Every finding on record at EverVella of White Hall

Based on interview and record review the facility failed to provide fluids on the night shift for 2 of 9 residents (R6, and R9) reviewed for hydration in the sample of 9. Findings include:1 On 2/23/2026 at 8:03AM R6 stated she does not always have water at bedside. R6 stated from 6-7pm until breakfast has nothing to drink.R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact.2 On 2/24/2026 at10:10 am R9 stated water is not passed on the night shift.R9's MDS dated [DATE] documents R9 is cognitively intact. The facility resident council minutes dated 2/2026 documents water not being passed on the night shift. On 2/25/2026 at 9:15AM, V1, Director of Nursing (DON) stated she would expect staff to be passing water/fluids on the night shift. The facility policy hydration, dated 2023 documents the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. The policy documents interventions will be individualized to address specific needs of the resident, but not limited to offer the resident a variety of fluids during and between meals.

Based on observation, interview and record review the facility failed to assist 1 of 4 residents (R3) reviewed for feeding assistance in the sample of 13. Findings include:R3's Face Sheet, print date of 11/20/25, documents R3 was admitted on [DATE] with diagnoses of Parkinson's Disease with Dyskinesia and Major Depressive Disorder with severe psychotic symptoms. R3's Minimum Data Set, dated [DATE], documents R3 has moderate cognitive impairment, requires set up clean up assistance for dining, requires supervision touch assist for toileting, partial to moderate assist with hygiene, sitting to standing position change, toilet transfer, and is occasionally incontinent of urine. On 11/16/25 at 7:34 AM R3 is sitting in the dining room. R3 has a plate of scrambled eggs, a muffin, a bowl of fruit loops, both juice and water, a Coke can, and both white and chocolate milk. R3 is attempting to grab and use her spoon. R3 is unable to manipulate the spoon. R3's left arm and hand are extremely shaky. At 7:42 AM, R3's plate is pushed aside. The plate remains untouched. At 7:48 AM, V6, Registered Nurse, asked R3, why are you not eating? R3 stated, I can't get my silverware. V6 put R3's spoon in the cereal bowl. At 7:55 AM R3's food remains untouched. R3 is sitting fidgeting with the Coke can and her water glass. She is not drinking either just touching them attempting to grab them. At 7:57 AM, V7, Human Resource / Certified Nurse Assistant, asked R3 to eat and could she get her something else. V7 asked if R3 would like a banana and V7 walked away. V7 returned with a banana, cut it in half and put it on R3's plate. At this time, R3 is holding the spoon that is in the cereal bowl attempting to utilize the spoon. R3 is holding the spoon straight up and down in the bowl and unable to scoop up the cereal. V7 walks away without helping R3. At 8:09 AM R3 is holding the spoon straight up and down in the cereal bowl. R3's plate remains untouched. R3 has not been able to get a bite of cereal. At 8:13 AM R3 grabs the banana half, R3 leans over her plate, R3 pushes the banana against the plate, and R3 manages to take 2 bites of the banana. At 8:21 AM R3 has a portion of the muffin in her hand and takes one bite. At 8:24 AM, V1, Administrator, encourages R3 to eat, but offers no physical assist. At 8:25 AM, V6 sits with R3 and offers physical assistance for R3 to eat the cereal. On 11/20/25 at 8:34 AM, V1, Administrator, stated if someone needs assistance with eating staff should assist them. On 11/20/25 at 8:36 AM, V6, stated if someone is struggling to eat staff needs to assist the resident.The policy Activities of Daily Living (ADL) Supporting, dated 7/15/25, documents, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance: d. dining (meals and snacks).

Based on interview and record review, the facility failed to maintain secure medical records for 1 of 4 (R11) reviewed for privacy / confidentiality of records in the sample of 13.Findings include:R11's Face Sheet, print date of 11/20/25, documents R11 was admitted on [DATE] with diagnosis of Dementia. R11's Minimum Data Set, dated [DATE], documents R11 is severely cognitively impaired. R11's Nurses Note, dated 11/16/25, documents R11 passed away under hospice care. On 11/20/25 at 8:10 AM, V33, Licensed Practical Nurse, (LPN), stated I was present when V34 LPN was upset because the narcotic count sheet for R11 was wrong. V34 went through and figured out that it was a math error not an actual drug divergence. V34 took it to V2, Director of Nurses, and wanted him to fix it. V34 was upset because V2 wouldn't fix it immediately. V2 told her he had to do an investigation into it. V34 told me she took a photo on her phone of the narcotic count sheet, a printed copy of the Medication Administration Record (MAR), and a printed copy of the narcotic count sheet. I did not see her leave the building with them, but I did here the printer going off to print the records. On 11/20/25 at 8:14 AM, V34 LPN, stated R11's morphine narcotic count sheet was off. I brought it up to V2. He wanted me to reach out to the nurse that worked prior to me. I called that nurse and told her she needed to come in and fix her mistake. She had made a math error. The amount of morphine in the bottle was correct it was just the narcotic count sheet was off. V2 told me I needed to write a statement for his investigation that he was doing. I took a photo of the narcotic count sheet on my phone. I wanted it to help me write my statement, so I had all the details. This happened on a Friday, and I told V2 I would bring my statement in on Monday. When I got home, I wrote my statement and then I deleted the photo on my phone. The photo did not have R11's name on it. I did not make any paper copies of R11's record and take them home. On 11/20/25 at 8:34 AM, V1, Administrator, stated she is unable to provide the complete investigation because it is in storage since the facility has new owners. When the new owners came in everything previously was boxed up and hauled away. The previous owners tell me they can locate the record and mail a copy to me. On 11/20/25 at 8:34 AM, V2, Administrator, stated staff should not be taking photos of residents' medical record on their phone or copies of the medical record and taking the record home. On 11/20/25 at 11:00 AM, V38, Director of Clinical Operations, stated no employee should take a picture of medical records on their personal phone.The Final Report - Potential HIPPA (Health Insurance Portability and Accountability), dated 9/29/25, documents, On 9/23/25, (V33) reported to (V2) that on 9/12/25 (v34) was observed to make a phot copy of resident (R11's) narcotic sheet and that (V34) stated, I am going to make a copy of the narc (narcotic) count sheet for that patient and keep it for my records. (V33) reported she also observed her printing and making a copy of the MAR and that (V34) stated to (V33), I am saving that too in case I need proof. It continues, (V34) was notified on 9/23/25 to bring any medical records back to the facility that was allegedly taken. (V34) was interviewed on 9/23/25 and reported that she did not take any paper copies of records from the facility but only took a photo and that no information including residents name was on the photo or was exposed. It continues, At this time we do not believe there was a violation of HIPAA as (V34) stated there was no patient information on the photo, information was not exposed, and the photo was deleted immediately. The policy Workforce Training - Privacy & Security Of Protected Health Information, undated, documents, Policy: All employees will receive appropriate training, regarding the policies and procedures for ensuring the secure and confidential receipt, transmission, storage, use and / or disclosure of protected health information.

Based on interview and record review, the facility failed to investigate and provide progressive interventions to prevent falls for one of 10 residents (R34) reviewed for accidents and supervision in the sample of 62. These failures resulted in R34 sustaining a laceration to the face requiring 5 sutures. Findings include: R34's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, muscle weakness, difficulty in walking, and need for assistance with personal care. R34's MDS dated [DATE] documented she was rarely/never understood, had a memory problem and her cognitive skills for daily decision-making regarding tasks of daily life were severely impaired. R34's Fall Risk assessment dated [DATE] and 6/12/25 documented she was a high fall risk and to implement high fall risk fall prevention interventions. R34's current Care plan requested and provided by the facility documented she had an actual fall with no injury initiated 11/22/24 with interventions as follow: on 4/23/25 R34 had a fall with minor injury on 4/23/25 and for staff to redirect her from ambulating through crowded space; intervention on 5/19/25 documented she had an actual fall with minor injury and for staff to assist her out of dining room chair after dinner and assist with toileting as tolerated. Care plan initiated on 7/9/25 (24 days after her 6/15/25 fall) documented R34 is a high fall risk related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs. Interventions for this care plan were initiated on 7/9/25 to anticipate and meet her needs, ensure proper footwear, and for physical therapy to evaluate and treat as ordered or as needed. R34's Progress note dated 6/15/25 at 2:31 AM, documented, Writer was informed by staff that R34 was on the floor and was bleeding from her head. Writer observed R34 at a 90-degree angle on the floor. Writer observed wound to be actively bleeding, unable to assess the size. Pressure applied. R34 assessed for any additional injuries. R34 noted to have bruising to the back of her right hand. R34's Progress note dated 6/15/25 at 6:35 AM, documented, writer spoke with local ER (emergency room) nurse and was informed that R34 received 5 sutures to her laceration, XR (x-ray) was performed of her right hand and no fx (fracture) has been found: DX (diagnosed) as a contusion. R34 will be returning to the facility via EMS (emergency medical services) per local ER nurse. On 8/27/25 at 9:15 AM, in a joint interview with V12 (LPN) and V26 (CNA), V26 looked up R34's electronic chart and stated R34 was moved closer to the nurse's station but not sure of what other measures are put in place. V26 stated she finds out details on concerns for the residents from the night shift before starting her shift but could not state who was at a high risk for falls or specific intervention/measures put in place for R34's fall prevention besides moving her closer to the nurse's station. On 8/28/25 at 10:10 AM, V38 (Physical Therapy) stated the last time R34 was evaluated was on 1/7/25. On 8/27/25 at 1:25 PM in a joint interview with V1 (Administrator), V2 DON (Director of Nursing), and V30 (Regional Nurse), V30 stated all residents have a right to fall. V2 stated they have an admission process for fall assessments and fall interventions to be put in place following. The facility's Interdisciplinary Fall Reduction/Injury Prevention Protocol dated 1/2025, documented the intent is an interdisciplinary approach at reducing falls, preventing injury, and increasing safety awareness ultimately resulting in improved quality of care for our residents. The policy continued to document recommendations included nursing to complete a fall risk evaluation up admission, re-admission, quarterly and with significant change. the total score places the resident at risk, determine appropriate interventions. Once selected, implement the interventions and then add to the resident's plan of care and resident Kardex. Consider an icon system for facilities with high fall percentage. Note that this type of system will need close monitoring and need a process owner. Examples, Falling Star and Falling Leaf programs. The policy further documented the environmental checklist to be reviewed monthly on facility round with executive director, maintenance, housekeeping.

Based on Interview, Observation, and Record Review, the facility failed to dispose of expired medications, properly label medications, and to keep food items out of the medication refrigerator reviewed for medication storage and labeling in the sample of 62. This failure had the potential to affect all residents in the facility. The Findings Include: 1. On 8/26/25 at 2:45 PM, the Rehab Medication Room was assessed with the following findings: Tuberculin (TB) Vial 1 ML (milliliter) had a sticker on the box for when it was opened on 7/15/25, the sticker documents Do Not Use 30 days past above date. Vitamin B-12 100 MCG (micrograms), 100-tab bottle expired on 7/2025. Docusate 100 MG (milligram), 1000-tab bottle expired on 7/2025. On 8/26/25 at 3:05 PM, V25, Registered Nurse (RN)/Nurse Manager/Infection Preventionist (IP), stated The TB vial in the Rehab Med Room is used mainly for all the residents. The TB stored in the med room up front, is used for all of the residents and the staff. On 8/27/25 at 1:00PM, V2, Director of Nursing (DON), stated I would expect the nurses to properly date all medications when opened, to discard any expired medication, to properly label each medication, and to keep food items out of the medication refrigerator. 2. On 08/26/2025 at 2:57 PM, the east west medication room was observed with V7, Licensed Practical Nurse. There was a bottle of Med Pass in the medication refrigerator. There was an undated tubersol vial. On 08/26/2025 at 3:00 PM, V7 stated I am not sure, but I think it was just opened yesterday to give a resident a TB test. I didn't know there was a bottle of Med Pass in there. 3. On 08/25/2025 at 2:00 PM medication cart on East Hall contained an oral inhaler with no label, and not in box. The inhaler had the last name of R9 written on the inhaler. R9's Physician Order (PO) dated 8/2025 documents Trellegy Ellipta (Fluticasone-Ulmeclidinium-vilanterol AEPB 100-62.5-25mcg inhalation i puff daily for Chronic obstructive pulmonary disease. 4. 08/25/2025 2:17 PM medication cart on rehab unit contained a lispro insulin, unlabeled and sticker on pen documented date of expiration 7/17/2025. V3, Licensed Practical Nurse (LPN) stated I don't know who it belongs to it is expired I will just get rid of it. On 8/28/2025 V32, Registered Nurse (RN) stated she had ordered a new inhaler for R9. The Facility's Medication Storage Policy, dated 11/2010, documents in part 9. Medications in the refrigerator are kept in closed, labeled containers or compartments. Internal and external medications within the refrigerator must also be separated. All of these medications must be separate physically from juices, applesauce, yogurts, shakes, and other foods for medication administration that are kept in this refrigerator. 12. The following medications must be removed from stock and disposed of properly on a continuing basis: outdated, contaminated, recalled, deteriorated, unlabeled medications, or those with soiled or broken/cracked containers. The Facility's Medication Labels Policy, dated 1/2015, documents in part Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy or consultant pharmacist can modify or change prescription labels. 1. Each prescription medication label includes: a. Resident's name; b. Specific directions for use, including route of administration; c. Brand or generic drug product name; d. Medication strength; e. Volume of dose needed to achieve dose strength.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, wear gloves, and wear Personal Protective Equipment for 4 of 20 residents (R2, R50, R61, R104) reviewed for infection control in the sample of 62.Findings include: 1.On 8/26/25 at 9:06 AM V29, Certified Nurse Aide, (CNA) and V28 CNA entered R50's room to transfer R50 to bed and check for incontinence. V28 did the incontinent care correctly but during the incontinence care, V28 changed gloves twice without hand hygiene in between. On 8/27/25 at 3:20 PM, V2, Director of Nurses, stated hands should be washed between glove changes. R50's admission Record, print date of 8/27/25, documents R50 was admitted on [DATE] and has a diagnosis of Dementia. 2. On 8/25/205 at 11:45 AM during lunch V4, CNA removed chocolate chip cookie from bag with bare hands and placed on table beside R104's plate. V4 did not sanitize hands prior to handling food or wear gloves. R104's face sheet documents R104 was admitted to the facility on [DATE]. 3. R2's admission Record, dated 8/27/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Type 2 DM, Chronic Kidney Disease, Neuromuscular dysfunction of bladder, Anemia, Diabetic foot ulcer, Osteomyelitis right ankle and foot, Bacteremia, Methicillin Resistant Staphylococcus Aureus (MRSA). R2's MDS, dated [DATE], documents R2 is cognitively intact. On 8/26/25 at 11:20 AM, V18, Registered Nurse/Wound Nurse, did wound care to R2's right heel and right top of foot. There was an Enhanced Barrier Precaution (EBP) sign with Personal Protective Equipment (PPE) available on door. V18 did not don on a gown, just donned gloves, and provide wound care to R2's heel. No other EBP PPE was used. On 8/27/25 at 2:00 PM, V30, RNC, stated Any resident getting wound care should be on Enhanced Barrier Precautions and staff should be wearing appropriate PPE while caring for that resident. This includes peri-care while they have a wound to their backside. 4. R61's admission Record, dated 8/27/25, documents R61 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction, Hemiplegia, Hemiparesis, Aphasia, Acute Kidney Failure, Type 2 Diabetes mellitus (DM), Atrial Fibrillation, Anemia, and Obesity. R61's MDS, dated [DATE], documents R61 has a severe cognitive impairment and requires substantial/maximal assistance for toileting, and transfers. R61 is occasionally incontinent of both bowel and bladder. On 8/25/25 at 9:42 AM, R61 was seen lying in bed, stated she has a sore on her butt and gets dressing changed. R61 stated the staff never put on gowns when they take care of her. On 8/26/25 at 11:05 AM, V18, RN/Wound Nurse, provided wound care to R61's right buttock which included cleaning with a wound cleanser, then applying skin prep to the site and leaving it open to air. There was no EBP sign or PPE available at the door. V18 washed hands and donned gloves with no gown or other PPE on, then provided wound care to R61's pressure wound to her buttock. The Facility's EBP sign posted documents Enhanced Barrier Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing Linens, providing Hygiene, changing briefs or assisting with toileting, device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. The Facility's Enhanced Barrier Precautions Policy, dated 4/2024, documents 2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident activities: a) Dressing; b) Bathing/showering; c) Transferring (in room, shower/tub rooms, and therapy gyms); d) AM/PM care; e) Changing linens; f) Changing briefs or assisting with toileting; g) Device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator; h) Wound care: any skin opening requiring a dressing. 3. Duration: Enhanced Barrier Precautions are intended to remain in effect for the duration of the resident stay or until the wound is closed/medical device removed. Equipment: 1. Door sign that reads Enhanced Barrier Precautions or Visitors Must See Nurse Before Entering. 2. Supply of gowns, gloves, and plastic bags.

