not to feel well. Cough noted from 4/3/26 continues. Lungs sounds, crackles lower left and inspiratory wheeze. Call placed to nurse practioner (NP) office for new orders. During observation 4/6/26, at approximately 12:30 p.m., R54 was in the therapy room riding a stationary bike. The physical therapist (PT)-A was also in the room standing beside her. Neither R54 nor PT-A were wearing masks or eye protection. At approximately 1:00 p.m. R54, PT-A, and LPN-C were in the therapy room and LPN-C was handing R54 and PT-A masks to wear. A few minutes later, PT-A brought R54 out of the therapy room and into her room via her wheelchair and then exited her room. Once outside the room, PT-A used hand sanitizer but did not remove their mask. The sign on the wall beside R54's door indicated she was on droplet precautions, and everyone must clean their hands (including before entering and when leaving the room), make sure their eyes, nose, and mouth are fully covered before room entry, and remove face protection before exiting the room. During interview on 4/6/26 at approximately 1:10 p.m. PT-A verified R54 was on droplet precautions but didn't know why. PT-A further verified the sign on the wall next to R54's door and stated I assume so when asked if they should be following the directions indicated on the sign. They also verified they should have been wearing eye protection and changing masks upon leaving R54's room. During interview on 4/6/26 at 6:15 p.m. R54 was sitting in her recliner in her room and she was coughing. She stated some of the staff wear PPE when they are providing cares and some don't, it just depends. During interview on 4/7/26 at 1:14 p.m., LPN-C stated R54 had been put on droplet precautions because she was having cold symptoms last week but R54 told her she didn't feel sick. Then they called the nurse practitioner again this week because R54 told her she wasn't feeling well and LPN-C wanted to do more in-depth testing. LPN-C stated R54 was permitted to leave her room if she was wearing a mask and verified neither R54 nor PT-A had been wearing masks during therapy on 4/6/26 and they had given them both masks to wear. During interview on 4/8/26 at 1:32 p.m. the DON/Infection Preventionist (IP) stated R54 was symptomatic and placed on droplet precautions. She should not leave the room but if someone on droplet precautions does have to leave the room, they should wear a mask and if staff were working with them (therapy) they should also be wearing a mask and eye protection. Facility policy Hand Hygiene dated 10/2/24, indicated, Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately before and after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other elders, personnel, equipment and/or the environment. Facility policy Enhanced Barrier Precautions dated 10/2024, indicated criteria for implementing EBP included, Presence of wounds and/or indwelling medical devices, even if there is no known infection or colonization with an MDRO [multidrug-resistant organism]. The facility policy on droplet precautions dated 10/2/24, indicated to limit the movement and transportation of the elder to essential purposes only, the elder should wear a mask when out of their room. Provide meals, therapies, and activities in the elder's room whenever possible during the acute phase of illness with consultation with the IP.

Based on observation, interview, and document review, the facility failed to ensure residents were safe for self-administration of medication (SAM) for 1 of 1 residents (R36) observed with a medication at the bedside. Findings include:R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 had intact cognition and required set up/clean up assistance to partial/moderate assistance for all self-care activities of daily living (ADLs). R36's diagnoses included multiple sclerosis (a disease affecting the nervous system and may cause weakness, numbness, and difficulty walking), chronic obstructive pulmonary disease (COPD), arthritis, and need for assistance with personal care. R36's care plan revised 12/8/25, indicated R36 had inability to manage self-care related to functional and cognitive decline. R36's care plan further indicated R36 had multiple sclerosis which affected ADL independence. The care plan identified R36 wanted to be involved in her care and medications, but instructed staff to administer medications as ordered. R36's care plan lacked specific information regarding self-administration of medications. R36's provider orders indicated the following:-11/02/23, R36 was ok to self-administer medications after set-up.-5/20/24, R36 required Ipratropium Bromide nasal solution 0.06% - 2 sprays in each nostril three times a day.-12/4/24, R36 required Fluticasone Propionate suspension 50mcg/act -2 sprays in each nostril every day. R36's medication administration record (MAR) dated 4/2026, indicated the Ipratropium Bromide nasal spray was scheduled for morning, evening, and bedtime. The MAR did not indicate this could be left at the bedside or could be self-administered. R36's MAR further indicated that the Fluticasone Propionate nasal spray was scheduled for 6:00 a.m. and was documented as given on 4/2 through 4/6 and 4/8. R36's SAM assessment dated [DATE], indicated R36 had No desire to self-administer. The SAM assessment further indicated the interdisciplinary team (IDT) did not feel the resident was safe for SAM. R36's provider progress noted dated 3/24/26 indicated under the Assessment/Plan that R36 provided unreliable information and could not complete assessments due to her history of and advanced dementia. During observation and interview on 4/8/26 at 8:16 a.m., licensed practical nurse (LPN)-B gathered R36's morning medications for administration which included nine oral medications and one nasal spray. LPN-B entered R36's room and administered the oral medications. LPN-B asked if he could administer her Ipratropium Bromide nasal spray and R36 picked up a bottle of that nasal spray from her side table and stated she had already used that this morning. R36 stated she self-administered the nasal spray at her bedside (Ipratropium Bromide) in the morning and occasionally in the afternoon if she felt she needed it. R36 initially stated she was not aware of a second nasal spray, but when LPN-A showed her the medication, which was stored in her locked in-room medicine cabinet, she thought it looked familiar. R36 could not recall using the Fluticasone Propionate this morning and thought she took that nasal spray in the afternoon. LPN-B stated R36 had been assessed as appropriate for self-administration of medications.During interview on 4/8/26 at 10:23 a.m., LPN-A stated R36 had memory issues and could not be trusted to provide accurate information regarding which medications she took and when. LPN-A reviewed R36's most recent SAM assessment and confirmed R36 had been assessed as not appropriate for SAM. LPN-A stated R36 had an order which indicated it was ok for SAM but stated R36 was no longer appropriate for SAM and should not have the nasal spray at the bedside. During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) stated in order for a medication to be left at the bedside for SAM, there had to be an order and an assessment. The SAM assessment should identify the medication and indicate that the resident understood when and how to administer it. DON further stated R36 was not appropriate for SAM and should not have any medications left at the bedside. A facility policy titled Self-Administration of Medication dated 11/13/17, indicated a resident could only be considered safe for SAM after an assessment and the IDT determined which medications would be safe for SAM. The policy further indicated the following:-The SAM assessment must include evaluation of the resident's ability to follow administration instructions including dose and time of administration. -A periodic re-evaluation should be completed based on cognitive changes.-A physician order would be obtained and must include which specific medications could be kept at the bedside.

Based on observation, interview, and document review, the facility failed to ensure personal privacy was maintained for 1 of 1 residents (R19) observed during personal cares.Findings include:R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, was dependent on staff for toileting and personal hygiene, and was always incontinent of urine and frequently incontinent of bowel. R19's diagnoses included chronic kidney disease, anxiety, and need for assistance with personal care. R19's care plan revised 4/6/26, indicated R19 required assistance of one for personal hygiene and substantial to total assistance for toileting. During observation on 4/7/26 at 10:05 a.m., nursing assistant (NA)-A entered R19's room and offered a brief change. R19 stated that she did need to be changed and cleaned. NA-A donned gloves and put the head of the bed flat, lifted R19's gown and removed her brief. NA-A did not close R19's door, which was open to the hallway. NA-A walked into the bathroom to obtain a new brief, while R19 waited, exposed from mid abdomen down. R19 was able to roll to her left side facing the window as her back side faced the door. While NA-A wiped R19's bottom physical therapist (PT)-A knocked once on the open door, did not wait for a response, and walked into R19's room as her bottom was exposed. PT-A stopped turned around and stated he would come back in a bit. NA-A completed peri care and placed a new brief. During interview on 4/7/26 at 10:16 a.m., NA-A stated she should have closed R19's door for privacy and agreed that PT-A had walked in and saw R19's exposed bottom. During interview on 4/7/26 at 10:18 a.m., R19 stated she wished the door would have been shut during peri care and was wondering why PT-A had just walked right in. During interview on 4/7/26 at 1:55 p.m., registered nurse (RN)-A stated resident doors should be closed during personal cares to protect their privacy. During interview on 4/8/26 at 10:23 a.m., licensed practical nurse (LPN)-A stated expected staff to close a resident's door during cares for privacy.During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) expected privacy to be maintained for all residents. Resident's door should be closed during brief changes and other personal cares.A facility policy titled Dignity dated 10/15/24, the facility was committed to providing care and services in such a way to maintain each resident's dignity, individuality, privacy, autonomy, and self-worth. The policy further indicated, Residents are provided privacy during personal care, bathing, dressing, toileting, and medical treatments. The policy further indicated, staff will knock and request permission before entering resident rooms whenever possible.

Based on observation, interview, and document review, the facility failed to ensure oxygen therapy was administered and maintained as ordered by the provider for 1 of 2 residents (R15) reviewed for respiratory care. Findings include:R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact, was dependent on staff for most self-care activities of daily living (ADLs), bed mobility and transfers. R15's diagnoses include chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease (COPD), anxiety, and dyspnea (shortness of breath). R15's provider orders dated 7/29/25, included the following:-Oxygen via nasal cannula at 4 liters per minute (lpm) continuous for dyspnea. -Change cannula/mask and tubing, date and initial weekly every Tuesday evening.R15's shortness of breath interview and evaluation assessment dated [DATE], indicated R15 was oxygen dependent.R15's care plan dated 8/6/25, indicated R15 had orders for oxygen therapy related to diagnoses and R15's oxygen saturations would drop into the 80s when oxygen was removed. The care plan instructed staff to administer oxygen via nasal cannula as ordered. During observation and interview on 4/6/26 at 2:03 p.m., R15 was lying in bed with the oxygen tubing/nasal cannula wrapped up and hanging off the oxygen concentrator out of R15's reach. The oxygen concentrator was on and set to 3 lpm. R15 stated she was supposed to have her oxygen on at 5 lpm. R15 stated she did not currently feel she was in any respiratory distress but could not remember how long she was without oxygen. R15's oxygen tubing was not labeled as to when it had been last changed. During observation on 4/7/26 at 8:19 a.m., R15 was in bed sleeping with the nasal cannula positioned on her chin rather than in her nares. The oxygen concentrator was set to 3 lpm. The oxygen tubing was not labeled as to when it had been last changed. During observation on 4/7/26 at 8:21 a.m., nursing assistant (NA)-I entered R15's room and delivered her breakfast tray. R15 did not address the oxygen tubing positioned on R15's chin or setting. During observation and interview on 4/7/26 at 8:32 a.m., NA-I and NA-B entered R15's room to boost her up in bed for breakfast. R15's oxygen tubing was now lying to the side of her on the bed. Neither NA-I nor NA-B addressed the oxygen tubing or flow rate. After the NAs left the room, R15 stated she took the oxygen off for breakfast and would replace it once she was done eating. During observation and interview on 4/7/26 at 11:19 a.m., R19 in bed with the oxygen nasal cannula in her nares. The oxygen concentrator was set at 3 liters per minute. NA-B entered R15's room and stated R15 was on continuous oxygen at 4 lpm. When asked to confirm the flow rate, NA-B confirmed the flow rate was currently set at 3 lpm but should be on 4 and changed it to 4 lpm. During interview on 4/7/26 at 11:27 a.m., registered nurse (RN)-A stated R15 was on continuous oxygen and that staff should encourage her to keep it on at all times. RN-A further stated she thought the flow rate could be adjusted during the day but could not find any reference to those instructions in R15's electronic health record (EHR). RN-A confirmed R15's oxygen order was for continuous oxygen at 4 lpm. RN-A further stated oxygen tubing was changed weekly and should be labeled to identify when it had been changed last. RN-A further stated NAs should not adjust oxygen flow rate and that NA-B should have notified a nurse about R15's incorrect oxygen flow rate. During interview on 4/8/26 at 10:20 a.m., licensed practical nurse (LPN)-A stated the oxygen flow rate should match the provider order, and oxygen tubing should be labeled and dated. LPN-A further stated NAs should not adjust the flow rate but rather notify a nurse when found to be incorrect.During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) expected R15's oxygen to be administered as ordered by the provider and tubing labeled and dated when to indicate when it was last changed. DON further stated NAs were not supposed to adjust oxygen flow rate and NA-B should have notified a nurse instead. A facility policy Safe Oxygen Use and Storage dated 8/28/20, indicated staff would take measures to ensure residents were educated and encouraged to use oxygen in a safe manner and any concerns would be reported to the RN.

Based on interview and document review, the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents (R10) reviewed for unnecessary medications. Findings include:R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had moderate cognitive impairment, was frequently incontinent of bowel, and was taking opioid medications during the seven-day lookback period. R10's diagnoses included adjustment disorder with mixed anxiety and depressed mood, chronic pain syndrome, and constipation. R10's care plan dated [DATE], indicated R10 used antidepressant medication and instructed staff to monitor adverse medication reactions such as constipation fecal impaction (when stool becomes hardened and stuck in the rectum due to long term constipation. The care plan further indicated R10 had chronic pain syndrome and instructed staff to give pain medications as ordered. R10's consultant pharmacy review (CPR) dated [DATE], indicated, The resident has orders for MiraLAX PRN [as needed] for constipation as well as docusate PRN for constipation. To ensure consistent administration and for state survey purposes, please set parameters for use [e.g. which to use first] or, if a duplication, consider discontinuing one of the above. The CPR had an undated handwritten note stating use MiraLAX first and was signed by an unidentified nurse practitioner.R10's CPR dated[DATE], indicated The resident has orders for MiraLAX PRN for constipation as well as docusate PRN for constipation. To ensure consistent administration and for state survey purposes, please set parameters for use or, if a duplication, consider discontinuing one of the above. The CPR had an undated handwritten note that indicated it was faxed to provider per licensed practical nurse (LPN)-A.R10's CPR dated [DATE] indicated, The resident has orders for MiraLAX PRN for constipation as well as docusate PRN for constipation. To ensure consistent administration and for state survey purposes, please set parameters for use or, if a duplication, consider discontinuing one of the above. The CPR had a handwritten note that indicated R10's medication administration record (MAR) was updated [DATE] by LPN-A.R10's monthly MARs dated 10/2025 through 2/2026, indicated, MiraLAX Oral Packet 17 GM.Give 17 gram by mouth every 24 hours as needed for Constipation. And Docusate Sodium Oral Capsule 100MG.Give 1 capsule by mouth every 24 hours as needed for Constipation. The monthly MARs lacked evidence of any instruction as to which medication to give first for constipation. During interview on [DATE] at 12:51 p.m., director of nursing (DON) expected R10's CPR would have been addressed timelier. DON stated the process for CPR was the clinical pharmacist would email the recommendations to the DON and each of the clinical nurse managers (CNM). The CNM who was responsible for the resident in the recommendation would forward to the provider if appropriate or address the recommendation if it was a nursing issue. DON further stated urgent recommendations should be addressed promptly, and less urgent ones should be addressed in one to two months at the most. During interview on [DATE] at 1:00 p.m., CP expected facilities to address the CPR within 30 days or so. CP stated should not have to issue the same recommendation without being addressed multiple times and would have expected R10's duplicate medications to have been addressed sooner than five months. Facility policy for pharmacy recommendation review was requested but was not provided.