Based on interview and record review, the failed review a urinalysis, complete a McGreer evaluation before notifying the doctor and starting antibiotics for 4 of 9 residents (R5, R14, R57, R61) reviewed for antibiotic stewardship in the sample of 62.Findings include:1. R57's admission record, print date of 8/27/25, documents R67 was admitted on [DATE] and has diagnoses of Dementia and a history of a stroke. R57's Nurses Note, dated 8/3/25, documents, Received UA (urinalysis) results, sent to (V37, Medical Director), awaiting culture. Received order for Augmentin 875mg (milligram) BID (twice a day) for 7 days. Orders put in. POA (Power of Attorney) notified. R57's Urinalysis with culture if indicated, resulted date of 8/4/25, document, Organism: (GNR) Gram Negative Rod, no sensitivity will be done. Growth: <10,000 cfu (colony forming unit)/ml (milliliter). R57's Medication Administration Record, August 2025, documents R57 received 16 doses of Amoxicillin-Pot Clavulanate Tablet 875-125 MG from 8/3/25 through 8/11/25. On 08/27/2025 at 12:12 PM, V25, Registered Nurse / Infection Preventionist stated it appears that no one reviewed R57's urine culture and notified the doctor. She should have been taken off the antibiotic. R57's McGreer evaluation, dated 8/3/25, and documents UTI (urinary tract infection) criteria not met. The policy Surveillance for Healthcare Associated Infections, dated 9/19/25, fails to document an antibiotic and culture review. 2. R14's admission Record, print date of 8/27/25, documents R14 was admitted on [DATE] and has a diagnosis of Chronic Kidney Disease. R14's Urine Culture, dated 8/11/25, documents, Results; Mixed genital flora isolated. These superficial bacteria are no indicative of a urinary infection. No further organism identification is warranted on this specimen. R14's Physician Order start date of 8/12/25, documents, Cefuroxime Axetil Oral Tablet 250 mg give 1 tablet by mouth two times a day. R14's August 2025 Medication Administration Record documents R14 received 14 doses of Cefuroxime from 8/12/25 - 8/19/25. R14's McGreer evaluation, undated, and documents UTI criteria not met. On 8/28/25 at 9:00 AM, V25 stated the doctor should have been notified and the antibiotic stopped. 3. R5's admission Record, print date of 8/27/25, documents R5 was admitted on [DATE] and has a diagnosis of Dementia. R5's Urine Culture, result date of 8/4/25 documents Organisms: Providencia Stuartii Growth: >100,000cfu/ml. R5's McGreer Evaluation, undated, and it documents UTI criteria not met. 4. R61's admission Record, print date of 8/27/25, documents R61 was admitted [NAME] 5/19/23 and has a diagnosis of a history of a stroke. R61's Nurse Note, dated 8/4/25, documents, Resident noted to have what appears to be blood in her urine, call placed to MD to update, new orders received for UA C&S (urinalysis and culture / sensitivity), resident aware. R61's McGreer Evaluation, dated 8/7/25, documents UTI criteria not met. On 08/27/2025 at 12:12 PM, V25, Registered Nurse / Infection Preventionist stated I know that the McGreer evaluation should be done even before the doctor is called. I have been trying to get the nurses to do it, but I am the one that does the McGreer evaluation after the fact. Sometimes I am not even sure of the symptoms to fill it out correctly are. The policy Antibiotic Stewardship Program, dated 10/22, documents, Sets standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics. Review antibiotic use data to ensure best practices are followed.

Based on interview, observation, and record review, the facility failed to provide range of motion for 2 of 2 residents (R23, R61) reviewed for contractures in the sample of 62. Findings include: R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set (MDS), dated [DATE] documents that R23 is cognitively intact. On 08/26/2025 at 12:44 PM, R23's Care Plan failed to document any restorative programing or limited range of motion. R23's Occupational Therapy Discharge summary, dated [DATE], documents, Discharge recommendations. Functional Maintenance Program Established / Trained = Range of Motion Program. Range of Motion Program Established / Trained: Therapist instructed staff in PROM program of bilateral shoulder flexion and abduction and ring and little digit extension up to 7x per week and for 2 sets of 10 reps (repetitions). On 8/26/25 at 12:30 PM, R23 attempted to open his left hand. R23 has 3 fingers that are curled up into the palm of his hand. R23's right hand has 2 contracted fingers. On 8/26/25 at 12:30 PM, R23 stated that he does not get exercises on his arm or hand. R23 stated he has limited movement in his left arm and hands. On 8/26/25 at 12;37 PM, V2, Director of Nurses, stated that the Certified Nurse Aides do the restorative exercises, and the therapy department makes up a restorative plan when the resident is discharged from therapy. We just started two restorative programs. V2 further stated that he agrees R23 has limited range of motion in both hands. On 8/26/25 at 2:30 PM, V2, stated that therapy only recommended that he do self-stretching of his fingers and that he had been educated. On 8/27/25 at 9:30 AM, V28, Certified Nurse Aide, (CNA), stated, I do range of motion with him with his normal daily cares, like when I put him on the pot, he has to stretch out his hands. I don't do any formal range of motion with him. On 8/27/25 at 9:45 AM, V29, CNA, stated, When I am on the floor I do range of motion with him on his fingers, but I am not on the floor much with my new position. 2. R61's admission Record, dated 8/27/25, documents R61 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction, Hemiplegia, Hemiparesis, Aphasia, Acute Kidney Failure, Type 2 Diabetes mellitus (DM), Atrial Fibrillation, Anemia, and Obesity. R61's Care Plan, 7/9/25, fails to document any restorative therapy, including Range of Motion (ROM) or exercises to be done on R61. R61's MDS, dated [DATE], documents R61 has a severe cognitive impairment and requires substantial/maximal assistance for toileting, and transfers. R61 is occasionally incontinent of both bowel and bladder. R61's MDS fails to document any limited ROM, with R61 having Hemiplegia/Hemiparesis to her right side. On 8/25/25 at 9:42 AM, R61 stated that she had a stroke and cannot move her right side. R61 stated she does not get Physical Therapy anymore and no one is working with her or doing ROM with her. R61's PT Discharge summary, dated [DATE], documents in part Discharge Recommendations: Patient would benefit from a restorative program for exercises to maintain strength and ROM of BLE's (bilateral extremities). Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Established/Trained: CNA/Nursing staff will perform R (right) [NAME] (lower extremity) PROM (passive range of motion) to AAROM (active assist range of motion) up to 30 reps for hip/knee/ankle and L (left) [NAME] AROM (active range of motion) up to 30 reps in all planes to promote maximal [NAME] strength and flexibility. During this investigation from 8/25/25 through 8/28/25, R61 was seen getting assistance from bed to her wheelchair and at no time was staff performing ROM or exercises with her. On 8/27/25 at 1:30 PM, V36, Speech Therapist/Therapy Supervisor, stated They were working with (R61) but she was discharged from therapy on 4/4/25 with instructions to continue a Functional Maintenance program. Once a resident is discharged , we give the instructions to the MDS nurse who will decide if the resident continues on Functional Maintenance or Restorative Therapy. That MDS nurse is no longer here, so I am not sure what was done for (R61). On 8/27/25 at 2:10 PM, V30, Regional Nurse Consultant (RNC), stated Our Corporate Leaders got rid of the Restorative Program here, but I would still think the staff are working with the residents for Range of Motion and things like that. On 8/27/25 at 3:20 PM, V2, DON, stated I just checked, and we do not have anything set up for staff to do ROM at this time. We are working on getting things set up to do so. On 8/27/25 at 3:40 PM, V25, Nurse Manager/ IP, stated We used to have a MDS Nurse and two Restorative CNAs who did restorative therapy on residents. We got a new Administrator, and he got rid of all three of them and told us he was going to train the CNAs himself on restorative therapy. Then one day, he cleaned out his office and disappeared and that was the end of that. It has not been started up again. The Facility's Range of Motion Policy, dated 11/2017, documents in part A range of motion program will be developed for a resident as indicated. Responsibility: Therapist, Restorative Nurse, Nursing Assistant.

Based on interviews, observations and record reviews the facility failed to provide dignity during meals for 2 out of 2 residents, (R49, R96); reviewed for resident rights in a sample of 62.Findings include: 1. R96's admission Record, dated 8/27/25, documents R96 was admitted to the facility on [DATE] with diagnosis of Dementia, Dysphasia, Phobic Anxiety disorders, Seizures, Type 2 Diabetic Mellitus (DM), and Congested Heart Failure (CHF). R96's Care Plan, dated 7/15/25, documents R96 is at increased nutritional risk related to her therapeutic diet, mechanically altered diet nectar (mildly) thickened liquids and Diagnosis of Type 2 DM, Dementia, history of dehydration. resident utilizes adaptive feeding equipment with meals. Interventions: assist with tray set up as needed: opening containers, etc. R96's MDS, dated [DATE], documents R96 has a severe cognitive impairment and requires set-up/clean-up assist for eating. 2. R49's admission Record, dated 8/27/25, documents R49 was admitted to the facility on [DATE] with diagnosis of Major Depressive Disorder (MDD), Type 2 DM, Chronic Kidney Disease (CKD), and Anemia. R49's Care Plan, dated 5/15/25, documents R49 has an individualized plan ofcare while at the facility. Intervention: Eating: Setup help only. It continues R49 is at nutritional risk related to his therapeutic diet, mechanically altered diet, and diagnosis of Type 2 DM, MDD, CKD. Interventions: Offer assistance with tray set up as needed. R49's MDS, dated [DATE], documents R49 has a severe cognitive impairment and requires partial/moderate assistance for eating. On 8/25/25 at 11:50 AM, V7, LPN, was seen standing next to R96 while feeding her, then walked to the other side of the table and fed R49 bites of his food. V7 then told V8, LPN, to Stand over here and feed R96. so V8 walked over and stood next to R96 and began feeding her bites of her meal. V8 then realized she was being observed and obtained a chair to sit down next to R96. On 8/27/25 at 1:00PM, V2, DON, stated I would expect all staff to sit down while feeding a resident, to perform hand hygiene before and in between feeding residents, and not to use their bare hands to feed a resident a food item. On 8/27/25 at 1:15 PM, V34, CNA, stated When I am assisting a resident with eating, I would sit down between residents and feed one resident with one hand and the other resident with my other hand. I would do hand hygiene before assisting them. I would use utensils to feed them things like bread or rolls and will not use my hands. The Facility's Resident [NAME] of Rights Policy, dated 1/2023, documents in part Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, ser=verity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion including those rights specified herein. 32. A safe, clean, comfortable home like environment. 33. To personal privacy and confidentiality in his or her accommodations, person and medical treatments and records, written and telephone communications, personal care, visits and meetings of family and resident groups.

Based on Interview, Observation, and Record Review, the facility failed to follow through with the Pharmacist's Medication Regimen Review (MRR), including notifying the physician and obtaining any medication changes as ordered for 3 of 5 residents (R1, R8, R9) reviewed for resident's MRR in the sample of 62.The Findings Include: 1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order (PO), dated 6/30/25, documents Escitalopram Oxalate Oral Tablet 5 MG Give 1 tablet by mouth in the morning related to Major Depressive Disorder. R1's PO, dated 6/25/25, documents Memantine HCl Oral Tablet 5 MG (milligram), give 1 tablet by mouth two times a day related to Unspecified Dementia. R1's PO, dated 6/25/25, documents Trazodone HCL Oral Tablet 150 MG, give 1 tablet by mouth one time a day related to Insomnia. R1's Pharmacy Note, dated 1/8/25, documents Trazodone 50 MG PO (oral) QHS (every night bedtime), (for insomnia) is due for a hypnotic drug and dose evaluation. Please check all that apply below:[ ] 1. Medical, environmental and psychosocial stressors have been eliminated as possible causes, and an order change may be harmful to the patient. The benefit vs risk has been considered, and the currently therapy will be evaluated every 90 days hereafter.[ ] 2. Previous attempts at order change and or reduction have been unsuccessful. Continue the current order.[ ] 3. A change in this order is felt to be appropriate at this time. See orders written below.NOTE: This review is required quarterly by CMS.Your Response:___ I agree (please write new order)___ I disagree (If no change is indicated, please provide reason:)1)___ _________________________________________________________2)__________ __________________________________________________ Response Signature/ Date. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.R1's Pharmacy Note, dated 5/5/25, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.2. R8's admission Record, dated 8/27/25, documents R8 was admitted to the facility on [DATE] with diagnosis of Dementia, Generalized Anxiety Disorder, and Schizophrenia.R8's MDS, dated [DATE], documents R8 is cognitively intact.R8's PO, dated 8/11/25, documents Fluphenazine HCl (hydrochloride) Tab 1 MG, give 2 tablets by mouth two times a day for Schizophrenia.R8's PO, dated 8/11/25, documents Hydroxyzine HCl Tab 10 MG, give 1 tablet by mouth two times a day for anxiety.R8's PO, dated 8/11/25, documents Memantine HCl Tab 5 MG, give 1 tablet by mouth one time a day for mood.R8's Pharmacy Note, dated 1/8/25 at 2:36 PM, documents Please be sure that an abnormal movement evaluation has been completed to monitor for side effects associated with antipsychotic drug therapy. This evaluation is recommended quarterly. Thank you. R8's Abnormal Involuntary Movement Scale (AIMS) was completed on 5/6/25, several months after pharmacy recommendation. R8's Pharmacy Note, dated 2/5/25 at 1:47 PM, documents Please be sure that the resident has had the following labs in the last 6 months. Thank you.TSH, HbA1c, CMP, CBC. NOTE: If these labs have not been drawn in the recommended time frame, please contact the physician to see if they may be appropriate. Thank you. The facility was unable to provide the Pharmacy's recommendation, the Physician's response. R8's Labs were not drawn until 4/18/25.3. R9's admission Record, dated 8/27/25, documents R9 was admitted to the facility 10/04/23 with diagnosis of Cerebral Infarction, Hemiplegia, Hemiparesis, Schizophrenia, Anxiety Disorder, Bipolar Disorder, Dementia, and Depression.R9's MDS, dated [DATE], documents R9 is cognitively intact.R9's PO, dated 8/25/25, documents Lorazepam Oral Tablet 1 MG give 1 tablet by mouth one time a day related to anxiety disorder. R9's PO, dated 8/19/25, documents Mirtazapine Oral Tablet 7.5 MG, give 1 tablet by mouth at bedtime for sleep/mood disturbance.R9's PO, dated 12/31/24, documents Olanzapine Oral Tablet 5 MG, give 1 tablet by mouth two times a day for bipolar disorder related to bipolar disorder. R9's PO, dated 12/14/24, documents Hydroxyzine HCl Oral Tablet 25 MG, give 1 tablet by mouth two times a day for anxiety related to bipolar disorder. R9's Pharmacy Note, dated 1/8/25 at 2:10 PM, documents Please be sure that an abnormal movement evaluation has been completed to monitor for side effects associated with antipsychotic drug therapy. This evaluation is recommended quarterly. Thank you. R9's AIMS was not completed until 8/5/25. R9's Pharmacy Note, dated 1/8/25 at 2:11 PM, documents This resident is receiving Hydroxyzine. This antihistamine is rarely considered the agent of choice due to its strong anticholinergic and sedative properties. If this is clinically relevant, may I suggest: Reference: Centers for Medicare and Medicaid Services. State Operations Manual, Survey Protocol for LTC. Appendix P, Rev. 22, 12/15/2006. In addition, CMS and Beers, et al., consider Hydroxyzine to be inappropriate for use in the elderly. They cite its strong anticholinergic side effects producing confusion, sedation, weakness, increased risk of falls, etc. Please review and assess the risks vs. benefits of the continued, routine use of Hydroxyzine; and document below or in a Progress Note the need for continued therapy and that the risks vs. benefits have been considered. Thank you.Your Response:___ I agree (please write new order)___ I disagree (If no change is indicated, please provide reason:)1)__________2)__________ __________________________________________________ Response Signature/ Date. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.R9's Pharmacy Note, dated 2/5/25 at 12:56 PM, documents Please be sure that the resident has had the following labs in the last 6 months. Thank you. CMP, HbA1c. Please be sure that the resident has had a Magnesium level in the last 12 months. Thank you. NOTE: If these labs have not been drawn in the recommended time frame, please contact the physician to see if they may be appropriate. Thank you. R9's Labs were drawn on 5/2/25, several months after pharmacy recommendation. R9's Pharmacy Note, dated 6/9/25 at 11:35 AM, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or any change in the medications. R9's Pharmacy Note, dated 8/8/25 at 1:03 PM, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or any change in the medications. On 8/27/25 at 10:15 AM, V2, Director of Nursing (DON), provided what he could find for residents MRR. V2 stated These are all that we can find regarding your resident's MRR's. We looked in paper chart and electronic chart and could not find any more.On 8/27/25 at 10:25 AM, V30, Regional Nurse Consultant (RNC), stated The pharmacy was entering MRR's into the residents electronic medical record and we were having to print that out and have physician sign the note. We decided that way was not working well, so we now have the pharmacy doing MRR's on a regular MRR form.On 8/27/25 at 10:27 AM, V2, DON, stated The MRR's are given to the DON, who will review and educate the nurses on the changes. This will be my first time doing them with the physician and will review the recommendations and educate the nurses of any changes.On 8/27/25 at 1:00PM, V2, DON, stated I would expect all Pharmacy Recommendations (MRR's) to be followed through with the notification of the physician, then following the order if changes were made.The Facility's Consultant Pharmacist Services Policy, dated 7/2021, documents in part Facility agrees to allow consultant pharmacist access to resident roster, medical records, medication storage areas, medication destruction records, and facility policy to facilitate an effective medication regimen review. The facility will retain Medication Regimen Review (MRR) reports and documentation of actions taken according to facility policy and/or state federal guidelines. The consultant pharmacist will ensure that the following services are performed: 1. Medication Regimen Review will be conducted monthly, utilizing state/federal guidelines, as well as professional standards of care. The consultant pharmacist generates a report for each resident's medical record. In addition, a summary report indicating that all residents' medication regimen reviews have been conducted, with their findings is to be provided to the Director of Nursing, Executive Director, and Medical Director. The report is to contain the resident's name, relevant drug and any irregularities. 4. Communicates to physician any identified problems attributed to drug therapy. Communicates to nursing any identified problems attributed to drug storage, administration, or documentation. The Physician and Director of Nursing will be notified upon identification of an irregularity that requires urgent action.