Based on observation, interviews and document review, the facility failed to follow professional standards when a staff crushed delayed release medications and crushed pill capsules with other medications instead of opening and emptying the pill capsules for 1 of 3 (R2) residents reviewed for medication administration.Findings include: R2's face sheet dated 10/16/25 indicated R2 was admitted to the facility on [DATE] and had diagnoses of severe vascular dementia without behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, epilepsy, chronic kidney disease stage 1 through 4 and depression.R2's quarterly minimum data set (MDS) assessment dated [DATE] indicated R2 was severely cognitively impaired and was dependent on staff for all activities of daily living.R2's October 2025 medication administration record (MAR) included physician orders for-Aspirin Enteric Coated Low Dose Oral Tablet Delayed Release 81 milligrams (aspirin). Give 81 milligrams by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Start date 3/29/25. Trained medication assistant (TMA)-A documented the morning dose on 10/16/25 as administered.-Pantoprazole Sodium Oral Tablet Delayed Release 20 milligrams. Give 40 milligrams by mouth one time a day for reflux disease total dose 40mg. Start date 3/29/25. TMA-A documented the morning dose on 10/16/25 as administered.-Sertraline Hydrochloric Acid Oral Tablet 100 milligrams. Give 1 tablet by mouth one time a day for depression related to depression. Start date 3/29/25. TMA-A documented the morning dose on 10/16/25 as administered.-Divalproex Sodium Oral Tablet Delayed Release 125 milligrams. Give 750 milligrams by mouth two times a day related to other seizures. Start date 3/28/25. TMA-A documented the morning dose on 10/16/25 as administered.-Acetaminophen Oral Tablet 500 milligrams. Give two tablets by mouth three times a day for pain. Start date 6/6/25. TMA-A documented the morning dose on 10/16/25 as administered.-Crush medications: if indicated by prescriber's order. May mix in a small substance (apple sauce, pudding, jelly) every shift for medication administration related to dysphagia following cerebral infarction. Start date 3/28/25. TMA-A documented a check mark for the morning of 10/16/25.On 10/16/25 at 8:45 a.m., TMA-A was observed preparing and passing medications to R2. TMA-A used hand sanitizer and wore gloves when handling the medications. TMA-A placed the following medications into a small plastic bag after verifying the orders:-Aspirin Enteric Coated Low Dose Oral Tablet Delayed Release 81 milligrams, 1 tablet-Pantoprazole Sodium Oral Tablet Delayed Release 20 milligrams, 2 tablets-Sertraline Hydrochloric Acid Oral Tablet 100 milligrams, 1 tablet-Divalproex Sodium Oral Tablet Delayed Release 125 milligrams, 6 capsules-Acetaminophen Oral Tablet 500 milligrams, 2 tabletsTMA-A used the pill crusher to crush all the medications in a small plastic bag. TMA-A then used a plastic spoon to try and remove the shredded capsule pieces from the bag. TMA-A attempted to crush the medications again. Some small pieces of capsule were still visible in the bag. TMA-A poured the medication powder into a medication cup and mixed with applesauce, entered the room and administered the medications to R2 by mouth with a spoon. R2 was able to swallow and finish the medications with applesauce. At 9:09 a.m., TMA-A was asked why she crushed the capsules. She stated it was hard to take apart capsules with gloves on, so she usually crushes them instead.During an interview on 10/16/15 at 1:00 p.m., TMA-A stated the facility has given her education on delayed release medications. She stated she was aware R2 had delayed release medications, and they shouldn't have been crushed or opened. TMA-A stated she could not remember what delayed release medications meant.During an interview on 10/16/25 at 1209 p.m., licensed practical nurse (LPN)-A stated there was recent education on medication administration. The education was about making sure dosages that are being given match the prescriber's order. LPN-A stated the physician should be called to determine if it is okay to open a delayed release capsule medication.During an interview on 10/16/25 at 1:08 p.m., TMA-B stated he would not crush capsule medications, he would open the capsule and empty it. TMA-B was unable to explain the purpose of delayed or extended-release medications or any concerns that would accompany crushing or opening delayed release medications.During an interview on 10/16/25 at 1:19 p.m., registered nurse (RN)-A stated the facility provided education on delayed release medications. Staff should check with the prescribing physician about opening a delayed release capsule. Capsules shouldn't be crushed. When asked about crushing delayed release medications, RN-A stated the medication effects could hit the patient quickly rather then slowly.During an interview on 10/16/15 at 12:26 p.m., a pharmacist stated that she was concerned that the pharmacy had it documented the Divalproex Sodium was being given in tablet form and not capsule form. The facility staff should not be crushing capsules, staff should be twisting the capsules to open them and sprinkle the powder out. If a medication was delayed or extended release and was being crushed, there could be a concern about dose dumping and the patient would be receiving the medication all at once. The facility's order for R2 about crushing medications for dysphagia would not apply.During an interview on 10/16/25 at 1:50 p.m., the director of nursing (DON) stated she would be concerned if she witnessed nursing staff crushing a pill capsule instead of opening it. The best practice is to open the capsule. If it was a medication that shouldn't be crushed, staff should clarify the order. There would be concerns with crushing delayed release medication such as a faster response. Nursing staff have been given training on administering delayed release medications and must pass competencies.The facility policy, Administration of Medication, last revised 6/25/25 directs the person administering medications must ensure that the right medication, right dose, right time and right method of administration are verified before the medication is administered.The facility policy, Medication Crushing Guidelines, undated, directs the nurse administering the medications should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form if possible. The policy further directs that timed release tablets are designed to release medication over a sustained period and to achieve prolonged medication action. These medications should not be crushed. Enteric coated tablets are designed to pass through the stomach whole and dissolve in the intestinal tract to prevent destruction of the medication by stomach acid, prevent the medication from irritating the stomach lining or to achieve prolonged action from the medication.

Based on observation, interview, and record review the facility failed to ensure 3 of 3 residents (R1, R2, and R3) reviewed had a dignified existence when the three residents had been told to use an incontinent brief to toilet rather than staff assisting them to the bathroom.Findings include: Upon observation and interview on 8/14/25 at 8:40 a.m. R1 was struggling to find her call light as it was wrapped around her bed rail and hanging to a floor. A voice from her camera saw the surveyor and asked to assist R1 as she needed to use the bathroom. A nursing assistant could not be found in the hallway, so licensed practical nurse (LPN)-A was asked to come into the room at 8:44 a.m. LPN-A placed her call light within her reach. At 8:45 a.m. R1 pushed her call light. At 8:47 a.m. nursing assistant (NA)-B entered the room, turned off the light and told R1 she would return. At 9:07 NA-B returned with another NA and started morning cares on R1. R1 stated it was common practice for the nursing assistances to turn off her light and tell her they would be back, sometimes they do and sometimes they do not. They always tell me to just go in my pad. R1's care plan dated 3/20/25 indicated for toilet use R1 required the assistance of one staff member for the transfer. Assistance of one staff member with toileting tasks and changing in bed. Staff was to offer and assist R1 with toileting upon rising, before and after meals, before bed and as needed when R1 requested to use the toilet. Use assistance of two staff members as needed related to weakness. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone), chronic kidney disease, pain, and unspecified dementia. An audio and video recording dated 8/17/25 showed R1 waving her hands to an unidentified nursing assistant (NA) who was in her room speaking with a maintenance staff member. R1 was heard saying, wait I have to pee, I have to pee. The NA replied, I'm in another room now, just let loose if you have to pee, you have a brief on. R1 stated I already did let loose. The NA left the room. An email from family member (FM)-A dated 8/18/25 at 12:19 p.m. indicated the video footage had been taken at the end of the day shift on 8/17/25. The NA's partner had left early leaving the NA by herself. A woman down the hall was on the toilet when the NA was called to assist maintenance with a call light. The NA left R1 to help the other woman. R1 knows now just to go in pants. When R1 did get to the toilet she had explosive diarrhea. The smell was so awful. The mess was awful. FM-A should have taken pictures. FM-A cleaned poop from the side of the toilet and the toilet seat. Upon interview on 8/14/25 at 9:43 FM-A stated she had multiple videos of staff telling R1 to use her incontinent pad instead of taking her to the bathroom. This has been the reason for a lot of her falls, R1 trying to self-transfer to the bathroom and not have to urinate in her pad. R2's quarterly MDS dated [DATE] indicated R2 had a BIMs score of 4 indicating R2 was severely cognitively impaired. R2 was totally dependent upon staff for dressing, bathing, toileting, and hygiene cares. He was dependent upon staff for all transferring in and out of bed. R2's pertinent diagnoses were coronary artery disease (damage or disease in the hearts major blood vessels), chronic pain, symptoms and signs with cognitive functions and awareness. R2's care plan dated 2/27/25 indicated R2's required assistance of two staff members and assistance with the Sara Steady (mechanical lift) for toileting and to have a urinal at bedside. R2's care plan dated 3/19/25 indicated R2 sometimes experienced confusion, weakness, and inability to communicate needs. Staff was to encourage R2 to use his urinal or the bathroom and would provide him reassurance and redirection. Upon interview on 8/14/25 at 4:18 p.m. FM-C stated she could not recall the date, but she overheard an NA telling R2 to urinate in his pad. She reported this to the director of nursing DON and the NA was talked to. FM-C stated she watched the video camera in his room, and she does not see him being offered toileting or his urinal. She witnessed staff changing his pad and at times does not witness staff in his room at all overnight. They don't honor our request to have him taken to the bathroom. Upon interview on 8/18/25 at 9:40 a.m. R2 stated he did not like to urinate in his pad, but he has no choice. R2 would not elaborate on his statement. Upon observation and interview on 8/18/25 at 11:30 a.m. R3 and family member (FM-D) were in R3's room. R3 was in her recliner. R3 stated she waited for staff often and has had skin breakdown due to waiting in a wet brief, but not currently. She stated she not aware that she had the choice to use the toilet. She asked multiple times during the interview if she could use the bathroom instead of urinating in her brief. FM-D stated he was not certain that R3 could transfer to the toilet as he had not seen her or heard her using the bathroom in months. FM-D stated he would talk to management about having her use the bathroom when she requests. R3's care plan dated 4/16/25 indicated R3's toilet use was an extensive assistance of 1-2 with transferring to the toilet with a gait belt. R3 would state the need for toileting, wears a brief. Usually incontinent of bowel and bladder. Apply moisture barrier with each incontinence or brief change. Report symptoms of constipation to the nurse. R3's quarterly MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 was cognitively intact. R3 required maximum assistance with toileting, bathing, dressing, and hygiene and transferring from her bed to a chair. R3's pertinent diagnoses were degenerative disease of the nervous system (progressive decline and death or nerve cells), chronic pain, cerebrovascular disease (disease that affects the blood vessels in the brain), hemiplegia (one side weakness following a stroke) following cerebral infarction and unspecified dementia. Upon interview on 8/18/25 at 2:02 p.m. the DON stated it was not o.k. to tell a resident to urinate or go to the bathroom in their incontinent brief. When the NA's are busy, they need to reach out to the nurses to assist them. Upon interview on 8/18/25 at 3:15 p.m. the Regional Operations Manager (filling in for the Administrator) stated telling residents to urinate in their incontinent brief was not the standard of care the facility endorsed. A facility policy regarding dignity was requested however none was received.