Based on interview and record review, the failed to notify the Physician to clarify the continued need for an antibiotic for 2 of 7 (R14, R57) reviewed for medications in the sample of 62.Findings include:1. R57's admission record, print date of 8/27/25, documents R67 was admitted on [DATE] and has diagnoses of Dementia and a history of a stroke. R57's Nurses Note, dated 8/3/25, documents, Received UA (urinalysis) results, sent to (V37, Medical Director), awaiting culture. Received order for Augmentin 875mg (milligram) BID (twice a day) for 7 days. Orders put in. POA (Power of Attorney) notified. R57's Urinalysis with culture if indicated, resulted date of 8/4/25, document, Organism: (GNR) Gram Negative Rod, no sensitivity will be done. Growth: <10,000 cfu (colony forming unit)/ml (milliliter). R57's Medication Administration Record, August 2025, documents R57 received 16 doses of Amoxicillin-Pot Clavulanate Tablet 875-125 MG from 8/3/25 through 8/11/25. On 08/27/2025 at 12:12 PM, V25, Registered Nurse / Infection Preventionist stated it appears that no one reviewed R57's urine culture and notified the doctor. She should have been taken off the antibiotic. 2. R14's admission Record, print date of 8/27/25, documents R14 was admitted on [DATE] and has a diagnosis of Chronic Kidney Disease. R14's Urine Culture, dated 8/11/25, documents, Results; Mixed genital flora isolated. These superficial bacteria are no indicative of a urinary infection. No further organism identification is warranted on this specimen. R14's Physician Order start date of 8/12/25, documents, Cefuroxime Axetil Oral Tablet 250 mg give 1 tablet by mouth two times a day. R14's August 2025 Medication Administration Record documents R14 received 14 doses of Cefuroxime from 8/12/25 - 8/19/25. On 8/28/25 at 9:00 AM, V25 stated the doctor should have been notified and the antibiotic stopped. The policy Surveillance for Healthcare Associated Infections, dated 9/19/25, fails to document an antibiotic and culture review. The policy Antibiotic Stewardship Program, dated 10/22, documents, Sets standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics. Review antibiotic use data to ensure best practices are followed.

Based on interviews, observation and record reviews the facility failed to provide feeding assistance for 1 out of 1 residents (R34); reviewed for Quality of Life in a sample of 62. Findings include:R34's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, vitamin deficiency, and abnormal weight loss.R34's Minimum Data Set (MDS) dated [DATE] documented she was rarely/never understood, had a memory problem, and required partial/moderate assistance from staff for eating. R34's Care Plan revised on 11/6/24 documented she was at increased nutritional risk; R34 is assisted at meals and offered encouragement/cueing as needed. Interventions added 11/6/24 documented for staff to offer finger foods also. R34's Progress note dated 8/22/25 at 1:59 PM, documented she is dependent on staff to meet ADLs (activities of daily living) and remains on hospice care services. On 8/25/25 at 11:18 AM R34 was sitting in an upright positioned recliner took her fork and stabbed it into her biscuit then attempted several times to take it out but couldn't. At 11:21 AM R34 was still attempting to get a bite of her biscuit unsuccessfully. At 11:25 AM R34 tried holding the container of orange sherbert but unable to eat it and puts back down. On 8/25/25 at 11:31 AM, R34 put her empty spoon in her mouth.On 8/25/25 at 11:44 AM, R34 took her empty spoon and put in her mouth, attempted to pick up her chicken with the spoon but kept pushing the chicken away. At 11:47 AM, R34 was finally able to get a bite of food into her mouth. At 11:55 AM, R34 took her empty spoon again and put in her mouth.On 8/25/25 at 12:10 PM, R34 got a spoonful of melted sherbert that spilled on the table and on her lap as she tried to eat it. On 8/25/25 at 12:15 PM, R34 tried to take her fork out of her biscuit again but was unable to. At 12:17 PM, R34 still tried to take her fork out of the biscuit, she then brought the entire biscuit to her mouth and tried to take bite of it. At 12:19 PM, R34 was able to get the fork out of her biscuit and then picked up the container of sherbert, which was melted now, and drank it. On 8/25/25 at 12:29 PM, R34 continued to drink her melted sherbert. V10 walked up to R34 talked to her and walked away with no additional assistance. R34 put down her sherbert and picked up her spoon upside down and put it to her mouth. R34's plate was about 5-10% eaten, was taken away without asking her if she was done. At 12:41 PM V14 (activity aide) poured milk into R34's cereal and walked away without assisting. R34 tried to take bites of her cereal with her spoon but dropped the cereal in process. R34 used her fingers to eat the cereal. At 12:44 PM, R34 was able to get a bite of cereal from her spoon. R34 picked up the previously spilled cereal from table and ate it. On 8/26/25 at 11:40 AM, R34 was eating without assistance. R34 took a bite of cereal from her spoon making one piece into her mouth followed by an empty spoonful. At 11:43 AM, R34 spilled some of the milk from her spoon while attempting to take another bite of milk with cereal. R34 proceeded to hold the spoon containing milk and cereal in front of her face without bringing it to her mouth until 11:52 AM when she finally put the spoon down on her plate. R34 then used her fingers to pick up her cereal from the spoon and ate one piece. At 11:54 AM, R34 picked up her spoon again and held it out in front of her face until 11:55 AM and took a bite. On 8/27/25 at 9:15 AM, in a joint interview with V12 (LPN) and V26 (CNA), V26 and V13 stated it is expected that a resident be assisted, cued or prompted when they are having difficulties eating. V26 stated we try to assist as much as possible. On 8/27/25 at 9:35 AM, V27 (staffing coordinator) stated if a resident is having difficulty eating, it is expected that they be assisted. On 8/27/25 at 1:25 PM, in a joint interview with V1 (administrator), V2 DON (director of nursing), and V30 (Regional Nurse), V2 stated residents are expected to be assisted with feeding if they are having difficulties. The facility's Dining Service Seating Policy dated 2016, documented residents who are unable to eat independently or who have special needs will be given individualized attention, assistance and care to help promote adequate food and fluid intakes.

Based on interview, observation, and record review, the facility failed to initiate a Care Plan for 2 of 20 residents (R23, R61) reviewed for Care Plans in the sample of 62.Findings include: 1 R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set, dated [DATE] documents that R23 is cognitively intact and has no limited range of motion. On 08/26/2025 at 12:44 PM, R23's current electronic Care Plan failed to document any restorative programing or limited range of motion. On 8/26/25 at 12:30 PM, R23 stated that he does not get exercises on his arm or hand. R23 stated he has limited movement in his left arm. On 8/26/25 at 12:30 PM, R23 attempted to open his left hand. R23 has 3 fingers that are curled up into the palm of his hand. R23's right hand has 2 contracted fingers. On 8/26/25 at 12;37 PM, V2, Director of Nurses, further stated that he agrees R23 has limited range of motion in both arms. On 8/27/25 at 1:44 PM, V33, LPN/MDS, stated, I have only been here for a month. I have looked at R23 and I agree that his MDS should indicate that he has limited range of motion. Once the MDS is triggered for limited range of motion it then generates a care plan for range of motion. V33 has one now because I just made him one. On 8/26/25 at 2:30 PM, V2, stated that therapy only recommended that he do self-stretching of his fingers and that he had been educated. 2. R61's admission Record, dated 8/27/25, documents R61 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction, Hemiplegia, Hemiparesis, Aphasia, Acute Kidney Failure, Type 2 Diabetes mellitus (DM), Atrial Fibrillation, Anemia, and Obesity. R61's Care Plan, 7/9/25, fails to document any restorative therapy, including Range of Motion (ROM) or exercises to be done on R61. R61's MDS, dated [DATE], documents R61 has a severe cognitive impairment and requires substantial/maximal assistance for toileting, and transfers. R61 is occasionally incontinent of both bowel and bladder. R61's MDS fails to document any limited ROM, with R61 having Hemiplegia/Hemiparesis to her right side. On 8/25/25 at 9:42 AM, R61 stated that she had a stroke and cannot move her right side. R61 stated she does not get Physical Therapy anymore and no one is working with her or doing ROM with her. R61's PT Discharge summary, dated [DATE], documents in part Discharge Recommendations: Patient would benefit from a restorative program for exercises to maintain strength and ROM of BLE's (bilateral extremities). Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Established/Trained: CNA/Nursing staff will perform R (right) [NAME] (lower extremity) PROM (passive range of motion) to AAROM (active assist range of motion) up to 30 reps for hip/knee/ankle and L (left) [NAME] AROM (active range of motion) up to 30 reps in all planes to promote maximal [NAME] strength and flexibility. During this investigation from 8/25/25 through 8/28/25, R61 was seen getting assistance for transfers and at no time was staff performing ROM or exercises with her. On 8/27/25 at 1:30 PM, V36, Speech Therapist/Therapy Supervisor, stated They were working with (R61) but she was discharged from therapy on 4/4/25 with instructions to continue a Functional Maintenance program. Once a resident is discharged , we give the instructions to the MDS nurse who will decide if the resident continues on Functional Maintenance or Restorative Therapy. That MDS nurse is no longer here, so I am not sure what was done for (R61). On 8/27/25 at 2:10 PM, V30, Regional Nurse Consultant (RNC), stated Our Corporate Leaders got rid of the Restorative Program here, but I would still think the staff are working with the residents for Range of Motion and things like that. On 8/27/25 at 3:20 PM, V2, DON, stated I just checked, and we do not have anything set up for staff to do ROM at this time. We are working on getting things set up to do so. On 8/27/25 at 3:40 PM, V25, Nurse Manager/ IP, stated We used to have a MDS Nurse and two Restorative CNAs who did restorative therapy on residents. We got a new Administrator, and he got rid of all three of them and told us he was going to train the CNAs himself on restorative therapy. Then one day, he cleaned out his office and disappeared and that was the end of that. It has not been started up again. The Facility's Comprehensive Person-Centered Care Plans Policy, dated 1/2025, documents in part Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Comprehensive Person-Centered Care Plan (CCP) contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. 5. For each problem, need, or strength a resident-centered goal is developed. Goals should be measurable. 6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention. 7. The Comprehensive Person-Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessments per the RAI (resident assessment instrument) manual.

Based on interview, observation, and record review, the facility failed to document limited range of motion for 2 of 20 residents (R23, R61) reviewed for Minimum Data Set accuracy in the sample of 62.Findings include: 1 R23's admission record, print date of 8/27/25, documents R23 was admitted on [DATE] and has a diagnosis of Cerebral Palsy. R23's Minimum Data Set (MDS), dated [DATE] documents that R23 is cognitively intact and has no limited range of motion. On 8/26/25 at 12:30 PM, R23 stated that he does not get exercises on his arm or hand. R23 stated he has limited movement in his left arm and hand. On 8/26/25 at 12:37 PM, V2, Director of Nurses, stated that he agrees R23 has limited range of motion in both hands. On 8/27/25 at 1:44 PM, V33, Licensed Practical Nurse (LPN)/MDS, stated, I have only been here for a month. I have looked at R23 and I agree that his MDS should indicate that he has limited range of motion. Once the MDS is triggered for limited range of motion it then generates a care plan for range of motion. V33 has one now because I just made him one. On 8/26/25 at 12:30 PM, R23 attempted to open his left hand. R23 has 3 fingers that are curled up into the palm of his hand. R23's right hand has 2 contracted fingers. 2. R61's admission Record, dated 8/27/25, documents R61 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction, Hemiplegia, Hemiparesis, Aphasia, Acute Kidney Failure, Type 2 Diabetes mellitus (DM), Atrial Fibrillation, Anemia, and Obesity. R61's Care Plan, 7/9/25, fails to document any restorative therapy, including Range of Motion (ROM) or exercises to be done on R61. R61's Minimum Data Set (MDS), dated [DATE], documents R61 has a severe cognitive impairment and requires substantial/maximal assistance for toileting, and transfers. R61 is occasionally incontinent of both bowel and bladder. R61's MDS fails to document any limited ROM, with R61 having Hemiplegia/Hemiparesis to her right side. On 8/25/25 at 9:42 AM, R61 stated that she had a stroke and cannot move her right side. R61 stated she does not get Physical Therapy anymore and no one is working with her or doing ROM with her. During this investigation, R61 was seen getting assistance from bed to her wheelchair and at no time was staff performing ROM or exercises with her. R61's PT Discharge summary, dated [DATE], documents in part Discharge Recommendations: Patient would benefit from a restorative program for exercises to maintain strength and ROM of BLE's (bilateral extremities). Restorative Program Established/Trained = Restorative Range of Motion Program. Range of Motion Established/Trained: CNA/Nursing staff will perform R (right) [NAME] (lower extremity) PROM (passive range of motion) to AAROM (active assist range of motion) up to 30 reps for hip/knee/ankle and L (left) [NAME] AROM (active range of motion) up to 30 reps in all planes to promote maximal [NAME] strength and flexibility. On 7/27/25 at 1:30 PM, V36, Speech Therapist/Therapy Supervisor, stated They were working with (R61) but she was discharged from therapy on 4/4/25 with instructions to continue a Functional Maintenance program. Once a resident is discharged , we give the instructions to the MDS nurse who will decide if the resident continues on Functional Maintenance or Restorative Therapy. That MDS nurse is no longer here, so I am not sure what was done for (R61). On 8/27/25 at 2:10 PM, V30, Regional Nurse Consultant (RNC), stated Our Corporate Leaders got rid of the Restorative Program here, but I would still think the staff are working with the residents for Range of Motion and things like that. On 8/27/25 at 3:20 PM, V2, DON, stated I just checked and we do not have anything set up for staff to do ROM at this time. We are working on getting things set up to do so. On 8/27/25 at 3:40 PM, V25, Nurse Manager/ IP, stated We used to have a MDS Nurse and two Restorative CNAs who did restorative therapy on residents. We got a new Administrator, and he got rid of all three of them and told us he was going to train the CNAs himself on restorative therapy. Then one day, he cleaned out his office and disappeared and that was the end of that. It has not been started up again. The Facility's MDS Assessment Policy, dated 6/2023, documents in part The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulation. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care is as a means by which the facility can track changes in a resident's status.