Based on observation, interview, and record review the facility failed to provide adequate supervision to reduce the risk of accidents for residents 2 of 3 (R1 and R2) reviewed for supervision. The facility did not assess and document the aimed use for the intent of alarms to be used temporarily to assess patterns and routines of the residents. R1 and R2's family requested the alarms following multiple falls and concerns about adequate supervision.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone, chronic kidney disease, pain, and unspecified dementia. R1's care plan dated 3/20/25 - 8/18/25 did not indicate any scheduled supervision of staff interventions for R1 including patterns or routines with the use of the position alarm. R1's fall log dated 3/20/25 - 8/18/25 included falls on 4/7/25, 5/13/25, 5/20/25, 5/27/25, 6/6/25, 6/27/25, 6/28/25 and 7/12/25. R1's care plan intervention related to potential for falls dated 5/15/25 indicated R1 forgets she cannot transfer or ambulate without assistance and will often attempt to transfer independently which leads to her falls. Signs placed by her bedside to remind her to use her call light to seek help. R1's care plan intervention related to potential for falls dated 5/17/25 indicated R1 believed she could crawl from her bed to the bathroom. Each shift reminds R1 to use her all light and to seek help and staff will point to her call light render posted by her bedside until she develops a habit to use her call light. R1's care intervention related to potential for falls dated 6/9/25 indicated R1 was experiencing increase in confusion and inability to remember to use the call light for help. Hospice was to evaluate her medications. R1's care intervention related to potential for falls dated 6/10/25 indicated R1 had the inability to understand her diminished physical mobility and therefor attempts to self-transfer. R1 would be toileted after each meal, at bedtime and upon rising in the morning to prevent her from self-transferring. R1's care intervention related to potential falls dated 6/27/25 indicated R1 was kneeling by her bedside with no call light on. Family reporting observing R1 on camera attempting to turn her television off. Staff will turn off her television at bedtime. R1's care intervention related to potential falls dated 6/30/25 indicated R1 was attempting to pick up her cell phone charger from the floor while in bed, which led to her rolling out of bed and landing on the floor. Staff was to be sure R1's cell phone charger was secured to her bed rail and in a reachable position. R1' care plan dated 7/2/25 indicated R1 had an alternation in mobility and a potential for injury related to a fall risk. Staff was to ensure bed/chair alarm was under R1 and check for alarm placement and function every shift. R1's care plan for potential fall intervention dated 7/14/25 indicated R1 was attempting to self-transfer from to the toilet without seeking support after lunch. Staff was to toilet R1 after each meal to prevent her from attempting to self-transfer. Upon interview on 8/14/25 at 8:40 a.m. R1 stated she was aware that she had the bed alarm, and she did not like it because she felt there was a resistance, and she had to lay still. She stated she did want the alarm because her family wanted her to have it because of so many falls so staff would hear the alarm and would come quickly. Upon interview on 8/14/25 at 9:43 a.m. R1's family member FM-A stated she heard another family at the facility used a bed alarm because they did not feel their family member was being supervised so FM-A decided to get one for R1. She stated it is so awful to watch an elderly family member struggle to get out of bed on their own when they needed something or to use the bathroom. At least if she had the alarm, she would get staffs attention to assist her. R2's fall log dated 2/18/25 - 3/18/25 indicated R2 had falls on 2/18/25, 2/20/25, 2/21/25, 3/5/25, 3/17/25, and 6/2/25. R2's care plan dated 2/27/25 indicated R2 was a fall risk. R2 was to have call light within reach. R2 needed prompt response. R2's family was to be educated about safety reminders and what to do if R2 falls. R2's fall risk care plan intervention dated 3/6/25 indicated R2 sometimes attempted to self-transfer without using his call light, staff was to perform hourly checks and asked elder if he needed help when awake. R2's fall risk care plan intervention dated 3/6/25 indicated staff would check R1's chair/bed alarm placement and function every shift. R2's quarterly MDS dated [DATE] indicated R2 had a BIMs score of 4 indicating R2 was severely cognitively impaired. R2 was totally dependent upon staff for dressing, bathing, toileting, and hygiene cares. He was dependent upon staff for all transferring in and out of bed. R2's pertinent diagnoses were coronary artery disease (damage or disease in the hearts major blood vessels), chronic pain, symptoms and signs with cognitive functions and awareness. R2's Physical Device Review Comprehensive dated 5/21/25 indicated R2 had an alarming device. The reason for the device was an alternation in safety awareness due to cognitive impairment, history of falls, difficulty with balance or trunk control and medications that increase the risk of falls. R2's alarm was to indicate to staff when R2 was getting out of bed. The alarm was to help at night when R2 got up unattended for staff to be aware. The device was used for fall prevention. Upon interview on 8/14/15 at 12:00 p.m. nursing assistant (NA)-B stated R2 did not need safety checks because he had an alarm to notify staff of when he moved. Upon interview on 8/14/25 at 4:15 p.m. R2's family member FM-C stated when R2 first moved to the facility in 2/2025 he had fallen and when she watched the video of the fall, she noticed that R2 had been on the floor for hours. She stated the facility took care of that matter and put in hourly safety checks, however when she viewed the video recording, she could still see no staff entering R2's room all night and the checks were not being performed during the day as well. She decided to put in a position change alarm to babysit R2. She stated at least she can peace of mind knowing if R2 continued to fall he would be tended to, or it could prevent a fall making staff was aware when he was up. Upon interview on 8/18/25 at 12:35 p.m. the facilities Medical Director was not aware that the facility had bed alarms in place. She stated that during QAPI (Quality Assurance and Performance Improvement) meetings the facility were addressing falls, however the alarms had not been brought up. She stated she understood the concerns of the families, however using an alarm does not absolve the facility from supervising residents. Upon interview on 8/18/25 at 2:02 p.m. the Director of Nursing, (DON) stated the bed alarms were placed due to the requests of the families that the facility does not recommend the alarms. She stated bed alarms can inhibit the residents from moving and she explained that the families. She said the residents get checked on every couple of hours, 2-3 hour at night. The DON was certain the residents were supervised. The facilityhad not have any audits of the staffing rounds on any of the shifts. Upon interview on 8/18/25 at 3:15 p.m. the Regional Operations Manager (filling in for the Administrator) stated two residents in the facility have positioning alarms. The facility did not offer alarms to families. She stated the families who have them felt like they needed another safety intervention. The facility uses a greenhouse of model, meaning they have private rooms and not a visible nurses station. The facility was starting a PIP (performance improvement plan) on falls and how the checks on residents for safety and if staff is following the care plan and the Kardex. The staff does two hours rounding for safety checks unless a resident does not want to any safety checks. A facility policy titled Fall Risk Assessments dated 4/2022 indicated All residents who are assessed as being at risk for falls will be identified and individualized fall precautions will be developed to decrease the number of falls whenever possible. It is the goal of the facility to achieve the resident's maximum potential of physical functioning, prevent injury, reduce falls, and enhance the resident's self-worth and dignity.Procedure:1. A Fall Risk Assessment will be completed at a minimum upon admission, quarterly in conjunction with the MDS schedule, upon significant change in status.2. Identified Fall risks will have appropriate interventions and precautions implemented and communicated to staff.3. Initiate, review and/or revise the care plan as appropriate.4. The IDT will, at a minimum of quarterly, review the resident's fall risk and care plan.5. The resident, responsible party and MD/NP will participate in the development of the plan to reduce falls.6. A post fall assessments will occur to review contributing factors and preventrecurrence of falls.7. Falls will be discussed at IDT daily stand up, Safety Committee and Quality Assurance meetings as warranted.8. Manufacturer's recommendations will be followed for fall prevention devices as needed.

Based on observation, interview, and record review the facility failed to attempt alternative devices before using bedrails on residents beds. The failed to accurately assess the residents for risk of entrapment by assessing residents medical diagnosis, size and weight, cognition, communication, and mobility for 3 of 3 residents (R1, R2, and R3) reviewed for bed rails. In addition, R2 had side rails used in conjunction with an air mattress. Findings include: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual retrieved from https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf indicated a physical restraint or method physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint definition. This can only be deterred on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material, or equipment. Recommendations for Health Care Providers Using Adult Portable Bed Rails retrieved from https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/BedRailSafety/ucm362848.htm indicated Food and Drug Administration (FDA) guidelines (Recommendations for Health Care Providers about Bed Rails) 2018 indicated health care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions, health care providers are to avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment, and restrict the use of physical restraints including restrictive use of bed rails, or chest, abdominal, wrist, or ankle restraints of any kind on individuals in bed. When installing and using bedrails select the appropriate bed rail, follow the health care providers procedures or manufacture recommendations, inspect, evaluate, and regularly check bedrails are appropriately matched to equipment and patient needs considering all relevant risk factors, to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress, which may be caused by patient weight, movement, bed position, or by using a specialty mattress. Recommendations for Health Care Providers Using Adult Portable Bed Rails retrieved fromhttps://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails indicated be aware that not all bed rails, mattresses, and bed frames are interchangeable, and not all bed rails fit all beds. Check with the manufacturers to make sure the bed rails, mattress, and bed frame are compatible. Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. R1's care plan dated 3/20/25 indicated she had bilateral mobility bars at the head of her bed to enhance her participation in positioning and bed mobility. R1's Physical Device Review Comprehensive dated 6/22/25 indicated R1 had right and left mobility bars, a floor mat, and a low bed. The reason for the use of the devices was R1 was non-ambulatory, her level of consciousness fluctuated, she had poor bed mobility or difficulty moving to a sitting position displayed. The devices would be used whenever R1 wanted to relax in her recliner. Her ability to demonstrate the appropriate use was marked as N/A (non-applicable). The device helped her assist with bed mobility. The device was not considered to be a therapeutic intervention to achieve proper body position, balance, or mobility, but indicated it was used for positioning. The devices were not used for fall prevention. The risks vs. benefits where they enabled R1 to assist with bed mobility and repositioning herself in bed. The summary of device use was side rails would assist with mobility and repositioning while in bed. The recliner chair would be used to help R1 relax. No risk or benefits or any other education was documented as provided to R1 or representative. In addition, R1's medical diagnosis, size and weight, cognition, communication, and mobility were not assessed for the medical device evaluation or if R1 could remove the device on her own indicating the device was not a restraint. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone, chronic kidney disease, pain, and unspecified dementia. R1's MDS did not indicate the use of bed rails. Upon observation and interview on 8/14/25 at 8:40 a.m. R1 was in her bed trying to call for staff assistance R1's had an extended call light cord wrapped around her half-length bed rail on the upper right side of her bed. R1 was placing her hand in and out of rail trying to untangle the light by herself. R1 had a left half-length bed rail as well, a floor mat, and her bed was in the lowest position. Both bed rails were permanently affixed to her bed. R1 stated she used the bed rails when she attempted to get out of bed on her own and reposition in bed. R2's care plan dated 2/19/25 - 8/18/35 did not indicate the use of bed rails. R2's quarterly MDS dated [DATE] indicated R2 had a BIMs score of 4 indicating R2 was severely cognitively impaired. R2 was totally dependent upon staff for dressing, bathing, toileting and hygiene cares. He was dependent upon staff for all transferring in and out of bed. R2's pertinent diagnoses were coronary artery disease (damage or disease in the hearts major blood vessels), chronic pain, symptoms and signs with cognitive functions and awareness. R2's MDS did not indicate the use of bed rails. R2's Physical Device Review Comprehensive dated 5/21/25 indicated the devices used by R2 were an electric reclining chair and an alarm device. The form did not indicate the bed rails on R2's bed. No risk or benefits or any other education was documented as provided to R2 or representative. In addition, R2's medical diagnosis, size and weight, cognition, communication, and mobility were not assessed for the medical device evaluation or if R2 could remove the device on her own indicating the device was not a restraint.Upon observation and interview on 8/14/25 at 9:39 a.m. R2 was seated in his chair, his bed had an air mattress and was positioned in the lowest level with permanently affixed bilateral half-length bed rails on his bed. R2 stated he did not know what the bed rails on his bed were for. R3's Care plan dated 4/16/25 indicated R3's bed mobility was an extensive assist of one staff member, encourage R3 and assist to use bilateral mobility bars. R3's quarterly MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 was cognitively intact. R3 required maximum assistance with toileting, bathing, dressing, and hygiene and transferring from her bed to a chair. R3's pertinent diagnoses were degenerative disease of the nervous system (progressive decline and death or nerve cells), chronic pain, cerebrovascular disease (disease that affects the blood vessels in the brain), hemiplegia (one side weakness following a stroke) following cerebral infarction and unspecified dementia. R3's Physical Device Review Comprehensive dated 7/21/25 indicated the devices used were right and left mobility bars. The reason for the use of the device was R3 was non-ambulatory, she had alteration in safety awareness due to cognitive impairment, history of falls, difficulty with balance and trunk control displayed. R3 was able to demonstrate the ability to use the device appropriately. The device benefited her as it served as a mobility enabler, repositioning tool, and safety. The device was considered to be a therapeutic intervention to achieve proper body positioning, balance and mobility and was used for a mobility enabler and positioning. The devices were not utilized as a fall prevention. The risks versus benefits were described as benefit: siderails are used when getting in and out of bed and for repositioning while in bed. The risk was all devices have the ability to cause injuries when not used properly. The summary of the device used indicated side rails were used when getting in and out of bed, and for repositioning while in bed. R3's medical diagnosis, size and weight, cognition, communication, and mobility were not assessed for the medical device evaluation or if R3 could remove the device on her own indicating the device was not a restraint. In addition, the risk and benefits documented did not include if the resident and or representative was educated. Upon observation and interview on 8/14/25 at 11:18 a.m. R3 was seated in her reclining chair, she had permanently affixed half-length bilateral bed rails on her bed. R3 stated she required the rails for all movement in bed. Upon interview on 8/14/15 at 11:09 a.m. licensed practical nurse (LPN)-A stated the facility assessed bed rails on all the residents on each quarterly assessment. The residents and/or representative is educated on the risks and benefits however the facility did not have a place to document the education. The facility did not try any alternative methods prior to the use of the bed rails and the bed rails are used for safety of the residents while in bed. Upon interview on 8/18/25 at 2:02 p.m. the director of nursing (DON) stated during the survey when surveyor requested bed rail information the facility realized they did not have all the criteria of the bed rail safety policy and removed most of the bed rails from residents except for a select few whose family were onsite and opposed the removal. The facility was going to start the side rails assessments from scratch following the survey. The DON stated the facility did not try alternative methods prior to installing the bed rails, asking what else are you going to use? She stated none of the rails the facility had on the bed were considered restraints because the residents were able to get in and out of bed. Upon interview on 8/18/25 at 3:15 p.m. the regional operations manager (filling in for the Administrator) stated the facility realized during the survey process that the facility was not following through on their process in regard to bed rails and on 8/15/25 removed most of the bed rails from the residents bed until new assessments could be completed. The facility sent an email to all the residents and/or resident representatives. A facility policy titled Bed Safety Policy dated 1/1/18 indicated half-side rails will be used only after an assessment has been made indicating a benefit to the resident's functional status. Continued use of the half-side rail will be reassessed periodically to determine if the side rails enhance the resident's mobility while in bed or restricts the resident's freedom of movement.

Based on interview and record review the facility failed to ensure a system to reduce the risk of significant medication errors for transdermal opioid patches for 1 of 3 residents (R1) reviewed for medication administration. R1 was ordered by her hospice agency to have a transdermal opioid patch (narcotic medicated patch that slowly releases the medication into the body) placed on her skin every seven days. On two occasions the nursing staff failed to remove the old patch from her skin when the new patch was placed on her.Findings include: R1's hospice care plan dated 5/28/25 indicated buprenorphine (Butrans) 5 micrograms per hour (mcg/hr.) patch (an opioid patch used to treat opioid use disorder but also used for pain management) was to be applied once every week. Remove old patch prior to new patch application for chronic pain. R1's facility providers order dated 5/29/25 indicated Butrans transdermal patch 5 mcg/hr. Apply 1 patch transdermal one time a day every seven days for pain. The facility's order did not include to remove the old patch. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone, chronic kidney disease, pain, and unspecified dementia. R1's progress notes dated 8/1/25 - 8/18/25 did not provide any documentation regarding medication error monitoring or follow-up. R1's medication error on 8/1/25 or the error on 8/8/25 including any follow-up assessments. A facility report titled Record of Customer and Family Concern dated 8/1/25 indicated hospice staff reported that they found two pain patches on R1 during her weekly shower. The oldest patch was removed and the newest was left on. R1's vital signs were obtained and were within baseline, staff was to continue to monitor R1, no acute changes noted. The Administrator and the director of nursing (DON) were notified on 8/4/25. The staff member who provided care was interviewed and stated she did not see an old patch and always removed an old patch. The action taken was patch training conducted, staff demonstrate understanding of the patch removal. R1's care plan and treatment administrator were updated. R1's family was notified on 8/4/25. The form did not indicate hospice, or the facilities medical provider were notified to obtain an order for any assessments following the error. A facility report titled Medication Error Report dated 8/11/25 indicated on 8/8/25 R1's family member (FM)-A notified staff that R1 had two pain patches on her, one was dated 7/31/25 and the other was not dated. Both patches were removed, and a new patch was applied. Hospice was updated on 8/11/25 and the staff was to monitor R1. The form did not indicate who was notified at hospice and what the staff was to monitor, in addition hospice was notified three days after the error occurred. There was no documentation of initial interventions to assess R1. A typed form by the facility dated 8/12/25 indicated FM-A was assisting change R1 into her nightgown and found two pain patches on R1's body. The first patch was on the front of R1 and not dated, while the second was dated and placed on her back. FM-A requested both patches to be removed by the nurse based on the instruction of a family member who was a doctor. The form did not indicate any communicate with hospice. The intervention was patch training conducted, staff administrating medications will ensure that the old patch was removed prior to new patch administration. There were no documented interventions for the care of R1 following the error. Upon interview on 8/14/25 at 11:09 a.m. licensed practical nurse (LPN)-A the nurse manager stated R1 did have two patches placed on her body at the same time twice. He stated the first time. R1 had two patches on it was the hospice nursing assistant who notified him. He stated he did monitor R1 following the error on 8/1/25 however he did not document exactly what he monitored. The second time the error happened he was not certain if hospice was notified as he was not onsite that day and he was not certain of the immediate action taken by staff to care for R1. Upon interview on 8/14/25 hospice registered nurse (RN)-A at 12:26 p.m. stated she was not aware of the doubling of the patches on 8/1/25, but was aware of the 8/7/25 incident as FM-A notified her. She stated the facility should have obtained orders to assess R1 and maybe even have the hospice staff make a visit if necessary. Upon interview on 8/14 at 1:01 p.m. R1's family member (FM)-B stated the facility failed R1 twice. FM-B's spouse was a Medical Doctor, and he told the facility they needed to remove both patches and start a new one. The facility was not able tell FM-B what their system was for a transdermal patch error. FM-B watched on R1's room camera if the staff checked in and completed vital signs often on R1 following the error and no additional monitoring was noticed. The day after the error R1 was very emotional and was calling the family crying, unable to state why she felt so awful. Upon interview on 8/18/25 at 8:39 a.m. the hospice Pharmacist stated the medication error caused R1 to receive an unintended increase in dose and how it affected her would be dependent on multiple different areas such as tolerance, how long both patches were on her, other medications. R1 should have been assessed for excess sedation, dizziness, it could have caused hypotension (low blood pressure) she could have had an increase in falls. The Pharmacist stated he would call have two opioid patches on an elderly residents skin at once a significant medication error because of the medication being an opioid and the route of administration, applying a patch is a significant nursing error as the nurse should ensure there is patch to remove or not. Upon interview on 8/18/25 at 8:55 a.m. the hospice medical provider stated hospice was not notified of the errors, there was no documentation in R1's hospice notes. R1 should have been assessed for drowsiness, dizziness and respirations can drop. Vital signs are very important following an opioid error. The provider would have ordered vital signs every 30 minutes for the first 4 hours, especially watching the pulse and respirations. This was a significant medication error. Upon interview on 8/18/25 at 12:35 p.m. the facilities medical director stated the patches should have been dated and since one of them was not both patches should have been removed during both error incidents and new patches applied. The prescribed should have been notified with an error of opioids for direction and awareness. Upon interview on 8/18/25 at 1:49 p.m. LPN-B stated she placed a patch on R1 and was re-educated by the facility. She stated she was told she did not remove an old patch on R1. She stated sometimes orders do not come in on time, so she thought maybe R1 did not have a patch on as she did not see one. LPN-B was a new nurse and reported not having training regarding patches and when and if to remove an old patch. She stated the order did not say to remove an old one. Upon interview on 8/18/25 at 2:02 p.m. the director of nursing (DON) stated she was unaware until the survey that R1 had medication error on 8/1/25 and was not certain what notifications were made following the error or how R1 had been monitored. She was aware of the error on 8/7/25 and stated LPN-B followed-up and re-educated the staff about removing an old patch. She stated R1's vital signs were documented following the second error, but no other monitoring was documented as being completed. A facility policy titled Med Error with a revision date of 8/1/21 indicated Policy: Medication Errors must be reported to the Supervisor immediately. Procedure: A medication Incident report must be filled out within 24 hours once the error has been discovered.Information should include the following.1. Name of Elder2. Date and time of incident3. Medications involved - give dose and directions for use4. Route of administration5. Detailed description of the error6. Physician notified7. Treatment given to the elder to counteract the effects of the error -if ordered8. Measures taken to rectify the error9. Any adverse consequences noted10. Elders general condition11. Name of staff responsible for error12. Preventative ActionAll reports must be turned in to the Director of nursing immediately. Eachmedication/treatment error will also be reviewed by the Medical Director and theConsulting Pharmacist. DON will counsel staff and any disciplinary issues will bedealt with according to facility policy. Education will be provided to the staff if necessary and a copy will be kept.

Based on observation, interview and document review, the facility failed to establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. R1 did not receive the necessary care and services when she had the same medication error occur twice. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met.Findings include: R1's hospice care plan dated 5/28/25 indicated buprenorphine (Butrans) 5 micrograms per hour (mcg/hr.) patch (an opioid patch used to treat opioid use disorder but also used for pain management) was to be applied once every week. Remove old patch prior to new patch application for chronic pain. R1's facility providers order dated 5/29/25 indicated Butrans transdermal patch 5 mcg/hr. Apply 1 patch transdermal (on the skin) one time a day every seven days for pain. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone, chronic kidney disease, pain, and unspecified dementia. A facility report titled Record of Customer and Family Concern dated 8/1/25 indicated hospice staff reported that they found two pain patches on R1 during her weekly shower. The oldest patch was removed and the newest was left on. R1's vital signs were obtained and were within baseline, staff was to continue to monitor the elder, no acute changes noted. The Administrator and the director of nursing (DON) were notified on 8/4/25. The staff member who provided care was interviewed and stated she did not see an old patch and always removed an old patch. The action taken was patch training conducted, staff demonstrate understanding of the patch removal. R1's care plan and treatment administrator were updated. R1's family was notified on 8/4/25. The date of the training was 8/13/25 and 8/14/25. The form did not indicate hospice, or the facilities medical provider were notified. A facility report titled Medication Error Report dated 8/11/25 indicated on 8/8/25 R1's family member (FM)-A notified staff that R1 had two pain patches on her, one was dated 7/31/25 and the other was not dated. Both patches were removed, and a new patch was applied. Hospice was updated on 8/11/25 and the staff was to monitor R1. The form did not indicate who was notified at hospice and what the staff was to monitor, in addition hospice was notified three days after the error occurred. A typed form by the facility dated 8/12/25 indicated FM-A was assisting change R1 into her nightgown and found two pain patches on R1's body. The first patch was on the front of R1 and not dated, while the second was dated and placed on her back. FM-A requested both patches to be removed by the nurse based on the instruction of a family member who was a doctor. The form did not indicate any communicate with hospice. The intervention was patch training conducted, staff administrating medications will ensure that the old patch was removed prior to new patch administration. Upon interview on 8/14/25 at 11:09 a.m. licensed practical nurse (LPN)-A the nurse manager stated R1 did have two patches placed on her body at the same time twice. He stated the first time. R1 had two patches on it was the hospice nursing assistant who notified him. He stated since it was the hospice aid was part of the hospice she would report to her leaders. The second time the error happened he was not certain if hospice was notified as he was not onsite that day. LPN-A stated the facility did not have a hospice coordinator to report incidents to. Upon interview on 8/14/25 hospice registered nurse (RN)-A stated she was not aware of the doubling of the patches on 8/1/25, but was aware of the 8/7/25 incident as FM-A notified her. RN-A stated she did not know of a hospice coordinator at the facility, she just spoke with the nurse on each floor of any orders, updates or concerns she had. Upon interview on 8/14/25 at 1:35 p.m. the Administrator in training stated she was not certain if the facility had a hospice coordinator. She stated to ask the DON as she had been at the facility for a long time. Upon interview on 8/14/25 at 1:35 p.m. the DON stated the facility did not have one actual person as the coordinator, it was a team effort. The social worker worked on referrals and admissions and the nurse manager work with the hospice companies once they are onboard. The facilities contract with hospice dated 3/14/22 indicated:Facility Representative: Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice to coordinate care provided by Facility staff and Hospice staff to any Hospice Patient under Hospice's care. Such interdisciplinary team member shall be responsible for the following: (i) collaborating with Hospice and coordinating Facility staff participating in the hospice care planning process for those Hospice Patients who are under Hospice's care; (ii) communicating with Hospice and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the Hospice Patient and family; (iii) ensuring that Facility communicates with the Hospice medical director, the Hospice Patient's attending physician, and other practitioners participating in the provision of care to the Hospice Patient as needed to coordinate the hospice care with the medical care provided by other physicians. A facility hospice policy was requested however none was provided.