Based on Interview, Observation, and Record Review, the facility failed to follow through on Pharmacist's recommendations, including notifying the physician for medication review for possible changes to antipsychotic, and antianxiety medications for 3 of 5 residents (R1, R8, R9) reviewed for chemical restraints in the sample of 62.The Findings Include:1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order (PO), dated 6/30/25, documents Escitalopram Oxalate Oral Tablet 5 MG Give 1 tablet by mouth in the morning related to Major Depressive Disorder. R1's PO, dated 6/25/25, documents Memantine HCl Oral Tablet 5 MG (milligram), give 1 tablet by mouth two times a day related to Unspecified Dementia. R1's PO, dated 6/25/25, documents Trazodone HCL Oral Tablet 150 MG, give 1 tablet by mouth one time a day related to Insomnia. R1's Pharmacy Note, dated 1/8/25, documents Trazodone 50 MG PO (oral) QHS (every night bedtime), (for insomnia) is due for a hypnotic drug and dose evaluation. Please check all that apply below:[ ] 1. Medical, environmental and psychosocial stressors have been eliminated as possible causes, and an order change may be harmful to the patient. The benefit vs risk has been considered, and the currently therapy will be evaluated every 90 days hereafter.[ ] 2. Previous attempts at order change and or reduction have been unsuccessful. Continue the current order.[ ] 3. A change in this order is felt to be appropriate at this time. See orders written below.NOTE: This review is required quarterly by CMS.Your Response:___ I agree (please write new order)___ I disagree (If no change is indicated, please provide reason:)1)__________2)__________ ______________________Response Signature/ Date. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.R1's Pharmacy Note, dated 5/5/25, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.2. R8's admission Record, dated 8/27/25, documents R8 was admitted to the facility on [DATE] with diagnosis of Dementia, Generalized Anxiety Disorder, and Schizophrenia.R8's MDS, dated [DATE], documents R8 is cognitively intact.R8's PO, dated 8/11/25, documents Fluphenazine HCl (hydrochloride) Tab 1 MG, give 2 tablets by mouth two times a day for Schizophrenia.R8's PO, dated 8/11/25, documents Hydroxyzine HCl Tab 10 MG, give 1 tablet by mouth two times a day for anxiety.R8's PO, dated 8/11/25, documents Memantine HCl Tab 5 MG, give 1 tablet by mouth one time a day for mood.R8's Pharmacy Note, dated 1/8/25 at 2:36 PM, documents Please be sure that an abnormal movement evaluation has been completed to monitor for side effects associated with antipsychotic drug therapy. This evaluation is recommended quarterly. Thank you. R8's Abnormal Involuntary Movement Scale (AIMS) was completed on 5/6/25, several months after pharmacy recommendation. R8's Pharmacy Note, dated 2/5/25 at 1:47 PM, documents Please be sure that the resident has had the following labs in the last 6 months. Thank you.TSH, HbA1c, CMP, CBC. NOTE: If these labs have not been drawn in the recommended time frame, please contact the physician to see if they may be appropriate. Thank you. The facility was unable to provide the Pharmacy's recommendation, the Physician's response. R8's Labs were not drawn until 4/18/25. 3. R9's admission Record, dated 8/27/25, documents R9 was admitted to the facility 10/04/23 with diagnosis of Cerebral Infarction, Hemiplegia, Hemiparesis, Schizophrenia, Anxiety Disorder, Bipolar Disorder, Dementia, and Depression.R9's MDS, dated [DATE], documents R9 is cognitively intact.R9's PO, dated 8/25/25, documents Lorazepam Oral Tablet 1 MG give 1 tablet by mouth one time a day related to anxiety disorder. R9's PO, dated 8/19/25, documents Mirtazapine Oral Tablet 7.5 MG, give 1 tablet by mouth at bedtime for sleep/mood disturbance.R9's PO, dated 12/31/24, documents Olanzapine Oral Tablet 5 MG, give 1 tablet by mouth two times a day for bipolar disorder related to bipolar disorder. R9's PO, dated 12/14/24, documents Hydroxyzine HCl Oral Tablet 25 MG, give 1 tablet by mouth two times a day for anxiety related to bipolar disorder. R9's Pharmacy Note, dated 1/8/25 at 2:10 PM, documents Please be sure that an abnormal movement evaluation has been completed to monitor for side effects associated with antipsychotic drug therapy. This evaluation is recommended quarterly. Thank you. R9's AIMS was not completed until 8/5/25. R9's Pharmacy Note, dated 1/8/25 at 2:11 PM, documents This resident is receiving Hydroxyzine. This antihistamine is rarely considered the agent of choice due to its strong anticholinergic and sedative properties. If this is clinically relevant, may I suggest: Reference: Centers for Medicare and Medicaid Services. State Operations Manual, Survey Protocol for LTC. Appendix P, Rev. 22, 12/15/2006. In addition, CMS and Beers, et al., consider Hydroxyzine to be inappropriate for use in the elderly. They cite its strong anticholinergic side effects producing confusion, sedation, weakness, increased risk of falls, etc. Please review and assess the risks vs. benefits of the continued, routine use of Hydroxyzine; and document below or in a Progress Note the need for continued therapy and that the risks vs. benefits have been considered. Thank you.Your Response:___ I agree (please write new order)___ I disagree (If no change is indicated, please provide reason:)1)__________2)__________ ________________________Response Signature/ Date. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or the change in the medication.R9's Pharmacy Note, dated 2/5/25 at 12:56 PM, documents Please be sure that the resident has had the following labs in the last 6 months. Thank you.CMP, HbA1c. Please be sure that the resident has had a Magnesium level in the last 12 months. Thank you. NOTE: If these labs have not been drawn in the recommended time frame, please contact the physician to see if they may be appropriate. Thank you. R9's Labs were drawn on 5/2/25, several months after pharmacy recommendation. R9's Pharmacy Note, dated 6/9/25 at 11:35 AM, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or any change in the medications. R9's Pharmacy Note, dated 8/8/25 at 1:03 PM, documents See physician recommendation. The facility was unable to provide the Pharmacy's recommendation, the Physician's response, or any change in the medications. On 8/27/25 at 10:15 AM, V2, Director of Nursing (DON), provided what he could find for residents MRR. V2 stated These are all that we can find regarding your resident's MRR's. We looked in paper chart and electronic chart and could not find any more.On 8/27/25 at 10:25 AM, V30, Regional Nurse Consultant (RNC), stated The pharmacy was entering MRR's into the residents electronic medical record and we were having to print that out and have physician sign the note. We decided that way was not working well, so we now have the pharmacy doing MRR's on a regular MRR form.On 8/27/25 at 10:27 AM, V2, DON, stated The MRR's are given to the DON, who will review and educate the nurses on the changes. This will be my first time doing them with the physician and will review the recommendations and educate the nurses of any changes.On 8/27/25 at 1:00PM, V2, DON, stated I would expect all Pharmacy Recommendations (MRR's) to be followed through with the notification of the physician, then following the order if changes were made.The Facility's Consultant Pharmacist Services Policy, dated 7/2021, documents in part Facility agrees to allow consultant pharmacist access to resident roster, medical records, medication storage areas, medication destruction records, and facility policy to facilitate an effective medication regimen review. The facility will retain Medication Regimen Review (MRR) reports and documentation of actions taken according to facility policy and/or state federal guidelines. The consultant pharmacist will ensure that the following services are performed: 1. Medication Regimen Review will be conducted monthly, utilizing state/federal guidelines, as well as professional standards of care. The consultant pharmacist generates a report for each resident's medical record. In addition, a summary report indicating that all residents' medication regimen reviews have been conducted, with their findings is to be provided to the Director of Nursing, Executive Director, and Medical Director. The report is to contain the resident's name, relevant drug and any irregularities. 4. Communicates to physician any identified problems attributed to drug therapy. Communicates to nursing any identified problems attributed to drug storage, administration, or documentation. The Physician and Director of Nursing will be notified upon identification of an irregularity that requires urgent action.The Facility's Abuse Prevention Policy, dated 1/2025, documents in part The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents, consultants, volunteer, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.The Facility's Behavior Management and Psychopharmacological Medication Monitoring Protocol Policy, dated 6/2025, documents in part Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the resident's condition. Prior to initiating or increasing a psychotropic medication, the resident must be notified of and have the right to participate in their treatment including the right to accept or decline the medication. Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. There will be an established Behavior Management Committee that will meet routinely to review all resident mentioned above and other as the committee deems appropriate. 4. Psychotropic: a. Within the first year in which a resident is admitted on any psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR (gradual dose reduction) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. Procedure: i) The Committee or Pharmacy Consultant will recommend the initiation, when applicable, of a gradual dose reduction, unless clinically contraindicated, in an effort to maintain the resident at the lowest possible dose or to discontinue the medication.

Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 . Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor space per resident in eight, 3-bed resident rooms for 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 . Findings include: On 08/28/25 at 11:55 AM, the 8 three-bed resident rooms, (Rooms 51-58). Each room has three beds in it. Each room was licensed and available for three residents per room. According to historical measurement data, these eight rooms only provide 77 square feet per resident bed. The following residents reside in these rooms: R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, and R99. On 8/28/2024 at 11:48 AM V1, Administrator, stated We evaluate the compatibility and any behaviors a resident may be having, prior to putting them in a 3-person room. All eight of these three-bed resident rooms are Medicare / Medicaid certified.

Based on interview and record review, the facility failed to coordinate services between the facility and resident's oncology provider for one of one resident (R3) reviewed for coordination of services to provide quality of care in the sample of 8. Findings include: R3's Care Plan, dated 10/10/2024, documents R3 is to have an individualized plan of care while at the facility. Staff to follow individualized plan of care to meet resident's needs. R3's Care Plan does not address her blood cancer or her seeing an oncologist, V8. R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). Testing.com website, documents the Jak2 Mutation test is used To help diagnose bone marrow disorders known as myeloproliferative neoplasms (MPNs) in which bone marrow produces too many or one or more types of blood cells. R3's Progress Note, 6/24/2024 at 3:51 PM, documents Res returned from (V8's), Oncologist, with findings of increase platelet counts, lab called with critical findings of 783 platelet count, (V10) MD notified. R3's Progress Note, dated 6/26/2024 at 8:52 PM, documents (V15, Nurse Practitioner), responded r.t (related to) R3 platelets for V10 to address at this time either via fax or at facility during his next rounding date. MUM (memory unit manager) (V16, Memory Unit Manger), aware. F/U (follow up) required in r.t results for further action required regarding plan of care moving forward. R3's Progress Note, dated 6/28/2024 at 10:46 AM, documents Spoke with MUM r/t high platelets & possible Hospice Referral. MUM to address this. R3's JAK-2 Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given. A stamp Scanned Date/Initials with unrecognizable date and initials. It also documents that R3 is positive for Jak-2. R3's Progress Note, dated 8/15/2024 at 11:17 PM, documents MD responded to fax sent regarding inquiry on if resident is currently seeing a hematologist specialist at this time d/t (due to) elevated H Platelet count. MD responded with new orders to have resident be referred to see a hematologist specialist for a consultation regards to lab results at this time. MUM notified r/t consult needing to be scheduled for specialist to be implemented on behalf of resident's account. F/U needed once appointment has been scheduled regarding this matter for time and date & w/ whom. R3's Progress Note, dated 8/20/2024 at 2:55 AM, documents Critical High Platelet level of 1167 called in from Lab. MD notified. NNO. MD wants res seen by Hematologist soon, questioning when appointment is. R3's Progress Notes, dated 8/20/2024 at 11:15 AM, documents Writer called (V8's) office, Oncology-Hematology, to schedule an appointment to be seen regarding the resident's recent critical platelet levels. Appointment has been scheduled for September 9th at 1:45PM at (City medical clinic) as the earliest available appointment. R3's Progress Note, dated 9/15/2024 at 10:43 AM, documents Nurses Note Text: Resident has appointment with hematology/oncology (V8) on September 27th, 2024, at 1:45 p.m. R3's Progress Note, dated 9/27/2024 3:17 PM, documents Nurses Note Text: (V8's) office called and scheduled a follow up appointment for after labs are drawn (they are waiting insurance approval). Appointment will be October 25th, 2024, at 10:30 a.m. Schedule person for facility notified. R3's Progress Note, dated 10/22/2024 at 11:20 PM, documents Nurses Note Text: F/U appointment with (V8) 10/25 @ (at) 1:45pm. R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: rec'd (received) call from (V8's) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab drawn prior to appt. Resident had a scheduled appointment for 10/25. F/U with office and asked would it be possible for lab to be drawn there. Nurse was unaware since resident resides at nursing home. Advised resident may have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this lab. Contacted (local hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would be sent out. (V8) office would like a f/u regarding if and when the lab will be drawn. Appointment for 10/25/24 has been canceled and need rescheduled. On 10/29/2024 at approximately 3:00 PM V3, Assistant Director of Nursing (ADON), provided documentation, dated 6/24/2024, that documents that Res returned from V8, Oncologist/Hematologist, with report of increase platelets, lab reported platelet count of 783. Please advise. On 10/29/2024 at 10:58 AM V5, V8's Oncology Registered Nurse, stated that R3 is a patient since August 2023. V5 stated that R3 has Myeloproliferative which is a rare blood cancer. V5 stated that R3 has not been seen by physician at the oncology office because the ordered lab work has not been completed. V5 stated that a Jak-2 lab was ordered on 6/24/2024. V5 stated that R3 was seen in the office when the lab was prescribed, and the order was sent with the resident and paper sent back to facility. V5 stated that the treatment for R3's diagnosis is Hydroxyurea. For this medication to be ordered and be effective the lab needs to be completed for dosing. This medication would decrease R3's platelet counts and prevent a stroke. This lab and medication are imperative. V5 stated that she has made multiple attempts to educate the staff on the importance of the lab and medication and nothing was done. V5 stated that she spoke the V3, ADON, on October 24th and stressed the importance of this lab and that R3 has not been seen and treated since June because the facility has not gotten the lab. V5 stated that they received the results with platelet count critical at 1410 from the hospital on October 25th. V5 stated that the have not received anything from the facility. V5 stated that they have called and talk with multiple people and nothing. V5 stated that at times they were not able to reach anyone. V5 stated that this lab is critical in R3's treatment. On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3 to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's office by V10. V3 stated that V8's office is a hematology and Oncology office. V3 stated that R3 was seen on 6/24/24 and with findings of increase platelets, splenomegaly, and weight loss. V3 stated that orders were received for boost, check Jak-2 mutation, continue ASA. V3 stated that R3 went to hospital and the Jak-2 lab was drawn. V3 stated that per the lab it was drawn 7/2/2024 and sent off. V3 stated that it takes about a week for the lab to be completed and results given. V3 stated that the lab then reported the results to the hospital 7/12/2024 and the facility received the lab 7/15/2024. V3 stated that there is a stamp on the lab with date and initials. V3 stated that she was not familiar with the initials. V3 stated that she spoke with V5 and informed her of this today. V3 stated that she was informed that the Oncology office did not receive the lab. V3 stated that she was unable to find confirmation that the lab was sent to the office or that it was received by the oncology office. On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find verification that the lab was communicated with the prescribing physician's office. On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday (10/29/24) and notified them that they just became aware that the Jak-2 lab was previously drawn and had not notified them. On 10/30/2024 at 3:37 PM V17, Oncology Nurse, stated that V10 only sees R3 because he is the house physician. V17 stated that R3 has been a patient of V8 since 2023. V17 stated that V10 does not handle her platelets that the results and treatment are handled by V8 not V10. V17 stated that V10 is only seeing R3 because he is the house physician. The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1. Guideline for notification of physician/responsible party f. Abnormal lab findings.

Based on interview and record review, the facility failed to ensure the Oncologist and the Attending Physician were notified of a significant lab value for 1 of 8 residents (R3) reviewed for reporting of laboratory results in the sample of 8. Findings include: R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets. Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET (Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals, check Jak-2 mutation, continue ASA (aspirin). R3's Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given. A stamp Scanned Date/Initials with unrecognizable date and initials. R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: received call from (V8's, Oncology Physician) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab drawn prior to appt. Resident had a scheduled appointment for 10/25. F/U (follow up) with office and asked would it be possible for lab to be drawn there. Nurse was unaware since resident resides at nursing home. Advised resident may have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this lab. Contacted (local hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would be sent out. (V8) office would like a f/u regarding if and when the lab will be drawn. Appointment for 10/25/24 has been canceled and need rescheduled. On 10/29/2024 at 10:58 AM V5, Oncology Registered Nurse, stated that R3 is a patient since August 2023. V5 stated that R3 has Myeloproliferative which a rare blood cancer. V5 stated that R3 has not been seen by physician because ordered lab work has not been completed. V5 stated that a Jak-2 lab was ordered 6/24/2024. V5 stated that R3 was seen in the office when the lab was prescribed, and the order was sent with the resident and paper sent back to facility. V5 stated that the treatment for R3's diagnosis is Hydroxyurea. For this medication to be ordered and be effective the lab needs to be completed for dosing. This medication would decrease R3's platelet counts and prevent a stroke. This lab and medication are imperative. V5 stated that she has made multiple attempts to educate the staff on the importance of the lab and medication and nothing was done. V5 stated that she spoke the V3, ADON, on October 24th and stressed the importance of this lab and that R3 has not been seen and treated since June because the facility has not gotten the lab. V5 stated that they received the results with platelet count critical at 1410 from the hospital on October 25th. V5 stated that the have not received anything from the facility. V5 stated that they have called and talk with multiple people and nothing. V5 stated that at times they were not able to reach anyone. V5 stated that this lab is critical in R3's treatment. On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3 to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's office by V10. V3 stated that V8's office is a hematology and Oncology office. V3 stated that R3 was seen on 6/24/24 and with findings of increase platelets, splenomegaly, and weight loss. V3 stated that orders were received for boost, check Jak-2 mutation, continue ASA. V3 stated that R3 went to hospital and the Jak-2 lab was drawn. V3 stated that per the lab it was drawn 7/2/2024 and sent off. V3 stated that it takes about a week for the lab to be completed and results given. V3 stated that the lab then reported the results to the hospital 7/12/2024 and the facility received the lab 7/15/2024. V3 stated that there is a stamp on the lab with date and initials. V3 stated that she was not familiar with the initials. V3 stated that she spoke with V5 and informed her of this today. V3 stated that she was informed that the Oncology office did not receive the lab. V3 stated that she was unable to find confirmation that the lab was sent to the office or that it was received by the oncology office. On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find verification that the lab was communicated with the prescribing physician's office. On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday and notified them that they just became aware that the Jak-2 lab was previously drawn and had not notified them. The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1. Guideline for notification of physician/responsible party f. Abnormal lab findings. The facility's Laboratory Tests policy, dated 11/17, documents Procedure: 9. The physician or physician extender will be promptly notified of abnormal results according to facility policy.