Based on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 3 of 3 residents (R1, R2, and R3) reviewed. The bed manufacturer guidelines indicated to visually inspect the bed and accessories monthly and indicated to follow the FDA guidance.Findings include: Recommendations for Health Care Providers Using Adult Portable Bed rails dated 2/27/2023 retrieved on 8/14/25 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds indicated, when evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system is used for purposes, or used in a care setting, not intended by the manufacturer. Evaluating the dimensional limits of gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment. Bed safety programs may also include plans for the reassessment of hospital bed systems. Reassessment may be appropriate when (1) there is reason to believe that some components are worn (e.g., rails wobble, rails have been damaged, mattresses are softer) and could cause increased spaces within the bed system, (2) when accessories such as mattress overlays or positioning poles are added or removed, or (3) when components of the bed system are changed or replaced (e.g., new bed rails or mattresses). This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. Descriptions of the seven entrapment zones appear on pages 15-21 in this guidance. Summary drawings of entrapment for all the zones appear in Appendix E. The seven areas in the bed system where there is a potential for entrapment are identified in the drawing below. Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split Bed Rails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End. Health Care providers should base the use of bed rails on individual resident assessments to ensure the individual is an appropriate candidate to reduce the risk of entrapment. Recommendations made for health care providers to evaluate the individual's need, to use the guidance documented Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment to have knowledge that not all bedrails, mattresses, and bed frames are interchangeable; check the manufacture instructions, health care providers are to avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment, and restrict the use of physical restraints including restrictive use of bed rails, or chest, abdominal, wrist, or ankle restraints of any kind on individuals in bed. When installing and using bedrails select the appropriate bed rail, follow the health care providers procedures or manufacture recommendations, inspect, evaluate, and regularly check bedrails are appropriately matched to equipment and patient needs considering all relevant risk factors, to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress, which may be caused by patient weight, movement, bed position, or by using a specialty mattress.The manufacture user-service manual for Joerns Assist Device and Side Rails [NAME]-Care Models, undated, indicated Maintenance/Inspection Information: Visually inspect the assist handle and mounting bracket, and check for loose hardware monthly. Tighten loose hardware as stated in the installation instructions.Warning: Risk of Serious Injury or Death. Properly locate the mounting brackets. The gap between the head/foot panel and the assist device or side rail must be small enough to prevent a resident from getting their head or neck caught in this location (see the installation instructions for more information, if applicable). If multiple assist devices are needed, position them such that the gap between them is large enough that the trunk and hips can easily pass through. Make sure that raising or lowering the bed, or adjusting the sleep surface, does not create hazardous gaps. The assist devices or side rails should not be used if ANY openings within the bed system allow a resident to get their head or neck lodged within these openings. Failure to do so could result in serious injury or death.Warning: An optimal bed system assessment should be conducted for each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration. Further information can be obtained at the following web address: http://www.fda. gov/MedicalDevices/ProductsandMedicalProcedures/ GeneralHospitalDevicesandSupplies/HospitalBeds/default.htm Upon observation and interview on 8/14/25 at 8:40 a.m. R1 was in her bed trying to call for staff assistance R1's had an extended call light cord wrapped around her half-length bed rail on the upper right side of her bed. R1 was placing her hand in and out of rail trying to untangle the light by herself. R1 had a left half-length bed rail as well, a floor mat, and her bed was in the lowest position. Both bed rails were permanently affixed to her bed. R1 stated she used the bed rails when she attempted to get out of bed on her own and reposition in bed. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status was a 13 indicating R1 was cognitively intact. R1 was dependent upon staff for dressing, bathing, toileting, and hygiene cares. She was dependent upon staff for all transferring in and out of bed. R1's pertinent diagnoses were cerebral vascular disease (a group of conditions that affect blood flow and blood vessels in the brain), hypothyroidism (the thyroid gland doe does not produce enough thyroid hormone, chronic kidney disease, pain, and unspecified dementia. R1's MDS did not indicate the use of bed rails. Upon observation and interview on 8/14/25 at 9:39 a.m. R2 was seated in his chair, his bed had an air mattress was in the lowest position with permanently affixed bilateral half-length bed rails on his bed. R2 stated he did not know what the bed rails on his bed were for. R2's quarterly MDS dated [DATE] indicated R2 had a BIMs score of 4 indicating R2 was severely cognitively impaired. R2 was totally dependent upon staff for dressing, bathing, toileting, and hygiene cares. He was dependent upon staff for all transferring in and out of bed. R2's pertinent diagnoses were coronary artery disease (damage or disease in the hearts major blood vessels), chronic pain, symptoms and signs with cognitive functions and awareness. R2's MDS did not indicate the use of bed rails. Upon observation and interview on 8/14/25 at 11:18 a.m. R3 was seated in her reclining chair, she had permanently affixed half-length bilateral bed rails on her bed. R3 stated she required the rails for all movement in bed. R3's quarterly MDS dated [DATE] indicated R3 had a BIMs score of 15 indicating R3 was cognitively intact. R3 required maximum assistance with toileting, bathing, dressing, and hygiene and transferring from her bed to a chair. R3's pertinent diagnoses were degenerative disease of the nervous system (progressive decline and death or nerve cells), chronic pain, cerebrovascular disease (disease that affects the blood vessels in the brain), hemiplegia (one side weakness following a stroke) following cerebral infarction and unspecified dementia. On 8/14/25 at 4:35 p.m. an email was sent to the Administrator in training requesting the maintenances department documentation of bed rail safety checks. An email response was received on 8/18/25 at 8:54 a.m. with a logbook page dated 8/15/25 with documentation of four residents on the fourth floor. The heading was bed and the form indicating zone 1, zone 2, zones 3 and 4 zone pass was checked after each zone. No other information was documented regarding the rails. Upon interview on 9:50 a.m. the maintenance director stated the maintenance department adds the rails to the beds upon nursing requests. The rails are stored in safe storage and them for safety when they are installed. The nurses notify maintenance of any concerns once the rails are on the beds. No other monitoring was completed by maintenance. Upon interview on 8/18/25 at 2:02 p.m. the director of nursing (DON) stated during the survey when surveyor requested side rail information the facility realized they did not have all the criteria of the side rail safety policy in place and that included any audits from the maintenance department. Upon interview on 8/18/25 at 3:15 p.m. the regional operations manager (filling in for the Administrator) stated the facility realized during the survey process that the facility was not following through on their process regarding side rails. In addition, there was not documentation of audits from the maintenance department. She stated the TELS system (the software system that notifies maintenance of tasks to complete) did not have the side rail safety inspector turned on to notify the staff. A facility policy titled Bed Safety Policy dated 1/1/18 indicated Maintenance monitors all bed rails for gaps between the mattress and bed rail, checks the mechanics of each side rail. Repair or replacement of the side rail is completed by the Maintenance department. Maintenance and/or the Health Unit Coordinator, or other designee, will replace any mattress with large gaps between the mattress and side rail.

Based on interview and record review the facility failed to ensure an allegation of abuse was reported immediately to the state agency and administrator of the facility, but not later than two hours after the allegation is made for 1 of 3 residents (R1) reviewed for abuse. R1 reported to multiple staff members the care she received was rough causing pain, staff yelled at her, and a staff member heard another staff member yelling at R1. Findings include: The facilities grievance log dated 1/1/25 - 5/16/25 did not indicate any grievances about R1. R1's re-admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score indicated a 99 meaning unable to complete. R1 was dependent upon staff for toileting hygiene, bathing, lower body dressing, and moving from a lying to a sitting position on the side of her bed. R1's pertinent diagnoses were hypovolemia (deficiency of volume of blood in the body), cirrhosis of the liver (scar tissue in the liver), unspecified dementia, unspecified severity without behaviors/psychosis/anxiety and an unspecified personality disorder. Upon interview on 5/16/25 at 1:58 p.m. R1 stated staff was always rough with her when repositioning her. A couple of weeks ago a nursing assistant (NA)-F entered her room the one who always yells at me, and was yelling at R1 telling her she had to go to bed and have her incontinence pad changed. Then NA-G came in to assist the NA-F and they jerked her around like she was a rag doll. This caused pain for the next days. R1 reported the incident to other staff members who she trusted. R1 stated she remembers incidents but does not recall the dates. She had lost the ability to write down dates and times because she was compromised on the right side of her body. Upon interview on 5/16/26 at 2:20 p.m. NA-A stated a few weeks ago she heard a serious confrontation of yelling between NA-B and R1. NA-A walked away from the situation as she did not want to get involved because she had a recent confrontation with NA-B as well. NA-A reported the yelling to licensed practical nurse (LPN)-A the nurse manager. NA-A referred to the yelling as verbal abuse and stated she did what she was supposed to and reported to the nurse manager. Upon interview on 5/16/25 at 2:45 p.m. NA-C stated R1 had aggressive behaviors because she would yell at staff, she had never heard staff yell back at R1. R1 told NA-C that a NA-F yelled at her. NA-C did not report the yelling allegations because she did not hear it firsthand. R1 always complained of rough cares and the nurses knew about R1's rough care concerns because R1 complained of rough cares to the nurses when they were assisting R1 with the nursing assistance. Upon interview on 5/16/25 an anonymous staff member stated R1 reported to them that the evening staff was rough with her, and she did not feel safe. R1 had cognitive deficits, so she is not the most accurate historian for reporting the dates. R1 did have the ability to accurately report occurrences and when negative occurrences happened at the facility and R1 tended to have more behaviors to defend herself. R1 told the staff member that two staff members were so forceful with her that she was frightened and felt pain for several days. R1 described one staff member who always yelled at her. The anonymous staff member stated they were aware that allegations of abuse are to be reported to the state agency within two hours. The staff member did report the allegations to the state agency in two hours but was not reporting on behalf of the facility. The staff member did not report the allegations to the facility because there had been enough instances where the facility had not investigated allegations, reported to the state agency, or taken any action. The staff member felt education about cares needed to be articulated to the staff and a level of trust needed to be displayed by the management team. Upon interview on 5/19/25 at 8:45 a.m. NA-D stated R1 told her that there is a huge difference between day and night shifts. The night shift performs their cares rough and argue with R1. NA-D did not hear any staff arguing with R1. She stated she reported to LPN-A R1 had complained of rough cares. NA-D stated nobody had followed-up with her after she reported the rough cares. Upon interview on 5/19/25 at 9:03 a.m. NA-E stated R1 mentioned that NA-F had yelled at her a few weeks ago, but he disregarded it because R1 was always yelling at staff herself and always complaining. Upon interview on 5/19/25 at 10:02 a.m. trained medication assistant (TMA)-A stated R1 had gotten angry at all staff. R1 complains of rough cares, but nothing specific is mentioned. TMA-A stated she reported rough cares to the supervisor multiple time over the past months. Upon interview on 5/19/25 at 10:15 a.m. LPN-A, nursing manager stated no staff member reported any specific concerns regarding R1. She stated she heard rumors that someone had pushed R1 over too hard. She did not investigate the rumors. She recalled NA-A had a complaint about NA-B yelling but could not recall the details. Upon interview on 5/29/25 at 1:07 p.m. the administrator stated her expectation would be for staff to report yelling and rough cares to their immediate supervisor and that supervisor to report any abuse allegations to the director of nursing or administrator. A facility policy titled Reporting and Investigation Procedure dated 11/15/23 indicated any employee, family member, volunteer or resident who suspects that an incident of maltreatment has occurred shall immediately report such incident to either the nurse on the station where the alleged incident occurred or to the employee/volunteer's immediate supervisor. NOTE: (NHA Notification Policy for immediate reporting requirement to facility administrator). Anyone who has reason to suspect that an incident of abuse or neglect has occurred has the right to make a report to the Office of Facility Health Complaints at the MDH. Incidents that must be reported to immediately to MDH: -Mistreatment -Neglect -Abuse - Inclusive of Resident-to-Resident Abuse and Self Abusive Behavior -Sexual Abuse -Injuries of an unknown source

Based on observation, interview, and document review the facility failed to revise the care plan for 1 of 3 residents (R2) who were reviewed for falls. Findings include: R2's face sheet dated 3/27/25, identified diagnosis of Parkinson's disease, dementia, and kidney disease. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, maximum assistance for bed mobility, dependent for transfers, and two or more falls since admission without injury. R2's fall focus care plan dated 11/13/24, identified at risk for falls. Goal of will not sustain serious injury. Interventions added as followed: -11/13/24 to place call light within reach and encourage to use it -12/11/24 ensure R2's phone is close to her bed where can be easily reached. -12/23/24 R2 sometimes wakes up confused and agitated, she will scream and attempt to get out of bed on her own, staff to provided reassurance and redirection until calmed. -12/26/24 R2 sometimes wakes up confused and attempts to climb out of bed, staff to inquire about toileting needs and assist to bathroom when necessary. -3/24/25 staff to avoid having R2 in living room -3/21/25 staff to sit with resident for five to ten minutes when restless and provide reassurance such as I am here to help, you are safe, it is okay, how can I help you. Review of R2's nursing assistant care sheets on 3/26/25 identified fall risk and interventions: place call light within reach, mobility bar in place, phone kept at bedside, staff to sit with R2 for ten-15 minutes when restless and avoid having R2 in living room. R2's incident report dated 12/21/25 at 2:06 a.m., identified R2 was found on floor in her room. New intervention for staff to provide reassurance and redirection until calmed. R2's care plan revised on 12/23/24 to provider reassurance until calmed. R2's incident report dated 1/2/25 at 4:46 a.m., identified R2 was found sitting on floor in her room. New intervention of frequent visual checks. R2's care plan did not identify intervention of frequent visual checks. R2's incident report dated 1/18/25 at 3:00 a.m., identified R2 was found lying on floor in room near bed. New intervention to check on every hour when awake and ask if she needs help. R2's care plan did not identify every hour checks. R2's incident report dated 1/24/25 at 7:33 a.m., identified R2 was found on floor near her bed. New intervention of staff to increase safety checks. R2's care plan did not identify safety checks. R2's incident report dated 2/16/25 at 10:30 a.m., identified R2 was found on floor on knees on side of bed. New intervention of staff to provide reassurance to R2 every shift. During an interview on 3/26/25 at 1:39 p.m., nursing assistant (NA)-C stated they do frequent checks for R2, but were not instructed on a specific timeframe on how often to check on her. NA-C stated staff did not document in R2's chart when they checked on her. During an observation and interview on 3/26/25 at 1:38 p.m., R2 was lying in bed with her call light within reach, bed in lowest position and a fall mat placed on the floor on the right side of her bed. NA-D stated R2 was high risk for falls, and they had been placing a fall mat next to her bed to protect her if she fell, however, NA-D verified the fall mat had not been added to the nursing assistant care sheet. NA-D stated if unfamiliar staff were working with R2 and were not aware of the fall mat, they could forget to place it on the floor. Review of R2's care plan on 3/26/25 did not identify fall mat to be placed next to bed. During an interview on 3/26/25 at 1:55 p.m., licensed practical nurse (LPN)-B stated R2's care plan did not identify any safety checks or fall mat and stated, It should have been added. During an interview on 3/26/25 at 3:08 p.m., director of nursing (DON) stated her expectation would be for any new fall intervention to be added to the care plan in a timely manner to reduce future falls. On 3/26/25 requested facility's care planning policy and did not receive.