Based on interview and record review the facility failed to provide a Registered Nurse (RN) for a least 8 consecutive hours a day for 7 days a week. This failure has the potential to affect all 106 residents residing at the facility. Findings include: On 10/17/24 at 10:30 AM V19, Licensed Practical Nurse, stated that the day shift for nurses was from 6 AM to 6 PM and the Night shift runs from 6 PM to 6 AM. The facility's Staff Assignments, for August 2024, September 2024 and October 2024 were reviewed and on these dates, 8/22/2024, 8/28/2024, 8/29/2024, 9/1/2024, 9/5/2024, 9/12/2024, 9/18/2024, 9/20/2024, 9/23/2024, 9/26/2024, and 10/3/2024, failed to document that there was a RN working the floor for 8 consecutive hours on these days. On 10/17/24 at 01:05 PM, V1, Administrator, stated that they have a new scheduler and that she may not understand that a new day starts at 12 midnight and that she did not know if the facility has a policy but they follow the federal guidelines for RN coverage. The facility's Long-term Care facility Application for Medicare and Medicaid, dated 10/15/2024, documented that there was 106 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, discard of potentially contaminated medications to prevent cross contamination. The facility also failed to have a system in place to monitor and track infections in the facility for 6 of 10 (R12, R16, R46, R47, R54 and R83) residents reviewed for infection control in the sample of 68. Findings include: 1. On 10/16/24 at 8:26 AM, V12, Licensed Practical Nurse, (LPN), prepared medication to be administered to R83. V12 obtained Tylenol 2 tablets, 1 tablet Magnesium Oxide 400 milligram (mg), 4 capsules of Vitamin D3 50 micrograms, and placed them into a medication cup. V12 donned gloves without hand hygiene, retrieved the Tylenol and Magnesium Oxide tablets, and placed them into a pill pouch so they could be crushed. V12 crushed the tablets, mixed them with pudding, added the Vitamin D3 capsules, removed her gloves. V12 then entered R83's room and administered the medications to R83. 2. On 10/16/24 at 8:39 AM, V12 opened R16's morning medication pass packet which include: Metoprolol 50 milligrams (mg), Losartan 100 mg, and hydrochlorothiazide 25 mg all 3 of the medications fell on to the top of V12's medication cart. V12 with her bare unsantized hands picked up the medications and placed them into a medication administration cup. V12 entered R16's room and administered the medications to R16. On 10/17/24 at 11:00 AM, V1, Administrator, stated that if medication falls onto the medication cart it should be discarded and not given to the resident. V1 further stated that staff should perform hand hygiene before putting gloves on and after removing them. V1 stated that the glove policy does not state hand hygiene before putting on gloves but it should be done. The policy hand Washing, dated 9/19, documents, Staff will use proper and washing technique to prevent the spread of infection. The policy Personal Protective Equipment Using Gloves, dated 2009, documents, 5. wash hands after removing gloves. 40650 3. R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI), SITE NOT SPECIFIED (N39.0) for 7 Days R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth three times a day for UTI for 5 Days R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days. R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders. R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI. The facility's infection control log, dated 09/2024, did not document the organism for R12's UTI 4. R46's Physician order, dated 8/13/2024, documented, Obtain UA with C&S if indicated. R46's Physicians order, dated 8/22/2024, documented, Cephalexin Cap 500 MG Give 1 capsule orally two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 08/29/2024. R46's McGreers Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R46's UTI. 5. R47's Physicians orders, dated 9/10/2024, documented, Levaquin Oral Tablet 500 MG (Levofloxacin) Give 1 tablet by mouth in the afternoon related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 5 Days R47's Physicians order, dated 9/22/2024, documented, Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth two times a day for infection related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) for 7 Days R47's Physician orders, dated 9/4/2024, documented, CBC bmp UA w/c and s one time only for pain while urinating for 1 Day. R47's McGreer's Criteria, undated, documeted, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R47's UTI. 6. R54's Physician order, dated 9/5/2024, documented, UA with C&S one time only for altered mental status for 1 Day R54's Physician order, dated 9/6/2024, documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day for UTI pending UA results for 7 Days Give 1 cap PO BID X 7 days. R54's McGreer's Criteria, undated, documented, UTI criteria not met. The facility's infection control log, dated 09/2024, did not document the organism for R54's UTI. On 10/21/2024 at 10:35 AM, V14, Infection Preventionist/RN, stated that she took over the infection tracking in June. She continued to state that she did not know what organisms were in the facility except what was on the rehab unit because she is the unit manger there. V14 stated that she would track and trend at the end of the month because that was when pharmacy would send her a list of residents and what antibiotics they were on but prior to that list coming she did not know what organisms were in the facility. She also stated that the McGreers criteria was completed after the resident was already placed on an antibiotic and that this should have been filled out when the resident was starting to have signs and symptoms. On 10/21/2024 at 12:47 PM, V1, Administrator, stated that she would expect that staff track and monitor all infections in the facility. The facility's Antibiotic Stewardship Program, dated 10/2022, documented, Tracking: Process measures: Track types and location of infections, and where the resident is located in the facility. It continues, Monitoring use: Facility will collect reports summarizing the antibiotic susceptibility patterns. It continues, Microbiology culture data will be used to assess and guide future antibiotic selection. The facility's Surveillance for Healthcare Associated Infections, dated 09/2029, documented, 8. Utilize you surveillance data to: a. Identify infections quickly. It continues, f. Compare unit by unit data.

Based on observation, interview and record review the facility failed to provide diet as ordered for 1 of 1 resident(R6) reviewed for therapeutic diets in the sample of 67. This failure resulted in R6 choking and required the [MEDICATION(S)] Maneuver to clear the obstruction. Findings include: R6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set (MDS), dated [DATE], documents R6 has severely impaired cognition. R6's Departmental Notes, dated 2/21/2022 at 8:55 AM the registered dietitian documents current diet is pureed, no issues with chewing/swallowing. R6's Resident Incident Report, dated 2/27/22 documents resident eating lunch in the dining room, eating potatoes, corn and grilled chicken (per her request was not pureed) resident stated she was attempting to chew food and a piece of chicken went down before she was ready and began to choke, CNA (certified nurse assistant) stated she was attempting to chew food and a piece of chicken went down before she was ready and began to choke, CNA responded to emergency and began [MEDICATION(S)] maneuver when requesting writer for assistance to dining room, responding to emergency and ran to dining room to assist by time writer entered resident had coughed up the piece of chicken obstructing her airway lung sounds are clear and resident is only complaining of discomfort from the [MEDICATION(S)] being done no bruising present does not hurt with breathing. continuing to monitor. No injury, some pain in throat from coughing. Immediate post-incident action: small bites of food and assistance with meals. R6's Care Plan dated 6/5/2022, documents I have a mechanical soft diet with thin liquids. If I am not eating, please offer me something else I may eat. I receive super cereal with breakfast. Choking was not documented on the resident's care plan. R6's Departmental Notes, dated 2/27/22 at 6:19 PM documents hospice returned phone call on diet clarification for resident, resident to be on regular diet with mech (mechanical) soft consistency, resident can choose to not eat or eat but cannot choose to have consistency regular because of safety of the resident. Will continue to monitor and educate resident and staff on resident diet. On 8/4/2022 at 11:30 AM, V1, Administrator, stated the resident is non complaint with the mechanical soft diet, the resident is on hospice and residents eat what they want to when they are on hospice. V1 expected staff to update the resident's care plan with progressive interventions to ensure the resident doesn't choke again. On 8/4/2022 at 3:15 PM, V1 stated she expected staff to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's Diet Orders policy dated 2016 documents each resident will have a diet order prescribed the physician and documented in the health record. Diet orders are clearly communicated, using the designated diet order communication form to food and nutrition services. All diet orders communication forms received by food and Nutrition services are confirmed for accuracy by the Director of Food and Nutrition Services are confirmed for accuracy by the Director of Food and Nutrition Services or designee and kept on file in a systematic way in the dining department. Diet orders are checked for accuracy regularly, at the quarterly care plan meeting, by comparing diet orders on file in food and nutrition services with the POS in the health record. If the diet order is not consistent, the Director of Food and Nutrition Services or designee will make the necessary changes to ensure the correct diet is on the POS and resident meal card.

Based on observation, interview, and record review, the facility failed to administer medications for pain management for 1 of 6 residents (R23) reviewed for pain in the sample of 24. This failure resulted in R23 being in constant pain. Findings include: R23's Nurses notes, dated 5/8/2022 at 3:04PM, document new order for Tylenol 500 milligram (mg) po (by mouth) q (every) 6 hours as needed for pain and fever. R23's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Minimum Data Set (MDS), dated [DATE], documents R23 is cognitively intact, requires extensive assistance and two plus physical assistance for bed mobility, transfer and toileting. R23's nursing notes, dated 5/10/22 at 12:45PM, documents R23 resting quietly in bed, complaint of pain in right leg foot 6 out of ten on the pain scale. Documents resident is currently on intravenous antibiotics for [CONDITION(S)]. R23's pain skilled charting, dated 5/10/2022 at 12:32PM, documents location of pain feet/legs chronic, burning, aching and throbbing. Documents frequency as continuous and activity triggers the onset pain intensity documented 6-7 severe pain (restless, bracing, guarding and grimacing) documents acceptable level of pain as no pain. Charting documents interventions as medication, PT (physical therapy), OT (occupational therapy), positioning, resident/family education regarding pain management, side effects and medication regime. R23's Pain skilled charting, dated 4/30/2022 at 12:24PM, documents the exact same thing as documentation on 5/10/2022. 5/1/2022 at 1:45AM pain skilled charting document the exact same information as documented on 5/10/2022. Pain charting, dated 5/2/2022 at 2:32AM, documents the exact same information as 5/10/2022. This remains the same as 5/10/2022 for 5/5/2022 at 1:58PM, 5/6/2022 at 3:42PM, 5/6/2022 at 11:38PM, 5/7/2022 at 6:23PM, and 5/8/2022 at 11:33PM. On 5/10/22 at 1:50PM, R23 was sitting up in a wheelchair, and stated he is supposed to get pain medication every 6 hours as needed. R23 stated he asked for medication the night before at 7:00PM, and did not get get medication until 10:00PM. R23 stated he has [CONDITION(S)], and if he does not get medication timely, he cannot get ahead of the pain. R23 stated he had a wound on his heel and sides of his foot. On 5/10/2022 at 2:10PM during treatment and dressing change to R23's wounds, R23 was complaining of pain. R23 stated his foot hurts like a heart beating in his heel. At no time did V13, Wound Nurse, ask R23 to rate his pain, or offer R23 any pain medication. V13 stated there had been no change in his treatment plan. V13 told R23, After this last dressing, you can go to sleep. On 5/10/2022 at 2:45PM V2, Director of Nursing (DON), stated she would expect R23's pain to be addressed. On 5/17/2022 at 2:06PM, V34, Physician, stated he would expect as needed (prn) medication to be given to R23. V34 stated he had not been made aware of the extent of R23's pain. The facility Pain Evaluation/Management policy, dated history 1/15, documents; if no relief or if the resident finds pain above acceptable level notify physician, notify physician if residents response to their medication is not satisfactory to develop further interventions for pain. The facility policy Medication Administration guidelines, dated history 8/16, documents medications are administered as prescribed. The policy documents when prn medications are administered the following documentation is provided *date and time of administration, dose, route of administration, if other than oral *complaints or symptoms for which the medication was given *resident pain evaluation per facility policy

Based on observation, interview, and record review, the facility failed to follow a physician's order to send a resident to the emergency room for one of 4 residents (R42) reviewed for change of condition in the sample of 52. This failure resulted in a three day delay of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: On 6/8/21 at 11:20 AM, R42 was walking out of the dining using his walker with assist of two staff, V9, Certified Nursing Assistant (CNA) and V2, Director of Nursing (DON). V7, Registered Nurse (RN) stated R42 was usually up walking with his walker and did not need assist. R42 stated he just didn't feel steady. V7 performed a blood glucose monitoring for R42, which resulted in 234. R42 was then assisted back to the dining room for lunch. A facility fax, dated 6/8/21, untimed, by V7 to V28, R42's MD (Medical Doctor) documents: Patient (R42) identified. Resident has BP (blood pressure) 160/80, HR (heart rate) 110, SPO2 (oxygen saturation) 94%, RR (respiratory rate) 22, Temp-102.4 F (Fahrenheit). Wife (R44) says that the resident told her he wants to go to the hospital. Tylenol 650 mg (milligram) given po (by mouth). Kindly advise on next steps. Thank you. At the bottom of this fax there is an order, Send to ER (emergency room ) please. This order was signed by V28, R42's medical doctor on 6/8/21 at 2:22 PM. Another copy of this same facility fax, without V28's response documented on it, has additional information at the bottom of the page which documents, May we obtain labs, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Profile), and U/A (urinalysis) and Chest x-ray first, instead of sending to the hospital at this time? There is no documentation of V28's acknowledgement or response to this fax by indicating that he received the second fax, or changed his order to send R42 to the ER. R42's Progress Note, dated 6/8/21 at 1:38 PM, by V7, Registered Nurse (RN), documented, The wife of (R42) reported to the writer that the husband has told her that he wants to go to the hospital because he is not feeling well. Vital signs taken on the resident: BP 160/80, HR 110, SPO2 94 %, Temp 102.4 F, RR 22. V28 ( R42's medical doctor) notified on fax. R42's Progress Note, dated 6/8/21 at 7:31 PM, documents: Addendum: We requested V28 (R42's MD) for lab investigations of CBC, CMP and UA together with a CXR (chest x-ray), still awaiting replies from V28. Handed over to the incoming nurse. There were no further progress notes documented for R42 until 6/9/21 at 2:51 PM which documented : COVID-19 rapid test done due to signs and symptom- elevated temperature- with negative results. On 6/9/21 at 9:30 AM, R42's wife/roommate (R44) stated R42 was not feeling good last night and wanted to go to the hospital. R44 stated no one had talked to them about sending R42 to the hospital after she told them he was not feeling good last night, and he did not get sent to the hospital. R44 stated R42 ate his breakfast this morning in the dining room, but couldn't walk to the dining room, and had to ride in the wheelchair instead. On 6/9/21 at 1:00 PM, V2, Director Of Nursing (DON), stated R42 had not been tested for COVID-19 the day before, even though he had a temperature of 102.4 She stated the nurse had faxed a report to V28 regarding R42's change of condition, including his wife reporting he did not feel good and wanted to go to the hospital, and his fever. V2 stated, after discussing R42's condition with a supervisor, the nurse sent another fax to the MD requesting labs and x-rays, but the doctor did not respond to that fax, and R42 did not get sent to the hospital. V2 stated R42 should have been tested for COVID due to having a signs of COVID. She stated she could not find any documentation he had been tested for COVID, sent to the ER as ordered, or the MD had responded to the request for labs and x-rays to done. V2 stated when V28 did not respond to the request to get labs and x-rays done in the facility, V7 should have sent R42 to the ER as ordered. On 6/9/21 at 1:30 PM, V6, Licensed Practical Nurse (LPN), was R42's nurse and she stated she had not received any report from the midnight nurse regarding R42 being sent to the hospital or any labs or x-rays being ordered. She stated she had not had any reports of anything going on with R42 today. She stated he has been out to the dining room for lunch and breakfast. She stated he did not walk to the dining room for lunch like he usually does, and she was not sure if he walked to breakfast or came up in the wheelchair. R42's Progress Note, dated 6/9/21 at 2:55 PM, by V2, DON, documents: Called V28's office regarding resident's recent elevated temperature. Left message with receptionist and left message on nurse voicemail. Waiting for orders. Will continue to monitor patient, no elevated temp at this time. R42's Progress Note, dated 6/9/21 at 4:08 PM, by V2, DON, documented, Spoke with (V28) regarding resident recent condition, per (V28) he did receive the notification asking for labs and x-ray and the MD would have been fine to go ahead and order labs to keep resident in house as long as it was okay with the resident. He was under the impression that the resident wanted to go to the hospital, however per conversation with the charge nurse, the wife and resident were agreeable to treat in house. (V28) said to disregard note to send to ER and gave orders to obtain CBC, CMP, Chest X-Ray and UA with C&S (Culture and Sensitivity) in house. R42's Progress Note, dated 6/9/21 at 5:25 PM, documents, (V29) (R42's state appointed guardian) aware of resident having a fever and Dr's (doctor's) stat orders of CBC, CMP, UA, culture if indicated and a 2 view chest X-ray. On 6/10/21 at 9:30 AM, R42 was sitting in his recliner watching television with his roommate/spouse (R44). R42 stated he still does not feel good and when asked what part of him did not feel good, he put both hands on his abdomen and stated, here. R44 (R42' spouse) stated R42 was not eating good and needed help. She stated he was using the wheelchair instead of walking with his walker to go to dinner last night and to breakfast this morning. She stated he had an x-ray done yesterday, but no blood work has been drawn yet. She stated, He's not right. He needs checked out. R44 stated R42 had still not been sent to the hospital. On 6/10/21 at 10:04 AM, V1, Administrator, stated the facility had called R42's doctor yesterday (6/9/21) to get orders for labs and x-rays. V1 stated if the nurse did not get a different order on 6/8/21 when the doctor ordered R42 to be sent to the ER, then she would have expected the nurse to send R42 to the emergency room as ordered. On 6/10/21 at 2:00 PM, V2, Director of Nursing, stated it is the facility's protocol if an order is received to send a resident to the ER, the nurse is to call the supervisor on call and discuss it with her, and if she is ok with transfer to the ER, the resident would be sent, but the supervisor may decide to have the nurse ask the doctor if it is ok to treat the resident in the facility by taking x-rays or getting labs, instead of sending the resident to the emergency room . V2 stated in R42's case, the supervisor told the nurse to check with R42's doctor to see if they could do a chest x-ray and labs in the facility, but that nurse did not get a response from the doctor, so R42 should have been sent to the ER as ordered by the physician on 6/8/21. On 6/10/21 at 2:40 PM, V2 stated she had just talked to R42's roommate/spouse who informed her she was very worried about R42 because he was not feeling good and had some diarrheal stools 3 times today. V2 stated the nurse was going to call R42's doctor to get an order to send him to the ER, but if they did not get a response from the MD , he was going to be sent out per nursing judgement. R42's Resident Transfer Form, dated 6/10/21, but untimed, documents, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Events or change in condition leading up to request for ER evaluation/ reason for ER visit or reason for consult: Wife requested. According to the transfer form, R42's fever was 99.5 at the time of transfer. On 6/11/21 at 1:10 PM, V29, R42's Guardian, stated she received a call on 6/9/21 in the afternoon informing her R42 had a fever and the doctor had ordered labs and an x-ray to be done. She stated that is the only call she received regarding R42 recently. She stated she did not receive a call on 6/8/21 to report any changes in his condition, and had not been notified he had been sent to the emergency room yesterday, on 6/10/21. V29 stated she had checked the on-call notifications, and nobody had notified OSG (Office of State Guardian) of R42 being sent to or admitted to the hospital. V29 stated if the doctor had ordered for R42 to go to the hospital on 6/8/21 and the facility did not receive a different order right away to do labs in the facility, she would have expected him to be sent to the emergency room as ordered. V29 stated she thought R42's fever had happened on 6/9/21 when she was notified of the new orders. On 6/11/21 at 1:35 PM, V13, Licensed Practical Nurse (LPN), stated on 6/8/21 it was brought to her attention R42 had a fever and the doctor gave an order to send him to the emergency room . V13 stated she discussed this with her supervisor, V2, and they decided to request the doctor order labs, a urinalysis and chest x-ray that could be done in the facility instead. She stated she discussed this with the nurse, V7, who was taking care of R42, and instructed her to notify the doctor and request labs and x-ray. She stated after that she was out of it .it was up to the nurse to notify the MD to request labs and x-ray instead of sending R42 to the hospital and to get the order. V13 stated because V7 did not get a different order, she should have followed the physician's orders and sent R42 to the hospital. V13 stated she gave V7 an education regarding following physician orders yesterday when V7 came to the facility, informing her the need to follow physician's orders. On 6/11/21 at 2:00 PM, V30, V28's nurse, stated the office closed at 5:00 PM on 6/8/21, so if the nurse sent across another fax requesting labs and X-rays for R42 at 7:00 in the evening, that fax would not have been seen until 8:00 AM the next day. V28 stated the facility should not have faxed the request, but should have called the on-call physician. She stated V28 is out of the office until Tuesday, but she has worked several years with him, and if he gave the order to send a resident to the ER, and the resident and family wanted that person to go, he would have expected the resident to be sent to the ER as ordered. On 6/11/21 at 3:00 PM, V28, MD, stated he did receive a faxed report on 6/8/21 at 2:22 PM, informing him R42 had a fever and that he wanted to go to the hospital. He stated he ordered for R42 to be sent to the emergency room , because if a resident is not feeling well and requests to be sent to the hospital, it is in the best interest of the patient to go ahead and send them to the hospital to have them assessed. V28 stated he is aware the facility is able to get labs and x-rays in the facility, but to have labs and x-rays in the hospital is more timely, and if a resident is acutely ill, to send him to the ER is the appropriate thing to do. V28 stated he received a phone call from the facility on 6/9/21, in the afternoon, from the facility asking about doing labs and chest x-ray on R42 in the facility. He stated he had been under the impression the resident and family had wanted him sent out to theER on [DATE], but the facility told him the resident and family were agreeable to R42 being treated in the facility. V28 stated he did not receive the second fax with the requests for labs and x-rays until after he had already spoken to the nurse from the facility on 6/9/21. He stated he received an update at that time that the resident's vital signs were stable and R42 was acting like his normal self. V28 stated he would have expected the facility to call him, not fax him, after hours if there was something they wanted. He stated he did not receive any further notification until the following day, and had not been aware until then that R42 had not been sent to the ER as ordered. V28 stated the facility knows they are to call the exchange for the physician on call or himself after hours. He stated the facility also has his cell phone and have contacted him on other occasions before this, even when he was not on call, so he knows they are able to reach him. He stated he had words about this with the facility on previous occasions and knows it is convenient to just fax something, but all faxes that come to him are put in a folder in the office, and he may not get the chance to view them until late in the day if the office gets busy. V28 stated he would have expected the facility to follow his orders unless he or another physician on call gave a different order. V28 stated he is aware R42 is in the hospital now, but was not able to determine what his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's Hospital Transfer Summary, dated 6/13/21 at 11:48 AM, documents he was admitted to the hospital on 6/10/21 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It documents during his hospitalization he was started on IV (intravenous) antibiotics and was discharged on oral antibiotics. On 6/15/21 at 9:42 AM, V2, DON, stated the facility does not have a specific policy regarding following physician orders, other than medication orders.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent resident to resident altercations for 4 of 4 residents (R40, R46, R51, R78) reviewed for incidents in the sample of 52. This failure resulted in R46, R51, R78 being fearful and experiencing intimidation related to R40's aggression. Findings include: R46's Care plan, dated 8/21/2020, documents she has diagnosis of Alzheimer's and becomes confused. It also documents that R46 does not like it when other residents come into her room and to please redirect them out. R51's Care plan, dated 4/29/2021, documents she has diagnosis of Dementia and becomes confused. It also documents R51 has depression and anxiety. R78's Care plan, dated 3/24/2021, documents she has diagnosis of Dementia, is easily confused, and can be verbally aggressive to staff and peers. R40's Care Plan, dated 7/21, documents Mental Wellness/Mood, I have dementia with behavioral disturbances, anxiety and [CONDITION(S)]. It also documents, I wander into other's rooms and take things out of their rooms. It continues, I am verbally aggressive, I may yell at staff or peers. Please track my behaviors and monitor me for side effects from my medication. R40's Care Plan also documents Behavior tracking in place, if interventions do not work please notify the nurse. R40's Minimum Data Set (MDS), dated [DATE], documents behavior did not exist for Physical, Verbal, Other Behavior symptoms directed towards others. R40's Departmental Notes, dated 6/8/2021 at 11:57, documents, Resident has entered R51's room on several occasions. Res (resident) has stood over peer in her bed, and gone through peers belonging. Res yells at peers, takes their personal items and then intimidates peers with threats to hit and hurt them. Peers have voiced concern and fearfulness of resident. R40's Departmental Notes, dated 6/8/2021 1:56 AM, documents Resident went into (room) and frightened both roommates with standing order (over) their beds, and going through their personal items. It also documents, Res attempted to go lay down in male peers room, in same bed with res. R40's Resident Incident Report, dated 6/13/2021, documents Res (resident) was arguing with female peer & reached out & started hitting her. While staff were separating res, res grabbed cup of water & threw it on peer. R40's Departmental Notes, dated 6/13/2021 12:52 AM , documents, At beginning of shift, dayroom was busy with a lot of residents were talking back and forth. Res was walking around room and many conversations btwn (between) peers. This stimulus made resident very anxious, res was talking fast and stated that 'I need everyone to stop talking, I can't take all the noise.' Attempted to remove resident from busy day room and escort resident to her own room where it was quiet and calm. Res came back to day room and was redirected back to her room where there was no outside stimulation. R40's Departmental Notes, dated 6/13/2021 2:45 AM, documents Res found in peers room going through peers drawers and closet. Resident was undressed except for sweater. It also documents Resident stated that since the plane crashed tonight, she could not find her clothes. R40's Departmental Notes, dated 6/13/2021 5:34 PM, documents Late entry @ 3:50 p.m. Res was arguing with female peer & reached out & started hitting her. While staff was separating res, res grabbed cup of water & threw it on peer. R40's Departmental Notes, dated 6/14/2021 11:58 PM, documents late entry for 135 pm 6/14/21 MUM (Memory Unit Manager) responded to noise from resident room. It continues to document (R40) took a cloth object and intentionally struck another resident. (R40) removed from the hallway and sent to the ER (emergency room ) for psych eval. On 6/14/2021 at 11:59 AM, R40 was sitting in room, on bed, eating meal with staff in room sitting on opposite bed. On 6/10/2021 at 2:15 PM, V34, Memory Unit Manager (MUM) stated R40 is not appropriate for the memory unit. V34 stated R40 requires more supervision. V34 stated R40 usually sleeps during the day and wakes up later in the day and her behaviors start at that time. V34 stated R40 believes the unit is her home and antagonizes the other residents, yelling at them. V34 stated when R40 had a private room off the unit, she did not have behaviors. V34 stated R40 was better. V34 stated she was not aware of the reason R40 was placed back on the unit. V34 stated there is a lot of stimulation that causes R40's behavior to increase. V34 stated R40 yells and hits other staff and residents on the hall and wanders into others rooms. V34 stated when this occurs, she attempts to redirect resident which at times can be difficult. V34 stated they direct R40 to her room. V34 stated R40 requires more supervision than the unit, and is not appropriate for the memory unit. On 6/14/2021 at 11:30 AM, V2, Director of Nursing (DON), stated R40 was going out to the Hospital. V2 stated last week she became aware of R40's behaviors. V2 stated she had identified the intimidated resident as her (V2's) grandmother. V2 stated once she became aware of R40's behaviors, she attempted to put things in place, but the resident had another altercation. V2 stated at that time, an order was received to send her to the hospital for psych evaluation, and R40 was placed on supervision. When asked if R40's behaviors of intimidation, sexually inappropriateness and resident to resident altercations would have been less or not happened if R40 would have been placed on supervision prior to today, V2 stated, Yes, that is why she is going to the hospital. V2 stated She (R40) is not appropriate for our facility. On 6/14/2021 at 11:50 AM, V26, Assistant Director of Nursing (ADON), stated she is the person that does the investigations with incidents, and had investigated the R40's incidents. V26 stated R40 was out on the regular floor and had a private room. V26 stated during this time, she did have verbal behaviors with staff. V26 stated R40 was moved to the unit and behaviors increased, and was more physical with staff and other residents. V26 stated on the unit, there is an increase in stimulation, and R40 does not do well with that. V26 stated resident does have behaviors of hitting, yelling, intimidating other residents, and a history of wanting to cuddle with male residents. V26 stated R40 is to be redirected to her room. V26 stated the intervention of coming back later is in place, but is at times not possible. V26 stated R40 requires more supervision than the Memory Unit, and is not appropriate for the unit. On 6/15/2021 at 2:30 PM, V34 stated R40 had a resident to resident altercation with R78 on 6/14/2021. V34 stated R78 and R51 were the residents in R51's room on 6/8/2021.

Based on observation, interview, and record review, the facility failed to provide person centered interventions or care to address dementia related behaviors such as wandering and resident to resident altercations for 1 of 1 residents reviewed for dementia care in the sample of 52. This failure resulted in R40 being sent to the hospital for psychiatric treatment with no psychiatric diagnosis. Findings include: R40's Care Plan, dated 7/21, documents Mental Wellness/Mood, I have dementia with behavioral disturbances, anxiety and [CONDITION(S)]. It also documents, I wander into other's rooms and take things out of their rooms. It continues, I am verbally aggressive, I may yell at staff or peers. Please track my behaviors and monitor me for side effects from my medication. R40's Care Plan also documents, Behavior tracking in place, if interventions do not work please notify the nurse. R40's Minimum Data Set (MDS), dated [DATE], documents behavior did not exist for Physical, Verbal, Other Behavior symptoms directed towards others. R40's Departmental Notes, dated 6/8/2021 at 1:56 AM, documents, Resident (resident) went into (room) and frightened both roommates with standing order (over) their beds, and going through their personal items. It also documents, Res attempted to go lay down in male peers room, in same bed with res. R40's Departmental Notes, dated 6/8/2021 11:57, documents, Resident has entered (R51's) room on several occasions. Res has stood over peer in her bed, and gone through peers belonging. Res yells at peers, takes their personal items and then intimidates peers with threats to hit and hurt them. Peers have voiced concern and fearfulness of resident. R40's Departmental Notes, dated 6/13/2021 at 12:52 AM , documents, At beginning of shift, dayroom was busy with a lot of residents were talking back and forth. Res was walking around room and many conversations btwn (between) peers. This stimulus made resident very anxious, res was talking fast and stated that 'I need everyone to stop talking, I can't take all the noise.' Attempted to remove resident from busy day room and escort resident to her own room where it was quiet and calm. Res came back to day room and was redirected back to her room where there was no outside stimulation. R40's Departmental Notes, dated 6/13/2021 at 2:45 AM, documents Res found in peers room going through peers drawers and closet. Resident was undressed except for sweater. It also documents, Resident stated that since the plane crashed tonight, she could not find her clothes. R40's Departmental Notes, dated 6/13/2021 at 5:34 PM, documents, Late entry @ 3:50 p.m. Res was arguing with female peer & reached out & started hitting her. While staff was separating res, res grabbed cup of water & threw it on peer. R40's Resident Incident Report, dated 6/13/2021, documents Res was arguing with female peer & reached out & started hitting her. While staff were separating res, res grabbed cup of water & threw it on peer. R40's Departmental Notes, dated 6/13/2021 11:47 PM, documents, Res has been sexually inappropriate with peer. It also documents, They were first found to be in peers room, both lying on the same bed. It continues to document, Resident did come to day room with staff for monitoring. Later, peer was sitting in chair in dining room and resident sat on his lap and they started to cuddle. On 6/14/2021 at 11:59 AM, R40 was sitting in her room, on the bed, eating a meal, with staff in the room sitting on the opposite bed. R40's Departmental Notes, dated 6/14/2021 11:58 PM, documents, late entry for 135 pm 6/14/21 MUM (Memory Unit Manager) responded to noise from resident room. It continues to document, (R40) took a cloth object and intentionally struck another resident. (R40) removed from the hallway and sent to the ER (emergency room ) for psych eval (psychiatric evaluation). On 6/10/2021 at 2:15 PM, V34, MUM, stated R40 is not appropriate for the memory unit. V34 stated R40 requires more supervision. V34 stated R40 usually sleeps during the day, and wakes up later in the day, and her behaviors start at that time. V34 stated R40 believes the unit is her home, and antagonizes the other residents, yelling at them. V34 stated when R40 had a private room off the unit, she did not have behaviors. V34 stated R40 was better. V34 stated she was not aware of the reason R40 was placed back on the unit. V34 stated there is a lot of stimulation that causes R40's behaviors to increase. V34 stated R40 yells and hits other staff and residents on the hall and wanders in others' rooms. V34 stated when this occurs, she attempts to redirect the resident, which at times can be difficult. V34 stated they direct R40 to her room. V34 stated R40 requires more supervision than the unit, and is not appropriate for the memory unit. On 6/14/2021 at 11:30 AM, V2, Director of Nursing (DON), stated R40 was going out to the hospital. V2 stated last week she became aware of R40's behaviors. V2 stated she had identified the intimidated resident as her (V2's) grandmother. V2 stated once she became aware of R40's behaviors she attempted to put things in place, but the resident had another altercation. V2 stated at that time, an order was received to send her to the hospital for psych evaluation, and R40 was placed on supervision. When asked if R40's behaviors of intimidation, sexually inappropriateness and resident to resident altercations would have been less or not happened if R40 would have been placed on supervision prior to today, V2 stated, Yes, that is why she is going to the hospital. V2 stated, She (R40) is not appropriate for our facility. On 6/14/2021 at 11:50 AM, V26, Assistant Director of Nursing (ADON), stated she is the person that does the investigations with incidents, and had investigated the R40's incidents. V26 stated R40 was out on the regular floor and had a private room. V26 stated during this time, she did have verbal behaviors with staff. V26 stated R40 was moved to the unit and behaviors increased and was more physical with staff and other residents. V26 stated on the unit, there is an increase stimulation, and that R40 does not do well with that. V26 stated resident does have behaviors of hitting, yelling, intimidating other residents, and a history of wanting to cuddle with male residents. V26 stated R40 is to be redirected to her room. V26 stated the intervention of coming back later is in place, but is at times not possible. V26 stated R40 requires more supervision than the Memory Unit, and is not appropriate for the unit. On 6/15/2021 at 2:30 PM, V34 stated R40 had a resident to resident altercation with R78 on 6/14/2021. V34 stated R78 and R51 were the residents in R51's room on 6/8/2021. V34 stated R40 had a sexually inappropriate encounter with R29. On 6/15/2021 at 8:50 AM, Behavioral Health Policy was requested. As of 6/15/2021 at 3:00 PM, the facility had not provided the policy.