Based on observation, interview, and document review the facility failed to comprehensively assess and monitor a skin tear (a traumatic wound that occurs when the top layer of skin separates from the underlying layers) for 1 of 1 resident (R3) reviewed for injury of unknown origin. Findings include: R3's face sheet dated 3/26/25, identified diagnoses of heart failure (condition in which heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). R3's care plan dated 1/22/25, identified R3 had actual impairment to skin integrity related to a healing skin tear on right upper arm. No other areas of skin impairment were identified. R3's admission nursing assessment dated [DATE], identified skin tear on right forearm measuring 3.2 centimeters (cm) x 1.2 cm. and included the skin tears need attention. R3's physician orders dated 2/4/25 to 2/20/25, identified an order for right arm skin tears (location of the skin injuries on the arm was not specifically identified): cleanse with normal saline. Apply skin sealant to intact periwound skin, let dry. Cover with non-adherent dressing and secure with roll gauze, tubular stockinet. Until resolved or new treatment. Review of the corresponding treatment administration record (TAR) indicated there were no treatments completed to R3's right arm between 2/21/25 to 3/26/25. R3's weekly skin body audit dated 2/23/25, identified bruising on right and left arm, however, did not have any measurements, description of bruise, or an open area on right forearm. R3's weekly skin body audit dated 3/9/25, identified bruising on left arm, however, did not have any measurements, descriptions, or an open area on right forearm. R3's skin body audit dated 3/25/25 at 9:02 p.m., identified a resolving open area on right forearm measuring 2.0 centimeters (cm) x 1.0 cm x 0.1 cm. During an interview on 3/25/25 at 5:14 p.m. nursing assistant (NA)-A stated the wound on R3's right forearm has been present since she came back from hospital, and it did not appear to be getting any smaller. During an interview on 3/25/25 at 5:16 p.m., NA-B stated R3's wound on her right forearm has been present since a return from the hospital in February and the nurses are not doing a treatment to the area. During an observation and interview on 3/25/25 at 2:49 p.m., R3 was seated in her wheelchair and had an open area on her right lower arm. Open area was oblong in shape, approximately 2.0 cm x 2.0 cm., base of wound was covered with slight yellow material, appeared dry, and did not have a dressing on the wound. R3 stated that wound had been there for a while, and stated she was not getting a treatment to the wound. Licensed practical nurse (LPN)-C entered R3's room and identified the wound did not have a physician ordered treatment order or nursing directive to monitor the wound. During an observation and interview on 3/25/25 at 3:08 p.m., LPN-B identified R3 had 2.0 cm x 1.0 cm x 0.1 cm wound on her right forearm. LPN-B described the wound as a non-healing skin tear with rolled edges and a slightly reddened center. R3 did not have a current order for treatment/monitoring for the wound. R3 only had an order for treatment of the skin tear on her right forearm after a re-admission on [DATE] from the hospital and it was discontinued on 2/20/25. LPN-B indicated according to the record there was not a comprehensive assessment related to the right forearm wound and the record did not include a reason why the treatment was stopped. LPN stated R3 had weekly skin check done on 2/3/25 upon re-admission, however, after that the skin checks were not being done consistently. The next skin check that was completed was not until 2/23/25, which did not identify the open area on the right forearm. A skin check did not get completed again until 2/23/25, and did not identify open area on right forearm. LPN-B stated all skin tears should have a weekly assessment to determine if they are healing. During an interview on 3/25/25 at 5:00 p.m., director of nursing (DON) stated her expectation would be for weekly skin assessments to be completed for all residents, and any new skin concern the nurses should report to the physician and have a treatment put in place until healed. Review of the facility's Skin Care Policy dated 1/2015, identified expected outcomes: -Assessment of potential skin problems are completed upon admission, on a routine basis, and as needed. -The healing of pressure injuries or other skin conditions that are present is promoted (including prevention of infection to the extend possible). -Prevention of the development of additional pressure ulcers or other skin problems is promoted.

Based on observation, interview and record review the facility failed to have a process in place to monitor refrigerator, dishwasher and breakfast food temperatures in all six unit kitchens in the care facility. In addition the facility failed to ensure opened food and beverage containers were dated to prevent unsafe consumption by residents. This had the ability to affect all 55 residents residing in the care facility. Findings include: During interview and observation on 9/9/24 at 11:45 a.m., the registered dietician (RD) stated there was one central kitchen where lunch and dinner were cooked, and each resident floor (two through seven) had their own full kitchen. Breakfast was cooked to order for each resident on the floors and lunch and dinner were kept warm in a steamer on the floors. Each floor had an industrial refrigerator, one unit residential type refrigerator and a high temperature dishwasher. During observation the second-floor kitchen lacked any temperature logs for the industrial and unit refrigerators and the dishwasher. The industrial refrigerator was showing two different temperatures on different thermometers of 8 degrees Fahrenheit and 50 degrees Fahrenheit. The RD stated, it feels cold, but I don't think that is right [the temperatures]. The third-floor kitchen also lacked any temperature logs for the industrial and unit refrigerators and dishwasher. The sixth-floor kitchen also lacked any temperature logs for the industrial and unit refrigerators and dishwasher. The RD stated she would assume it should be her that is currently monitoring the temperatures in the kitchen, stating there had been a gap in the position (of kitchen manager) and the unit kitchens were not up to standard yet. The RD stated they were further in a transition from kitchen staff overseeing the unit kitchens to the nursing staff and that the nursing assistants needed training on proper food temperatures and monitoring refrigerator and dishwasher temperatures and their currently was a process in place for checking food temperatures for the breakfast prior to serving. During observation on 9/9/24 at 1:23 p.m., the sixth-floor unit refrigerator had a temperature log hung on the side that was dated December 2023 and blank. Inside the refrigerator was an open, undated milk container. During observation on 9/9/24 at 1:31 p.m., the seventh-floor unit refrigerator had an open, undated milk container and liquid eggs in an opened and undated container. During interview and observation of the breakfast service on seventh-floor on 9/11/24 at 7:35 a.m., R39 was served a glass of milk out of the unit refrigerator. R39 stated, I think this milk has turned, it tastes sour. During an interview at 9/11/24 at 7:47 a.m., nursing assistant (NA)-M they worked with preparing breakfast meals for residents and stated the kitchen staff were responsible for taking food temperatures and was unsure who was responsible for monitoring the refrigerator or dishwasher temperatures. During an interview on 9/11/24 at 8:50 a.m., NA-N stated the NAs were responsible for making the residents breakfast and that the kitchen staff were responsible for taking all the food temperatures for the other meals, refrigerator temperatures and dishwasher temperatures. NA-N further stated it was expected for all opened food containters to be dated when opened and discarded after seven days. During an interview on 9/11/24 at 8:18 a.m., a cook (C)-A from the central kitchen stated the kitchen staff were responsible for taking lunch and dinner temperatures before taking the food to the unit kitchens and they did not temp the breakfasts. C-A stated the NAs were responsible for monitoring the temperatures of the refrigerators and dishwashers on the individual floors and for temping any food prepared on the individual floors. During observation on 9/12/24 at 8:31 a.m., the second-floor unit refrigerator did not have a temperature log and had an open, undated milk carton and an opened, undated container of half and half inside. The industrial refrigerator had a temperature log hanging on the outside with one temperature recorded for the month on 9/9/24. The dishwasher had a temperature log hanging above it with temperatures recorded on 9/10/24 and 9/11/24 only. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During observation on 9/12/24 at 8:25 a.m., the third-floor unit fridge did not have a temperature log. The industrial refrigerator had a temperature log hanging on it however lacked any recorded temperatures. The dishwasher had a temperature log hanging above it with temperatures recorded for the month on 9/9/24, 9/10/24, and 9/11/24 only. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During observation on 9/12/24 at 8:22 a.m., the fourth-floor unit refrigerator did not have a temperature log and had an open, undated milk carton and an opened, undated container of half and half inside. The industrial refrigerator had a temperature log hanging on the outside with one temperature for the month recorded on 9/11/24. The dishwasher had a temperature log hanging above it however lacked any recorded temperatures. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During observation on 9/12/24 at 8:18 a.m., the fifth-floor unit refrigerator did not have a temperature log and had an open, undated milk carton and an opened and undated liquid eggs container inside. The industrial refrigerator had a temperature log hanging on the outside with two temperatures recorded for the month on 9/10/24 and 9/11/24. The dishwasher had a temperature log hanging above it however lacked any recorded temperatures. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During observation on 9/12/24 at 8:14 a.m., the sixth-floor unit refrigerator did not have a temperature log. The industrial refrigerator had a temperature log hanging on the outside with two temperatures for the month recorded on 9/9/24 and 9/10/24. The dishwasher had a temperature log hanging above it with two temperatures recorded on 9/9/24 and 9/10/24. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During observation on 9/12/24 at b8:15 a.m., the seventh-floor unit refrigerators had a temperature log hanging on the side with one recorded temperature from 9/9/24. The industrial refrigerator had a temperature log hanging on the outside however lacked any recorded temperatures. The dishwasher had a temperature log hanging above it however lacked any recorded temperatures. A food temperature log was also hanging on the refrigerator however it lacked breakfast food temperatures. During an interview on 9/12/24 at 10:00 a.m., the RD acknowledged and stated awareness of the temperatures for the refrigerators and dishwashers were not being monitored on the resident floors as well as the temperatures not being monitored for the breakfasts prepared on the individual floors. The RD stated the expectation was for the NAs to monitor breakfast food temperatures and they would need to receive training on that. The RD further stated it was expected for all opened food or drinks to be dated and discarded within seven days or discarded if a food container was in the refrigerators open and undated. The RD stated monitoring of food, refrigerator, and dishwasher temperatures, along with dating opened food or drink containers was important due to the vulnerable state of the population they serve and to prevent any potential food borne illness. A facility policy titled Date Marking and Labeling, dated 3/2016, indicated that all food held for more than 24 hours would be labeled. A policy on refrigeration and dishwasher temperature monitoring was requested but not received.

Based on observation, interview, and document review, the facility failed to the facility failed to ensure proper use of gloves while providing personal cares for 1 of 1 resident (R35) observed for personal cares. In addition, the facility failed to sanitize a standing lift sling shared by residents for 2 of 2 residents (R35 and R9) observed for infection control practices. Findings include: Hand Hygiene R35's quarterly Minimum Assessment Data (MDS) dated [DATE], indicated R35 had moderate cognitive impairment, needed setup to eat, supervision with oral hygiene, and was dependent with bathing, toileting, dressing, bed mobility and transfers. R35's clinical diagnoses record printed 9/12/24, indicated diagnoses of epileptic syndrome (a unique combination of symptoms or by the location in the brain where the seizures originate), malignant neoplasm of the frontal lobe (brain cancer), essential hypertension(abnormally high blood pressure that's not the result of a medical condition), pain, unspecified dementia, type 2 diabetes (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), left bundle branch block (a delay or blockage of electrical impulses to the left side of the heart), dysphagia (difficulty swallowing), and erythematous condition (red discoloration of the skin caused by infectious agents, drug hypersensitivity, or underlying disease). During observation on 9/11/24 at 7:30 a.m., two nursing assistants (NA)-H and NA-I entered R35's room to assist R35 with personal cares. R35 had used a bed pan to have a bowel movement. After removing the bed pan, R35 laid down on her back. NA-H wore gloves and provided peri-care. NA-I assisted R35 to stay on her side while NA-H used wipes to clean R35's rectal area. When R35 was cleaned NA-H and NA-I put on a clean brief. NA-H did not change her gloves and proceeded to assist resident to get dressed. NA-H and NA-I assisted resident to put on clean pants, a top, and shoes. Still wearing the same gloves, NA-H pulled the standing lift closer to R35's bed, grabbed the stand's sling, and with the help of NA-I they put on sling, connected it to lift, and transferred R35 to her wheelchair. NA-H gathered garbage in a clear plastic bag and removed her soiled gloves. NA-H rubbed her hands with hand sanitizer and left the room. During interview on 9/11/24 at 8:17 a.m., NA-H stated she failed to change her gloves or wash her hands and put on new gloves after she provided peri care for R35. NA-H stated she should have changed her gloves to minimize the potential of contaminating R35's clothes with body fluids, her own clothes, and any surface she touched with her dirty gloves. During interview on 9/11/24 at 8:24 a.m., clinical coordinator/licensed practical nurse (LPN)-C stated the expectation was for nursing assistants to change their gloves after they provided peri-care. LPN-C stated failure to change gloves after peri-care increased the risk for cross-contamination and was an infection control issue. Standing lift slings During observation on 9/11/24 at 7:30 a.m., NA-H and NA-I provided personal cares and assisted R35 to get ready for breakfast. NA-H and NA-I moved a standing lift close to R35's bed. The NAs put a sling around R35's lower back, connected it to lift, and transferred R35 to her wheelchair. During observation and interview on 9/11/24 at 7:41 a.m., after providing personal cares and using a standing lift to transfer R35, NA-H was observed cleaning the standing lift but not the sling. NA-H stated the standing lift and slings were shared by several residents on the second floor. NA-H stated the standing lifts were cleaned/sanitized after each use but not the slings. NA-H stated the laundry washes the slings, I think once a week. During interview on 9/11/24 at 7:43 a.m., NA-I stated staff sanitize the standing lifts after every use, but they did not sanitize the slings between residents. R9's quarterly Minimum Assessment Data (MDS) dated [DATE], indicated R9 had severe cognitive impairment, was dependent with toileting and transfers, maximal assistance with dressing and bathing, and needed moderate assistance with upper body dressing and personal hygiene. Diagnoses included hypertension, diabetes (A group of diseases that result in too much sugar in the blood), hyperlipidemia (high levels of fat particles in the blood), dementia, hemiplegia (paralysis of one side of the body), anxiety, and depression. Nursing Assistants care plan printed on 9/12/24, indicated R9 transferred with staff assistance and a standing lift. During continuous observation on 9/11/24 at 7:52 a.m., NA-H and NA-I took standing lift and unsanitized sling from R35's to R9's room. After providing personal cares and dressing R9, NA-H and NA-I used standing lift and the unsanitized sling to transfer resident from her bed to her wheelchair. During interview on 9/11/24 at 8:17 a.m., LPN-C stated the standing lifts and the slings needed to be sanitized after every use. LPN-C stated the laundry didn't wash the slings, the NAs wash the slings in the laundry rooms located in each floor. LPN-C stated failure to sanitize slings between residents was an infection control concern. Facility policy's titled Standard Precautions dated March 10, 2020, indicated Gloves are to be worn when contact with blood, body fluids, secretions, excretions, and contaminated items is possible. New clean non-sterile gloves are to be worn immediately after washing hands and just prior to touching mucous membranes and non-intact skin. New gloves will be applied when performing tasks and procedures on the same elder when cross-contamination is possible. Gloves are to be removed immediately after use, and before touching non-contaminated items and environmental surfaces and before going to another elder or different task. Hands are to be washed immediately after gloves are removed. Gloves are to be removed prior to leaving room. Facility policy titled Infection Control - Equipment & Care Items (reuse) dated March 2020, indicated To ensure that all reusable resident/patient equipment is not used by another person until the item has been cleaned and or disinfected according to current Infection Prevention guidelines written in this policy and procedure. This policy also ensures that single use items are disposed of properly.