Based on observation, interview, and record review the facility failed to assess and provide restorative services to maintain range of motion (ROM) and prevent contractures for 1 of 2 residents (R55) reviewed for restorative services in the sample of 64. This failure resulted in decline of both of R55's upper and lower extremity range of motion and development of upper and lower extremity contractures. Findings include: On 11/18/19 at 11:19 AM, R55 was in dining room. R55's arms were contracted with her left arm at her abdomen and her right arm across her chest. R55's legs were contracted at the knees at approximately a 30-degree angle that remained that way throughout lunch. R55's Minimum Data Set (MDS) of 4/24/18 documents R55 requires extensive assistance of two or more staff persons for Activities of Daily Living (ADL's) and that R55 does not walk in room or corridor during the assessment period. R55's MDS documents she has no range of motion impairments in her upper and lower extremities. On 11/21/19 at 11:19 PM, V3, Assistant Director of Nursing, stated R55's MDS had been coded wrong for range of motion and confirmed R55 had contractures. R55's Care Plan dated 10/10/19 documents R55 is dependent upon staff for ADLs. R55's Care Plan documents her needs will be met through staff interventions through next review 1/2020. There is no documentation in R55's medical record that she has been assessed for restorative services related to her upper and lower extremity contractures. The Facility's Restorative Program Tracker dated (MONTH) 2019 does not document R55 as receiving restorative services. On 11/20/19 at 9:37 AM, V24, Restorative Nurse, stated R55 was discharged from hospice about a month ago. V24 stated hospice residents can receive restorative services. V24 stated R55 had been contracted in her upper and lower extremities since she (V24) began working at the facility in (YEAR). V24 stated the facility has 2 Restorative aides and they are trying to get more help for me. V24 states she and the restorative aides get pulled to the floor a lot. V24 stated residents who have had a stroke ([MEDICAL CONDITION]) or are oxygen do not receive restorative services. V24 stated she thought this was company policy. V24 stated R55 was not receiving any type of restorative services including range of motion. On 11/20/19 at 10:27 AM V25, Certified Nurse Assistant (CNA) stated R55 used to have braces for her contractures but she was not sure what happened to them. V25 states sometimes he does Range of Motion on residents when getting them up, but he doesn't do restorative program exercises and R55 does not get any. On 11/21/19 at 9:27 AM, V2, Director of Nursing (DON), states facility has a restorative nurse (V24) and she goes around and views the whole facility and sees if there is any problems or issues that need to be added or taken off. V2 states V24 talks to staff and brings to morning meetings and works closely with therapy for individualize plans. V2 states Hospice is not picked up by restorative, or anyone on oxygen or that has had a [MEDICAL CONDITION]- they are not restorative services. V2 stated R55 came in about 2 years ago walking independently and that R55 has slowly declined. V2 stated (R55) is on (V24's) radar. On 11/21/19 at 11:20 AM, V3, performed passive ROM to R55. V3 straightened R55's right leg, right arm and fingers using passive range of motion. V3 straightened R55's left leg and attempted to straighten R55's left arm but was unable, as R55 was crying. R55's upper right arm returned to her original positioning across chest and R55's fingers returned to a closed fist position. R55's bilateral lower extremities returned to knees bent in original position. R55 was unable to perform any range of motion independently. R55 yelling out upon V3 performing ROM. V3 stated in her professional opinion that R55 would not benefit from restorative services due to her [DIAGNOSES REDACTED]. The Facility's Nursing Rehabilitation/Restorative Care Policy, dated 10/09, documents Rehabilitation or restorative care refers to nursing intervention that promote the resident's ability to adapt and adjust to living as independently and safely as is possible. Focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A restorative program should be started when a resident is admitted with restorative needs, but not a candidate for therapy, or when the need arises during the course of a stay.

Based on interview, observation, and record review the facility failed to provide safe transfer techniques to prevent accidents for 2 of 6 residents (R6, R199) reviewed for transfers in the sample of 64. This failure resulted in R199 falling during a transfer and sustaining a left thigh bone fracture requiring surgical intervention. Findings include: 1.R199's physician's orders [REDACTED]. R199's Minimum Data Set ((MDS) dated [DATE] documents R199 is cognitively intact with a Brief Interview Mental Status (BIMS) of 15. R199's MDS documents that R199 requires extensive assistance and one-person physical assistance for transfers, and toileting. R199's MDS documented she was not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers. R199's Care Plan dated 8/19/19 documents that R119 is at risk for falls related to her [DIAGNOSES REDACTED]. R199's Care Plan documents that R199 requires extensive assistance with Activities of Daily Living (ADL), and transfers to wheelchair with one assist. R199's Late Entry Departmental Note dated 11/11/19 at 10:50 AM documents that V12, Certified Nurse's Aide, called V3, Assistant Director of Nurse's to R199's room due to R199 fell in the bathroom. The notes document that R199's left leg was bent up behind the right leg and R199 did complain of pain. R199's notes document that R199 was transferred to the hospital by ambulance. The Note documented at 3:00 PM the hospital staff contacted the facility and stated R199 was admitted to the hospital with [REDACTED]. The hospital x-ray report dated 11/11/19 at 1:09 PM documents an acute comminuted displaced spiral [MEDICAL CONDITION] femur (thigh bone). R199's Departmental Note, dated 11/14/19 documented R199 had surgery on 11/13/19 for her fractured left thigh bone. The Facility's Investigation Report dated 11/14/19 documented On 11/11/19 (R199) called for assistance to the bathroom in her room. CNA on duty, (V12) pushed resident's wheelchair to bathroom doorway. Resident locked her wheelchair brakes and stood holding the assist bar. Resident lost her balance and fell on to the floor. CNA did not have gait belt in place on resident. The Report documented that V12 and nursing staff were educated on proper use of gait belts after this incident. On 11/19/19 at 7:30 AM V2, Director of Nursing (DON) stated that R199 was being assisted in the bathroom by CN[NAME] V2 stated that R199 has a built-up shoe due to a previous hip replacement. V2 stated the CNA did not use a gait belt to assist R199 with the transfer and R199 fell . V2 stated staff had to be re-trained on the use of gait belt. On 11/21/19 at 8:00AM, V12 stated that on 11/11/19, R199 was in her room in her wheelchair and turned on her call light and was taken to the bathroom. V12 stated that R199 did have a built-up shoe on one foot due to a previous hip surgery. V12 stated that V12 was an assist of one. V12 stated that R199 had both hands on the bar and started wobbling and fell . V12 stated that R199 was not moved and emergency staff called. V12 stated it is standard practice for staff to utilize a gait belt for transfers at this facility. V12 stated that she did not use a gait belt when transferring R199 to the toilet. On 11/21/19 at 9:00 AM, V13, R199's Physician/Medical Director, stated a gait belt should be used for transfers as it gives staff another way of holding on to the resident to assist with the prevention of fractures. V12 stated he was not aware that staff did not use a gait belt for transferring R199 on the day she fell and fractured her femur. The Facility Policy Transfer/Gait Belts, review date of 1/2015, documents the resident is transferred by grasping the secured gait belt to provide stability and balance during movement. 2. R6's Care Plan, dated 5/31/2016, documents, Resident is at risk for falls related to [DIAGNOSES REDACTED]. Resident is an assist of two for transfers. Place resident in bed or recliner after meals. R6's MDS, dated [DATE], documents R6 requires extensive physical assist of 2 staff for transfers. R6's Morse Fall Scale, dated 11/19/2019, documents (R6) has a history of falls, impaired gait and is high risk for falls. On 11/18/19 at 9:30 AM, V7 and V8, CNAs, transferred R6 to the bed from a reclining wheelchair using a full body mechanical lift. V7 and V8 applied the sling traps to the full body mechanical lift. V8 was operating the controls and started lifting R6 into the air. Once R6 was in the air V7 walked around to the opposite side of the bed and maneuvered the reclining wheelchair leaving R6 unattended and free swinging from the bed to the wheelchair. On 11/25/19 at 9:45 AM V7 stated, When transferring a resident. I put a gait belt on the resident. I always use a gait belt. You have to use a gait belt, or your back will be messed up like mine. When transferring a resident in the lift you have 2 staff. 1 person has the machine and the other person has the sling until the transfer is complete for safety and stability. On 11/25/2019 at 9:50 AM V12, CNA, stated We use 2 people for the lift transfers. 1 person controls the lift and the other controls the sling. (Full Body) Total Lift Policy, dated 8/2016, documents #11 Maintain contact with the resident in order to guide or steady the resident during lift, as necessary. #12 Maintain contact with the resident to steady and/or guide, as necessary.

Based on observations, record review and interview the facility failed to ensure adequate supervision to prevent multiple falls for 1 of 7 residents (R16) reviewed for falls in a sample of 62. This failure resulted in R16 fracturing her femur and continuing to have falls after the fracture. Finding includes: Throughout the survey from 10/16 through 10/24/18, R16 was observed propelling herself in her wheelchair. R16 was deaf and communicated to staff by using gestures or writing. R16's Minimum Data Set ((MDS) dated [DATE], documents that R16 needs extensive assistance from two plus person physical assist with transfers, walk in room, walk in corridor, locomotion on unit, and locomotion off unit. The MDS documents R16 needs extensive assistance from one person physical assist for bed mobility and toilet use. The MDS documented R16 had a Brief Interview of Mental Status score of 0, indicating severe cognitive impairment. R16's Instant Care Plan upon admission, dated 10/12/17, documents that R16 had an actual fall and required fall precautions of bed/chair alarm, low bed, and Therapy. R16's Care Plan dated 10/18/17 documents under problem that resident is at risk for falls due to immobility and noncompliance with transfers. Under goals: Resident will have no injury from falls thru next review 10/2018. The Resident Incident Report documents on 3/27/18 at 2:31 AM, R16 was found on the floor. The Report documented R16 yelled and a staff member found her on the floor. The Incident Report documented she was sitting with legs straight out in front of her at foot of bed with noticeable shortening of left leg. The report documented she was sent to emergency room complaining of left leg pain. The report documented that R16 had inability to understand others and was deaf. The Post Incident Action form, dated 3/27/18, documented Pee noted on floor where resident was sitting. Resident slipped in wet area and fell . The facility provided four Falls Witness' statements, all dated 3/27/18, documented that R16 was attempting to go to the bathroom when she fell . These statements all documented there were no safety devices intact or alarming at the time of the incident. R16's Care Plan was revised on 3/27/18 with interventions to offer toilet with bed checks, monitor for signs and symptoms of pain. The Final Investigation Letter dated 3/31/18 documented R16 was alert with confusion and required assist of one for ambulation. The Letter documented she was found on the floor and was sent to the hospital and diagnosed with [REDACTED]. R16's Resident Incident Report, dated 4/24/18 at 7:01 AM documented she was propelling herself in her wheelchair and fell out forward onto her knees. The Post Incident Actions report documented monitor positioning of resident in wheelchair and reposition as needed, remind resident to slow down in wheelchair and not to lean so far forward, therapy to screen. R16's Fall Risk evaluation dated 4/24/18 documents R16 scored an 80 indicating a High Risk for falls. According to the Fall Risk evaluation, scoring 46 and above is High Risk and to implement high risk fall prevention using the Falling Leaf Program. The Resident Incident Report documents on 5/11/18 R16 was found sitting on the floor in her room. The Report documented R16 said she was pushing the w/c and walking behind it when the w/c got away from her and she landed on her buttocks. The Report documented R16 complained of left hip pain with rotation of the left foot. The Report documented she was sent to the ER. Post-Incident Actions, dated 5/11/18 documented Rearranged room, personal bed alarm to wheelchair and bed. The Fall Witness Statement report, dated 5/11/18 documented R16 stated she was pushing her wheelchair and was walking behind it. The Statement documented Take the w/c out of Resident room. Remind resident to ask for help. Resident is care planned for noncompliance of w/c. The Statement documents R16 had just eaten lunch, she has unsteady gait and she was pushing her w/c. Post Investigation Letter for the incident of 5/11/18, documents R16 fell and sustained a fractured femur. The Letter documented R16 was getting up without assistance to the bathroom and fell . This Letter documented the following interventions were put into place: monitor pain and administer medications as ordered; non-pharmacological interventions performed such as ice; notify physician of any changes; follow up with orthopedic as ordered; abductor pillow as ordered; rearranged R16's bed and wheelchair; and non weight bearing as ordered. The Care Plan was revised on 5/11/18 and documented to rearrange her room, abductor pillow as ordered, non weight bearing as ordered and personal alarm to wheelchair and bed. There was no documenation the facility reassess to determine the root cause analysis of R16's falls and her need for increased supervison. The Resident Incident Report documents on 5/28/18 at 8:20 AM, in her room, R16 was found sitting on the foot pedals of her wheelchair by bathroom door. The Post-Incident Actions, dated 5/28/18 documented resident assisted to bed and bed pan offered hourly, monitor for signs and symptoms of pain, continued therapy, PBA (Personal Body Alarm) sounding, resident continues to be non compliant with transfers and toileting. The facility had no further assessment to address R16's non compliance and need for further supervision. The Fall Witness Statement report, dated 6/2/18, documents R16 was trying to take self to the bathroom. The Statement documented that no safety device was intact and alarming at the time of the fall. Another Witness Statement documented that R16 was last seen sitting in her wheelchair by her bed. The Resident Incident Report documents on 6/2/18, at 7:20 PM, R16 was found in her room on the floor. The Report documented she was attempting to transfer herself from her wheelchair to bed and slipped from wheelchair to the floor. The Post Incident Actions, dated 6/2/18 documented to offer resident to lay down at 7:00 pm if she desires, resident continues to be non compliant with transferring herself, continue therapy and PBA sounding. The facility had no documentation they reassessed R16 for her need for more supervision. The Resident Incident Report documents on 6/4/18 at 8:53 AM, R16 was found in her bathroom. The Report documents she was attempting to go to the bathroom on her own and slid down onto her wheelchair legs. The Post -Incident Actions, dated 6/4/18 documented Resident continues to be non compliant with call light and transferring herself, applied dycem to wheelchair, continue therapy, monitor for signs and symptoms of pain, PBA sounding. R16's care plan was updated with dycem in wheelchair cushion. The facility had no documentation they reassessed R16's non compliance and need for more supervision. The Resident Incident Report documents on 6/22/18 at 10:15 AM, R16 was again found in her bathroom alone. The report documented R16 was found sitting on the floor in front of the toilet leaning to R (Right) side. The Report documented she had toileted herself after removing her personal body alarm. The Report documented her hand slid off bar and she slid to floor. The Post-Incident Actions, dated 6/22/18 documented a transfer screen had been completed and R16 was changed to transfer of two assist to toilet instead of bed pan. The Resident Incident Report documents on 6/25/18 at 6:21 PM, another resident was trying to assist the resident to bed and R16 is non compliant with listening to staff for safety. The Report documents R16 was found on the floor in her room by her bed. The Post-Incident Actions, dated 6/25/18 documents R16's alarm was sounding, continue with therapy, toileting program still in place and she continues to be non-compliant. R16's Care Plan was reviewed on 6/25/18 with interventions monitor signs and symptoms of pain, continue therapy. The facility had no further reassessment to address R16's non compliance and need for more supervision. The Fall Witness Statement, dated 6/25/18 documents R16 last seen during supper. The Statement documented to prevent future falls more people to help during supper so we can monitor the halls with 2 aides instead of one. The Resident Incident Report dated 7/10/18 at 9:16 AM documents R16 was taking self to bathroom and upon going back to her chair she lost her balance and sat on the floor. The Post-Incident Actions, dated 7/10/18 documents Pressure alarm that cannot be shut off by resident, non-slip socks, social services to do 1:1 activities. The Resident Incident Report documents on 9/7/18 at 4:30 PM in her room R16 was found sitting on her buttocks leaning on the nightstand to her back. The Report documented that resident was trying to get in the bed and her chair slid backwards because her wheels were not locked. The Post-Incident Actions dated 9/7/18 documents the resident continues to be non compliant and anti-tipping device added to w/c wheel. The Resident Incident Report documents on 10/01/18 at 11:15 PM in her room, Resident alarm was sounding and she was found in her room on her rt (right) knee, she slid herself out of her chair. The Report documented she sustained a small abrasion to her right knee. The Post-Incident Actions, dated 10/1/18 documented R16's personal alarm is already in place, medication review, and continues to be non compliant, schedule routine pain medication per physician orders. The facility had no reassessment or care plan to address R16's need for more supervision. The Resident Incident Report documents on 10/16/18 at 4:56 PM in her room R16 was found sitting on her buttocks in front of wheelchair. The Post-Incident Actions dated 10/16/18 documented gripper socks were placed on residents and the alarms were checked to make sure they were working properly. R16's Care Plan, dated 10/17/18 was revised and stated to take resident to dining room at 4:30 PM and feed her and then take her back to room and lie her down. There was no documentation of the facility reassessing R16 for non compliance of self transferring and need for increased supervision. The Resident Incident Report documents on 10/19/18 at 6:31 PM R16 in her room. The Report documented R16 fell while going from her w/c to her bed. The Care Plan was revised on 10/19/18 and documents dycem to mattress. There was no documentation the facility conducted an assessment to determine the root cause analysis of R16's falls and reassess her need for more supervision. On 10/24/18 at 09:57 AM V2 (Director of Nurses/DON) stated that she hasn't been trained on the Falling Leaf Program. On 10/24/18 10:07 AM V14 (Certified Nursing Assistant/CNA) stated that she was not sure what the Falling Leaf program was about. On 10/24/18 10:07 AM V16 (CNA) stated that the Falling Leaf program was to indicate a person was a fall risk and that the person would have a leaf by their name tag on the wall next to their room to notify staff of it. V16 also stated that they haven't been doing that. V16 stated, We have the daily care guide which has the fall risks on it. On 10/24/18 at 10:45 AM V1 (Administrator) stated that they do not have a Falling Leaf Program. V1 stated, We just use the Morse Fall Scale as an assessment guide. The nurses and CNA's have a pocket guide they use on the unit. I have done all I can do for (R16). I can't put her on 1:1; she will have a fit. I guess I will have to discharge her. Then who will take her? Nobody! Nobody is going to take her! The facility policy on Accident and Incident, Documentation and Investigation, Resident Incident revised 7/2018 documents under Policy: Accident and/or incidents involving resident care will be investigated and documented on the Resident Incident Report entry form in the LTC system. An 'incident' is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accident and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measure to reduce the occurrence of incidents.