Based on observation, interview and document review, the facility failed to ensure unqualified staff did not administer as needed (PRN) medication used for skin rash for 1 of 1 resident (R1) reviewed for qualified staffing. Findings include, R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and had diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) , hypertension (high blood pressure), and diabetes. R1's Clinical Diagnoses record printed 9/12/24, indicated diagnoses of local infection of the skin and subcutaneous tissue (under the skin), and irritant contact dermatitis (a skin rash caused by contact with a certain substance) due to fecal and urinary incontinence. R1's Clinical Orders record printed 9/12/24, included an order for Nystatin powder (used to treat fungal or yeast infections) 100,000 unit/gm (gram) topical under breast every 12 hours as needed (PRN) for skin rash. R1's Medication Administration Record (MAR) dated September 2024, indicated a PRN order for Nystatin powder, which had not been documented as being administered to date during the month of September. During observation on 9/11/24 at 9:07 a.m., nursing assistant (NA)- G and NA-F provided personal cares to R1. NA-F used a wipe to clean R1's skin under her breast, abdomen, and groin areas. NA-F took a bottle of Nystatin powder from R1's nightstand and administered the medication on R1's skin under her breast and groin areas. During interview on 9/11/24 at 2:35 p.m., NA-F stated when she applies the Nystatin powder, she washes the areas, dries the area to ensure it is clean and then she applies the powder. NA-F stated the nurses had talked to her to ensure she understood how to do it, but only the nurses can assess and document. During interview on 9/12/24 at 10:08 a.m., registered nurse (RN)-C stated the nursing assistants were not authorized to administer the Nystatin powder or any medicated creams. RN-C stated trained medication aids (TMA) were able to administer scheduled creams and powders to the skin, but the administration of PRN medications required a nursing assessment. RN-C stated nursing assistants were not licensed to do assessments. RN-C stated NA-F had not informed her about administering the Nystatin powder to R1. During interview on 9/12/24 at 10:38 a.m., clinical coordinator/licensed practical nurse (LPN)-C stated nursing assistants were not trained to do assessments or apply Nystatin powder. LPN-C stated nursing assistants were supposed to report any resident's skin concerns to the nurse. LPN-C stated only the nurses can do an assessment and determine if a PRN needs to be administrated. Facility policy on medication administration requested but not received.

Based on observation, interview and record review the facility failed to ensure assistance with personal hygiene for 2 of 2 residents (R6, R44 ) reviewed for activities of daily living (ADLs) for dependent residents. Findings include: R6 R6's annual Minimum Data Set (MDS) dated [DATE], identified severe impairment of cognition, diagnoses of Alzheimer's and heart failure, and R6 required extensive assistance with ADL's. In addition, R6 did not display rejection of cares. R6's Care Area Assessment (CAA) identified triggers for delirium, cognitive loss/dementia, functional abilities, psychosocial well-being, mood state, and psychotropic drug use (medications used to treat mental health disorders). R6's care plan (CP) dated 8/2/22, and revised 8/21/23 identified, PERSONAL HYGIENE/ORAL CARE: I require limited to extensive assist of 1 staff for personal hygiene and oral care. R6's nursing assistant (NAR) task form in the electronic medical record (EMR) for dates of 8/12/24 to 9/9/24 identified, PERSONAL HYGIENE: SUPPORT PROVIDED-How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers was documented one to two times per day during that period. All entries but one (9/5/24 at 9:02 p.m.) were documented as, One person physical assist. R6's NAR care sheet titled, Eldershahbaz Care Plan-[NAME] House-4th Floor downloaded 9/10/24, had a column with a section titled, Grooming. The column identified for R6 documented, Extensive assist 1 with no indication anywhere else on the document for shaving support. During observation on 9/9/24 at 1:57 p.m., R6 was observed sitting in a wheelchair in her room. R6 was fully dressed with hair pulled back into ponytail. R6 had several 1.5-inch white hairs noted to left of chin on the face. R6 not interviewable. During observation on 9/10/24 at 1:46 p.m., R6 was laying in bed and stated she had finished eating lunch and was resting. R6 was observed with several 1.5-inch white hairs noted on the left side of her chin. R6 touched the chin hairs and stated, I don't like that one bit. I want them cut. During interview with family member (FM)-A on 9/10/24 at 2:00 p.m., FM-A stated, [R6] would not like to have long facial hair. FM-A stated it was important for [R6] to be well groomed, so having a long whisker or several of them would be awful for [R6]. I know they [facility] clean [R6] up and shower [R6], but they should at least make sure [R6's] facial hair is trimmed. No one from the facility has reached out to me about [R6] possibly refusing to be shaved or trimmed. During interview with NA-A on 9/10/24 at 1:49 p.m., NA-A stated all nursing assistants were expected to review the resident care plan, pointing to the Eldershahbaz Care Plan-[NAME] House-4th Floor to tell us what we need to do for the residents. During interview with NA-C on 9/10/24 at 3:10 p.m., NA-C stated, I get the care plan sheet [sic]. It tells me what to do [for each resident]. NA-C stated if a resident refuses care then we are to re-approach the resident. If resident refuses care completely, then NA-C stated the nursing assistants were expected to document refusals in the EMR and notify the nurse. NA-C stated, women residents should be asked every day if they would like to have their facial hair trimmed. Here, we[staff] have a lot of free time so we can always ask and offer to help to shave them. NA-C stated, nursing assistants were responsible for providing personal hygiene, including facial hairs. During interview with NA-B on 9/10/24 at 3:23 p.m., NA- B stated the expectation for nursing assistants was to always ask. Especially for ladies, we should be offering to shave or trim chin hairs every day if we see long hair on the faces. Most women would not like that at all. NA-B stated all nursing assistants were expected to document in the EMR for tasks assigned to aides per the printed Eldershahbaz Care Plan-[NAME] House-4th Floor. During observation and interview on 9/11/24 at 8:15 a.m., NA-D stated she was familiar with R6 and had worked at facility for two years. R6 was observed sitting at dining room table alone eating breakfast. R6 was dressed, with hair pulled back into a ponytail. R6 with several 1.5-inch white hairs noted to left of chin on face. NA-D stated, the hair on [R6] chin is pretty long. Obviously it is not a good thing. I would not like to have hairs like that on my face. It would really bother me. During observation and interview with licensed practical nurse (LPN)-A on 9/11/24 at 8:35 a.m., LPN-A stated he worked at facility for three years and was familiar with the 4th floor unit residents. LPN-A stated the expectation of nursing assistants was to review the resident care sheets, pointing to the Eldershahbaz Care Plan-[NAME] House-4th Floor sheet and prioritize resident needs. LPN-A stated, shaving is part of personal cares. LPN-A observed R6 and stated, I can see that it [chin hairs] needs to be shaved. It hasn't been done for a couple weeks. The razors are available on the unit [for aides to use]. We should ask her [R6] and then do it. I would not like it if my mom or loved one had long facial hair like that. It would really bother her. [R6] should at least be asked if she wants it cut off or not. During interview with LPN-B on 9/11/24 at 8:55 a.m., LPN-B stated, she was employed full time and worked at facility for over a year and a half. LPN-B stated, personal cares should be every day. Personal cares include washing face, brushing teeth, hair, nails, dressing, and shaving. Shaving should be done on the days it is seen not just on bath days. Facial hair on women is not appealing and long facial hair shows neglect. I would not like if I was left with long facial hair. It is a dignity thing. I would be very angry if my mom was left with long facial hair. That is not ok with me. 47495 R44 R44's quarterly Minimum Data Set, dated dated [DATE], indicated R44 was admitted to the care facility on 5/2/22, had moderate cognitive impairment and was dependent on staff for showers and personal hygiene to include shaving. R44's care plan, dated 8/15/24, indicated R44 had an ADL [activities of daily living] self-care performance deficit r/t [related to] right BKA [below knee amputation], diabetes, A fib [atrial fibrillation], HTN [hypertension], anemia, osteoporosis, DM [diabetes mellitus], wounds. Elder is needing more assistance with ADLS and does get irritated when asked if they can help him. R44's picture in his electronic medical record (EMR) showed R44 to be clean shaven. During observation on 9/9/24 at 4:09 p.m., R44 was sitting in his room. R44 had a full-face beard at least 1/2 inch long with dried particles stuck in his beard. R44 stated he prefers to be clean shaven but does not get help with his beard despite asking. During an interview on 9/11/24 at 8:50 a.m., nursing assistant (NA)-N stated the NAs should offer to shave resident on bath days or if they notice a resident is out of the usual. NA-N stated R44 had his own shaver and at times would shave himself but he did prefer to be clean shaven and staff should be offering to shave him on bath days. During interview and observation on 9/11/24 at 9:00 a.m., R44 was out at the breakfast table clean shaven. R44 stated they just came at me with a shaver and gave me a shave. It was kind of a forced shaving. During interview with nurse manager and registered nurse (RN)-A on 9/11/24 at 11:43 a.m., RN-A stated the expectation of staff is to provide personal cares daily. RN-A stated a failure to provide shaving or trimming of facial hair is a concern for dignity, especially if you are a woman. Facility policy titled Standard of Care/Elder Rights revised on 4/2022, documented Assistance or supervision of shaving as needed to keep clan[sic] and well groomed.

Based on observation, interview, and record review, the facility failed to implement individualized fall interventions for 2 of 3 residents (R27, R35) and failed to ensure a route cause analysis was completed and new interventions were implemented following a fall for 1 of 1 resident (R6), who was at risk for and had a history of falls. This resulted in harm when R6 had a subsequent fall on 5/16/23 and sustained a lumbar fracture. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of congestive heart failure (CHF), unspecified fall, abnormalities of gait and mobility, low back pain, and history of falling. It further indicated R6 was independent with all activities of daily living (ADL), occasionally incontinent of bladder, frequently incontinent of bowel, had a previous fall history prior to admission, and had received an antidepressant 7/7 and a diuretic 6/7 days in the look back period. R6's Care Area Assessment (CAA) dated 5/4/23, indicated R6 was at risk for falling and risk factors included: history of falling, incontinence, orders for scheduled antidepressants, cardiovascular (heart) medications, diuretics, and diagnoses of depression, dementia, arthritis, diabetes mellitus, and CHF. R6's care plan dated 4/28/23 included R6 was at high risk for falls related to a history of impaired mobility, diabetes, dementia, CHF, a history of falls, and a recent fall on 5/16/23. It further included interventions to anticipate and meet the resident's needs, ensure his call light was within reach and encourage him to use it for assistance as needed, promptly respond to all requests for assistance, educate resident/family/caregivers about safety reminders and what to do if a fall occurs, follow facility fall protocol, provide a safe environment, place walker within reach, frequent reminders to use call light, physical therapy to evaluate and treat as ordered or as needed. R6's care plan dated 5/12/23, indicated R6 had an ADL self-care performance deficit related to weakness, recent closed fracture of L2 vertebrae (lumbar fracture) with interventions of toilet use: independent. Extensive assist by 1 staff for toileting as needed. and transfer: independent. Extensive assistance by 1 staff to move between surfaces every shift as necessary. It further indicated R6 had limited physical mobility with an intervention of ambulation: independent. Limited assist of 1 staff as needed, uses a walker. A review of R6's fall risk management reports indicated: -On 5/9/23, indicated R6's call light was on, when NA went to resident's room and found him on the floor. Upon arrival, noticed the resident was sitting on the floor near the foot of the bed and his back was resting on the TV table/wall by the bathroom door. R6 stated he was trying to go to bed, lost his balance, bumped his armpit on the bedframe and fell but he did not hit his head. The risk management lacked any documentation of an investigation, root cause analysis, or new interventions to prevent future falls. Approaches previously care planned: call light within reach. Approaches to prevent reoccurrences: encouraged to use call light when he needed assistance. -On 5/17/23, indicated R6 was found sitting on the floor in his bedroom. He stated I lost my balance and ended up on the floor sitting on my bottom. It further indicated, an investigation and interview with staff and resident indicated that care plan interventions were in place. Resident was independent with his ADL's, elder (resident) has a history of falls due to unsteady gait and weakness. Approaches previously care planned: call light within reach and encourage to use call light when he needed assistance and frequent visual checks. Approaches to prevent reoccurrences: frequent reminders to use call button for assistance, place walker within reach, and frequent visual checks. -On 6/18/23, indicated nursing assistant found R6 sitting on the floor against the wall in his bathroom. R6 stated he saw broken pieces of glass on the floor, and he was trying to kick it aside, lost his balance, and fell . It further indicated an investigation and interview with staff and R6 indicated care plan interventions were in place. Approaches previously care planned: Education provided to R6 to call for assistance. Approaches to prevent reoccurrences: staff will continue frequent visual checks and R6's son brought a reacher from home to assist him to pick up objects off the floor. -On 7/22/23, indicated R6 fell in the bathroom at around 8:00 p.m. He was found sitting on the floor, blood flowing from the back of his head. The writer called for emergency services to transfer him to the hospital for further examination and treatment. It further indicated an investigation and interview with staff and R6 indicated the care planned interventions were in place. Resident had some degree of cognitive impairment which limits his understanding of his physical limitations. He needs contact guard assistance of 1 with ambulation/transfer from room to the bathroom/hallway due to unsteady gait and was care planned as such, however, after review of R6 care plan it lacked documentation of the need for contact guard assistance of 1 with ambulation/transfer. R6 prefers to be independent with ADL's. Approaches previously care planned: staff will continue to encourage elder to call for assistance. Approaches to prevent reoccurrences: offer to toilet every 2-3 hours and as needed and continue frequent visual checks. R6's progress note dated 5/17/2023, indicated R6 complained of severe pain 10/10 in his lower back. Resident had a fall at 2100 (9:00 p.m.) while trying to ambulate to the restroom. Call to provider to request an x-ray and pain medication. Per physician, send patient to the hospital. R6's progress noted dated 5/17/2023 at 13:19 (1:19 p.m.) indicated R6 was sent to the hospital by ambulance for evaluation. His son was notified and will meet R6 at the hospital. R6's progress noted dated 5/17/2023 at 15:52 (3:52 p.m.), indicated called the hospital for an update, spoke with the nurse (unknown) who stated, elder was admitted with lumbar spine compression fracture, spine surgery was consulted, and they want him to wear a brace for 8-10 weeks while the fracture heals. Unable to determine a discharge date . During an interview on 8/3/23 at 11:40 a.m., the nurse manager registered nurse (RN)-A stated the process when a resident fall was for the nurse to assess the resident, make sure they don't have a fracture, check their vital signs, and their range of motion (ROM). If the resident was suspected of having a fracture, the nurse should leave them on the floor, call 911, and then notify the doctor, family, nurse manager, director of nursing (DON), and administrator. RN-A stated since she was the nurse manager it was her responsibility to investigate the incident and try to figure out the cause. The nurses would be responsible for taking the resident's VS and performing neurological checks for 72 hours (after the fall occurred) and the DON would look at the camera footage to see the last time staff was in the resident's room. RN-A further stated they discuss each fall at the IDT meeting and put measures in place to prevent future falls, but any nurse can put interventions in place. RN-A verified R6 had fallen on 5/9/23 and there was no documentation that an investigation, route cause analysis, or new interventions had been put into place stating, I probably investigated this, but I probably didn't document it. RN-A further stated R6 wanted to be independent and therefore won't put on his call light, stating it wasn't an appropriate fall intervention. She also stated R6 had a fall intervention of frequent checks but was unable to give a specific amount of time of how often frequent checks should be done. RN-A stated she doesn't like to give a specific time because staff might be busy with other elders [residents]. I encourage night shift to take a peek on him at night, because one of R6's falls was during the night. RN-A also verified R6 had an intervention for staff to offer to assist him to use the toilet, but he does not wait for assistance and toilets himself, therefore it was not an appropriate intervention. R6's care plan indicated he was independent with transfers and mobility but needed assistance of 1 staff as needed. RN-A was unable to explain how staff were supposed to make that determination and stated the therapy department was responsible for determining how much assistance R6 needed. During an interview on 8/3/23 at 3:03 p.m., the director of nursing (DON) stated the process for when a resident fall would be to report the fall to a nurse (if it is an NA), the nurse would complete an assessment, take VS, and then once the resident had been taken care of, record it in risk management. If the nurses document it the correct way it will automatically go into the progress notes. The risk management talks about the assessment and what interventions to put in place. Whoever (nurse) was responsible for the resident should try to put in a new intervention, they also know they can call the DON and and she will help them come up with some interventions. The nurses are responsible for filling out an incident report and the next working day they review the fall in the IDT meeting. They (management) investigates the fall and do a root cause analysis. If it happened in a common area or a resident's room, they look at the cameras to give them clues on what was going on at that time and put any new interventions in place. The DON stated she makes sure a follow up note has been done, the nurse filling out the report signs off on it, the nurse manger, and the administrator. The DON verified there was no root cause analysis or new interventions implemented following R6's fall on 5/6/23. She also stated regular rounding should be done every 2-3 hours, and frequent checks were considered more than that. There's not really a checklist, or a set time. The DON verified if R6 wasn't using his call light and was toileting himself without asking for assistance then those wouldn't be appropriate interventions. During a continuous observation on 8/3/23 following events occured: -7:56 a.m. R6 came out of his room, with his back brace on and walked down the hallway independently (using his walker) to the dining room and sat down at the table. There was no staff present in the hallway while he was walking. -8:02 a.m. R6 was sitting at dining room table, eating breakfast. -8:24 a.m. R6 stood up from the table independently, grabbed onto his walker (which was sitting next to him), and walked down the hallway to his room, went in and shut the door. There was no staff in the hallway while he was walking. -9:01 a.m. R6 was in his room with the door closed, no staff have checked on him or offered to assist him to use the toilet. -9:26 a.m. R6 was in his room with the door closed, no staff have checked on him or offered to assist him to use the toilet. -9:58 a.m. NA-I entered R6's room and asked him if he needed anything. R6 stated he hadn't seen the nurse yet and NA-I offered to get the nurse for him. It had been approximately 1.5 hours since staff had checked on/seen R6. During interview on 7/31/23 at 9:57 a.m., R6 stated he doesn't need assistance with cares, (getting up, walking, or using the bathroom) and he doesn't use his call light because he doesn't need help. R6 further stated he doesn't remember any one at the facilty telling him he needed to use his call light before getting up. During an interview on 8/3/23 at 7:58 a.m., NA-J stated R6 needs assistance with cares but he doesn't use his call light to request help. During an interview on 8/3/23 at 9:55 a.m., RN-C stated nursing assistants are supposed to do rounds every 2-3 hours and frequent checks should be done every hour. During an interview on 8/3/23 at 10:01 a.m., NA-K stated R6 was independent but he needed assistance from staff to check on him after he goes to the bathroom to clean up after him and he doesn't use his call light when he needs to use the bathroom or to get up and walk around. NA-K stated frequent checks should be done every 2-3 hours but R6 doesn't need frequent checks. During an interview on 8/3/23 at 1:30 p.m., the rehabilitation program manager stated they received orders for therapy for R6 on 5/15/23, due to a history of falls, back pain, and lumbar fracture. R6 had a PT evaluation on 5/22/23, was discharged on [DATE] due to a hospitalization , and then started again on 6/19/23. R6 has PT but was not on an ambulation or gait program. The rehabilitation program manager further stated R6 shouldn't be walking independently. He needs supervision, he abandons his walker, and he's not been cleared by therapy to ambulate independently. 42580 R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits and was unable to complete the Brief Interview for Mental Status (BIMS) assessment, required extensive assist of two staff with bed mobility and toileting and one person assist with transfers. R27's diagnoses included non-traumatic brain dysfunction and Alzheimer's disease. R27's fall care plan dated 4/7/22, indicated R27 had a high risk for falls with interventions which included, call light is within reach and encourage me to use it for assistance; floor mat next to bed, updated on 8/1/23 for the new intervention implemented for the fall on 7/25/23. Physician progress notes dated 7/26/23, indicated facility updated triage yesterday that patient fell overnight and had pain to right knee. X-ray was done yesterday which found comminuted intra-articular fractures (a fracture that crosses into the surface of a joint, resulting in damage to the cartilage) in the right tibia. R27's Falls Risks Evaluation dated 7/30/23, indicated date of last fall on 7/25/23, new intervention included a matt on the floor just in case she falls, which is unlikely because she is not able to move in bed without assistance. R27's nursing assistants care sheets undated, indicated Safety: fall risk: place call light within reach, prefers bed in low position at all times, frequent visual checks and floor mat next bed (SIC). During the following observations R27 did not have a floor mat in her room or on the floor near her bed: -8/1/23, at 11:35 a.m., no floor mat in place near bed. -8/1/23, at 4:47 a.m., no floor mat in place near bed. -8/1/23, at 6:39 a.m., no floor mat in place near bed. -8/2/23, at 8:37 a.m., no floor mat in place near bed. -8/2/23, at 1:55 p.m., no floor mat in place near bed. While observing R27 on 8/3/23 at 9:08 a.m., one floor mat was noted to right side of bed near window, however, the left side of R27's bed had no floor mat near bed which is the side of the bed R27 gets out of bed on. During observation and interview on 8/2/23 at 9:18 a.m., nursing assistant (NA)-A and another NA were getting R27 changed in bed. No floor mat was near bed or in room. When asked if R27 had a floor mat, NA-A stated she had never seen a floor mat in R27's room. During interview with nurse manager (NM) on 8/2/23 at 2:42 p.m., NM stated after R27's fall on 7/25/23, NM implemented floor mat to floor, and updated the care plan and nursing assistants care sheets as a fall intervention. During interview on 8/3/23 at 11:42 p.m., family member (FM)-A stated usually visited with R27 around 2-3 times a week and the sister also visited about 3-4 times a week. FM-A stated had never seen a floor mat when came to visit resident prior to 8/3/23. FM-A was visiting with R27 during interview with surveyor on 8/3/23. When interviewed on 8/2/23 at 3:00 p.m., NA-B stated, When I take care of a resident, I look at the nursing assistant care sheets to know how to care for the resident. I have never seen a floor mat in R27's room and I have worked here for about two months and have been working with R27. When interviewed on 8/3/23 at 4:18 p.m., director of nursing (DON) explained she was told the floor mat had been implemented right after R27's fall on 7/25/23 and did not know until today when the NM mentioned to her the floor mat was not placed until after interview with surveyor on 8/2/23. DON stated she believed NM got busy and did not get a chance to place the floor mat timely, per care plan intervention for falls. 44647 R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 was cognitively impaired and had diagnoses of stroke, dementia, and Parkinson's disease. Furthermore, R45's MDS indicated R45 was a fall risk and required extensive assist with one person for transfers and ambulation. R45's fall Care Area Assessment (CAA) dated10/3/22, indicated R45 was a fall risk related to Parkinson's disease, impaired balance, gait problems and impaired judgement. R45's care plan revised 5/27/23, indicated R45 was a high fall risk related to impaired balance, stroke, and Parkinson's disease. Staff were directed to anticipate and meet my needs, assist to toilet per toileting plan, frequent safety checks, encourage use of call light and ensure it was within reach, and have walker in front of resident to assist with attempts to walk unassisted. A review of R45's fall risk management report indicated: -on 6/16/23, R45 had an unwitnessed fall in the lounge area. Approaches previously care planned was frequent safety checks and pivot transfer only. Approaches to prevent reoccurrence was staff to maintain frequent visual checks and continue to have staff monitor her when in the lounge and continue to educate to ask for assistance. -on 6/17/23, R45 had an unwitnessed fall in lounge area. Approaches previously care planned included constant visual checks and anticipating needs. Approaches to prevent reoccurrences was to continue with care plan. No new intervention indicated. -on 6/28/23, R45 had an unwitnessed fall in her room. Approaches to previously care planned included visual checks and toileting program. Approaches to prevent reoccurrences was a perimeter mattress. -on 7/3/23, R45 had a witnessed fall while trying to self-transfer in her room. R45 was sent to the emergency room for a face hematoma. Fall discussed in morning meeting and fall interventions remain in place. No new intervention indicated. -on 7/17/23, R45 had an un-witnessed fall and was found sitting on the floor outside nursing station. Fall discussed in morning meeting and R45 forgot to use call light for assistance and continued to self- transfer without walker. R45 will continue therapy. No new intervention indicated. -on 7/19/23, R45 had an unwitnessed fall in her bathroom with tube feeding pole tipped over and tube stretched. Approaches previously care planned include assistive devices of walker and wheelchair, to be in lounge for close monitoring, and permitter mattress. Approaches to prevent reoccurrence was to have call light in reach and educate resident to use and adjust tube feeding times. -on 7/21/23, R45 had a witnessed fall in the lounge. R45 got up from chair and was attempting to walk when she fell . Approaches to prevent reoccurrence was keep walker with seat in front of resident for use if attempts to self-transfer and continue therapy. R45's hourly rounding documentation from 7/26/23-8/2/23, was reviewed and lacked consistent documentation hourly rounding had occurred including an entire evening shift on 8/2/23. An observation on 8/1/23 at 9:46 a.m., R45 was sleeping in bed. R45's call light was on the floor to the right side of R45's bed and not in reach. Next to the door was a folded walker placed up against the wall. A 4-wheeled rolling walker with a seat was placed against the wall away from the bed and just in front of the door. An observation at 8/2/23 at 3:11 p.m., R45 was sitting in the wheelchair in the lounge area sleeping. At 3:30 p.m., nursing assistant (NA)-H pushed R45 back into her room. At 4:11 p.m. R45 was sitting in the wheelchair in her room. R45's call light was over by the bed and not in reach. A walker was folded up and placed against the wall and a 4-wheeled walker was close to the door. Neither of the walkers were in reach of R45. An observation on 8/2/23 at 8:09 a.m., R45 was seated in a chair in the lounge. R45's walker was not in the lounge and was noted in her room. When interviewed on 8/2/23 at 8:01 a.m., family member (FM)-A stated R45 was very impulsive and often attempted to get up without help and had multiple falls. FM-A further stated R45 required assistance with any transfer or ambulation. FM-A stated R45's walker was not always nearby and so when R45 would attempt to get up and walk, she would usually fall. FM-A discussed with the facility the desire to have R45's walker in place so maybe R45 would use it and not fall if attempting to self-transfer. FM-A thought this was happening. FM-A further verified R45 rarely used the call light and stated the facility tried to encourage her to use it but did not feel any education was going to be useful as R45 wouldn't remember. When interviewed on 8/2/23 at 9:06 a.m., NA-C stated R45 was able to make some needs known when asking simple questions. NA-C stated sometimes R45 wanted to walk in her room to the bathroom and when she wanted to walk a walker and gait belt was used. If R45 did not want to walk, a gait belt was used to transfer into the wheelchair and R45 was wheeled into the bathroom and then transferred with assist of one. NA-C stated R45 did not wait for help and really did not use the call light. R45 was quick and so staff had her out in the lounge most of the time so there was more staff around. NA-C staff would place R45's walker next to the door or away from her so she would be discouraged from using it. When interviewed on 8/2/23 at 9:06 a.m., licensed practical nurse (LPN)-A stated after a resident falls, the floor nurse filled out a risk management form to document what happened and some immediate interventions. LPN-A stated usually, the interventions that are put in place was to keep call light in reach and re-educate about call light use. LPN-A stated R45 was impulsive and a high risk for falls. Currently, R45 was on hourly checks by either the NA or the nurse. Upon review of the hourly checks, LPN-A verified there was some missing times, and the entire evening shift was blank from 8/2/23. When interviewed on 8/3/23 at 1:53 p.m., registered nurse (RN)-B stated falls were discussed in morning meetings and the root cause and interventions were discussed and nurse managers update care plan and care sheets. RN-B stated R45 was very impulsive and had some changes in mobility related to a stroke. R45 did not use a call light and would walk without her walker. RN-B stated family wanted R45's walker next to her so if she did get up R45 may use it. RN-B verified some of the interventions listed for R45 may not be appropriate or individualized due to R45's impulsiveness and stated R45 was now on hourly checks as well. RN-B expected staff to follow the fall interventions on R45's care plan and care sheets. A facility policy titled Fall Risk Assessment revised 4/2022, directed staff to implement individualized fall precautions for all residents who are at risk for falls. Furthermore, the policy directed staff to initiate, review and revise the care plan as appropriate and communicate interventions to staff.