Based on interview, observation and record review, the facility failed to develop/implement effective care plans to prevent falls, failed to ensure safety devices were in place, failed to provide adequate supervision and safe transfers were used for 3 of 6 residents (R7, R8, R9) reviewed for falls in a sample of 10. These failures resulted in R9 having multiple falls with a laceration requiring staples in his head sustained in a fall on 7/16/18 and in R7 falling on 7/19/18 resulting in a fractured right hip requiring surgery/closed reduction. Findings include: 1. A. R9's Profile in the Electronic Health Record (EHR) documents R9 is a [AGE] year old male admitted to the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] documents R9 to have short/long term memory with cognitive deficits. The MDS also documents R9 to require extensive assist of one staff for bed mobility, transfers, walking in/out of room, and on/off unit. The MDS documents R9's balance during transitions and walking to be not steady, only able to stabilize with staff assistance. The MDS identifies no mobility devices used for R9 at the time of admission. R9's room on admission is listed on the secured dementia unit. A Fall Risk assessment dated [DATE] identifies R9 to be high risk for falls. The care plan dated 5/18/18 identifies R9 is at risk for falls related to [DIAGNOSES REDACTED]. Resident is incontinent of bladder at times. Resident ambulates independently throughout unit and will attempt to walk quickly or run to the door to get out of unit. The goal is R9 will not have any falls through next review 9/2/18. Interventions include therapy as needed, monitor for unsteady gait, notify physician if resident has unsteady gait, resident to have proper foot wear, environment free of clutter, redirect resident as needed and explain to resident he needs to slow down when walking fast/running by redirection. The falls prevention plan fails to address needed assistance as indicated in the MDS and supervision when getting up unattended due to his instability. An Incident Report documents R9's first fall following admission occurred on 7/5/18 at 9:30am and documents activities director heard res (resident) hollering for help. Res was found lying on floor between bed and w/c (wheelchair) in room [ROOM NUMBER]. When writer entered room, res was in sitting position attempting to get up. Writer trying to assist res & res stated 'I got it' and got himself off the floor. Res was wearing grippy socks. Floor was dry. The immediate action following the fall was to monitor wandering behavior, redirect to common area as appropriate, and offer snacks and activities when res is up wandering. There is no evidence the facility identified the root cause of R9's fall in the report. The care plan's added intervention following his fall on 7/5/18 was to monitor for signs/symptoms of pain, check for proper foot wear even though the report documents he had grippy socks on at the time of the fall. On 8/9/19 at 2:00pm, V2 (Director of Nursing) when asked if they determined the cause of the fall, stated she wasn't sure and when asked about added proper footwear on the care plan when it was already on it and R9 had grippy socks on when he fell , stated they would consider grippy socks appropriate footwear if the grippy part was face down. V2 did not identify R9 getting up unassisted to be a causative factor. Progress Notes in the EHR dated 7/6/18 at 2:19pm document res has been exit door seeking most of the day. Progress notes in the EHR dated 7/6/18 at 3:19pm document R9 was up independently throughout the unit this evening. Progress notes dated 7/9/18 at 10:15pm document physician stated he would like to dc (discontinue) [MEDICATION NAME] and begin [MEDICATION NAME] as long as family was ok with decision . On 7/12/18, the progress notes in the EHR at 7:52am document Resident was up multiple times during the night wandering in hallways and went into peer resident room several times. Staff tried to redirect and res became agitated and yelling/threatened to punch female CNA . was up hitting on door and wall trying to exit, trying to get behind nurses desk and take chair using inappropriate language and threatening to hit female CNA.s Staff would offer food, toilet, resting, TV (television), calling wife, became more agitated with suggestions so staff left him along to decrease agitation. On 7/13/18 at 7:44pm, the progress notes in the EHR document was reported res was disoriented at times with increase confusion with a request to decrease [MEDICATION NAME]. There were no revisions to R9's Fall Prevention plan in regards to the addition of [MEDICATION NAME] and the possible side effects increasing his fall risk factor. On 7/16/18 at 1:20pm, V24 Licensed Practical Nurse (LPN) documented R9 came down the hall with blood on the back of his head. It was noted pt (patient) apparently got up and fell backwards hitting head on the footboard of the bed next to him. Pt had an appox (approximately) 1 - 1 1/2 in laceration on the posterior head. The note continues to document the physician was notified and R9 was sent to the hospital. V24 documented that R9 returned to the facility on [DATE] at 9:27pm with 7 staples in his head. A Witness statement dated 7/16/18 documents R9 was last seen in bed prior to the fall. The Incident report documents the same information on this fall on 7/16/18 but fails to document the root cause of the fall. The immediate post incident action was added alarm while in bed, keep res in common areas as tolerated, check room arrangement. The care plan interventions dated 7/16/18 reflects the same as the incident report but again fails to identify needed assistance with ambulation and/or increased supervision. The next entry into the progress notes is on 7/17/18 at 6:44pm by V24 LPN who wrote at approximately 1:30pm, pt was found lying on his floor by his bed. Pt was trying to get up. Pt was assessed, no injuries were noted. Pt immediately got up off the floor and began walking down hallway. The Incident Report dated 7/17/18 fails to reflect a root cause analysis but documents the immediate post incident action as pt will have a bed alarm place on his bed. More freq (frequent) checks will be done of pt. On 8/9/18 at 2:40pm, V24 stated R9 was up walking in the hallways right before he fell , not in bed. There was no explanation as to why they added a bed alarm as an effective intervention if R9 was not in bed. There was also no witness statement in the report to determine where R9 was immediately prior to the fall and where staff was and no reference to added supervision and/or assistance. Progress Notes dated 7/19/18 at 9:45pm entered by V27 LPN documents R9's gait unsteady at times, wandering aimlessly late this evening despite constant staff redirection. On 7/20/18 at 3:24pm, V24 document in the progress notes in EHR resident lays in bed for short period and then removes alarms and gets out of bed. On 7/24/18 at 7:54pm, V27 entered into the progress notes in the EHR res started on [MEDICATION NAME] due to increased agitation and combative behaviors. Since then res has had increased confusion and is off balance when he is walking. The physician was asked to decrease the [MEDICATION NAME] to 25mg from 50mg at hs if no improvement in res balance and confusion, nursing will ask MD to do GDR (gradual dose reduction) of [MEDICATION NAME] to 12.5mg. Team will review again in 1 week. On 7/25/18 at 7:54pm, V27 documented in the EHR progress notes res is sleepy throughout day & is unsteady at times when walking. V27 documented a message was sent to the MD, V25. On 7/26/18 at 10:56pm, the EHR progress notes entered by V24 document pt was walking down the hall, lost balance and fell backwards. Pt was assessed by nurse, pt then stood up could not hold balance and began to collapse x 3 with pupils fixed. Pt blood pressure was low and could not be confirmed, unable to hear, pulse rate 25-52 and SPO2 (oxygen) was 88 to 91, Dr V25 called, pt sent to ER via ambulance. The Incident Report dated 7/26/18 fails to identify the root cause of the fall. Immediate actions documented as taken was pt will be assist of one, cont with GDR of [MEDICATION NAME]. The current care plan fails to include this fall and the added assistance needed. Social Service note dated 7/26/18 at 6:36am entered by V28, Social Service Designee (SSD), documents Resident is taking [MEDICATION NAME] 50mg (milligrams) at HS (bedtime) and [MEDICATION NAME] 125mg 4 caps twice daily, and [MEDICATION NAME] 12.5mg daily and [MEDICATION NAME] 50 at HS was added on 7/8/18 but noticed that resident was off balance so on 7/14/18 [MEDICATION NAME] was (reduced) to 25mg at HS. Resident still has no improvement so asking that resident have gdr of 12.5 and team will review in one week. The Falls prevention plan in the care plan fails to list the addition of [MEDICATION NAME] as a concern for increase fall risk. There is no new fall risk assessment completed. On 8/9/18 at 2:30pm, V2 Director of Nurses (DON) stated R9 wanders constantly. V2 was asked why added supervision and/or assistance were not added sooner; V2 stated R9 was independent in ambulation but has since required more help. V2 was asked where R9's room was and stated it was at the end of the hallway. When asked why they would not have considered moving him closer to the nurses station instead of being the room the furthest away, V2 stated they didn't consider it but couldn't state why. On 8/9/18 at 11:35am, the facility's policy/procedure for Falls Prevention was requested and V1, Administrator provided a policy entitled Transfer Screen dated 8/11 which documents the policy as such: To determine a safe and appropriate method of transferring a resident, nursing staff will perform a transfer screen on each resident. Complete upon admission, readmission and/or quarterly. The policy does not include any procedure to determine falls risk and putting an effective plan in place to address risk and prevention of falls. B) On 8/8/18 at 7:50 AM R9 was sitting in a chair in the dining room. R9 did not have a personal body alarm present. R9's Care Plan dated 5/18/18 documents R9 is at risk for falls related to [DIAGNOSES REDACTED]. Personal Body Alarm at all times. On 8/9/18 at 11:36 AM V2 DON stated she would expect R9 to have a personal body alarm on at all times as identified as an intervention. 2. R7's MDS dated [DATE] documents R7 requires extensive assistance and one person physical assistance for bed mobility, transfers and ambulation. R7's MDS dated [DATE] documents that R7 requires extensive assistance and two plus physical assistance for bed mobility and transfer. R7 has a [DIAGNOSES REDACTED]. R7's Fall scale dated 7/19/18 documents a score of 95, with a score of 46 or above as high risk R7's Care Plan dated 11/25/15, documents R7 is at risk for fall related to [MEDICAL CONDITION] and history of falls. R7's Care Plan documents on 10/18/17, R7 was found on the floor with interventions listed: frequent visual checks and touch sensitive alarm in bed. R7's Care plan documents on 7/19/18 R7 slipped in puddle of fluid on bathroom floor and that R7 continues to be noncompliant with transfers. R7's careplan documents an intervention dated 8/1/18 Weight Bearing as tolerated to Right Lower extremity and transfer to wheelchair with two assist. R7's x-ray report dated 7/19/18 documents a severely comminuted displaced fracture proximal right femur involving the intertrochanterric region. R7's hospital consultation note dated 7/19/18 that documents R7 had a closed reduction of right hip and intramedullar nailing. On 8/9/18 at 2:15pm V2 DON stated that it was determined that R7 was trying to use the bathroom as the causative factor. V2, DON stated R7 had dismantled the touch sensitive alarm. On 8/9/18 at 3:15 PM V26 CNA stated that she was on duty when R7 fell on [DATE]. V26 stated that the alarm was not sounding as R7 had dismantled the alarm. V2 (Administrator) present at this time and stated that R7 dismantles the alarm all the time. On 8/9/18 at 3:10 PM V25, R7's physician, stated that he had not been made aware that R7 dismantled his alarm. V25 stated that if an intervention for falls is ineffective, something else should be implemented. When asked if R7's fall resulting in a fracture could have been prevented because of ineffective interventions, V25 stated possibly. The current care plan fails to identify that R7 dismantles his alarm and no interventions are present to address this safety concern or that R7 gets up unassisted. On 8/8/18 at 1:29 PM at 1:29 PM R7 was sitting in wheelchair and V20, V21 and V22 CNAs, and V23 LPN were in R7's room. R7 stated he needed to go to the bathroom prior to laying down. V20 and V22 transferred R7 from the wheelchair to the toilet with the use of a gait belt. During the transfer R7 did not assist with the transfer by bearing any weight. After toileting, V20 and V22 transferred R7 from the toilet back to the wheelchair with the use of a gait belt but no support to his lower extremities. R7 did not bear any type of weight and was holding on to the grab bar in the bathroom. V21 CNA slid the wheelchair under R7, as V20 and V22 were unable to complete the transfer. After R7 was seated in his wheelchair R7 was then pushed to the side of the bed facing the window. R7 was then transferred from his wheelchair to the bed using a gait belt by V20 and V22. At no time during the transfer did R7 bear any type of weight nor did staff encourage/direct him to put his feet on the floor and assist by standing up. On 8/9/18 V1 Administrator stated a thorough investigation is done on all falls including witness statements if there are any witnesses. On 8/8/18 at 4:15 PM V2, DON stated that staff are aware that if during a transfer if a resident needs additional assistance, they can provide that to ensure safety. 3. On 8/8/18 at 4:32 PM, R8 was physically picked up out of her bed by V12 Certifed Assistant (CNA) without the use of agait belt and sat in her wheelchair. There was no gait belt in R8's room as verified by V2, Director of Nursing (DON). R8's Care Plan dated 12/27/12 documents R8 is at risk for falls and requires extensive assist of two with a gait belt for all transfers. R8's Care Plan documents intervention of two person assist with gait belt for transfers. R8's Minimum Data Set ((MDS) dated [DATE] documents R8 requires extensive assistance and two plus person physical assistance for transfers and bed mobility. On 8/8/18 4:34 PM V2, (DON) stated that she would expect staff to use a gait belt for transfers. The Facility Policy Transfer Belts/ Gait Belts, dated 4/14, documents a gait belt is used if indicated on the Care Plan.

Based on interview, observation and record review the facility failed to identify and assess a pressure wound and failed to follow physician orders [REDACTED]. This failure resulted in R10 developing a facility acquired unstageable pressure ulcer. Findings include: R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10's Skin and Wound Evaluation Form dated 09/08/17 documents in part, R10 has a left venous ulcer left inner ankle 0.6 X 0.8 X 0.1. Left outer foot peri wound 1.0 X 0.7 X 0.1, red and intact. Sacrum stage II peri wound 2.1 X 1.4 X 0.1, red blanchable. R10's wound clinic notes on 09/20/17 document, Findings: Right Ischium 2.0 X 2.8 X 0.1, Stage II pressure injury. Left dorsal lateral foot: 3.5 X 1.5 X 0.2, 100% slough, Arterial. Left medial ankle: 0.5 X 1.0 X 0.1, 100% slough, Arterial. Left heel: 1.0 X 0.8 X 0.1, 100% necrotic Pressure Injury, Unstageable. Recommendations: Right Ischium, cleanse with normal saline, foam dressing. Change every 3 days and prn (as needed). Left dorsal foot and ankle: Triple antibiotic ointment after cleansing with normal saline, cover with dry gauze daily. Place Off Loading Boot on at all times except with shower. Left heel: Cleanse with normal saline, foam cup, change when soiled. Off Loading Boot LLE (left lower extremity). Change position hourly while in chair and lay down daily. On 09/26/17 at 8:40 AM, E11 Licensed Practical Nurse (LPN) Wound Nurse, removed a dressing that was partially off of R10's left heel, cleansed R10's left heel with wound cleanser and applied a foam boarder dressing, put the foam cup on and placed the foot back in the Off Loading Boot. On 09/26/17 at 12:40 PM, E11 stated, I don't agree with the wound clinics orders; I put the foam dressing on the wound because it is an open wound and needs to be covered with a dressing. R10'sTreatment Administration Record (TAR) dated 09/20/17 to 09/30/17 documents E11 cleansed R10's left heel with normal saline and applied foam cup and placed in Off Loading Boot. No documentation was made that E11 put the foam dressing on. R10's weekly wound report does not address R10's wound to his left heel. The only documentation of R10's wound on his left heel is on the Skin and Bath report dated 09/13/17 with left heel measurements of 1.7 X 0.5, no assessment of the wound, no signature as to who did the measurements. No further wound measurements or assessments were made of the wound on R10's heel since 09/13/17. On 09/27/17 at 9:24 AM, Z1 Wound Clinic RN (Registered Nurse) Certified Wound Nurse, stated, I was not aware the facility was putting the foam boarder dressing on his left heel; that is not what was ordered. A foam boarder dressing can provide a moist environment; it could have provided more moisture which could prevent healing. On 09/28/17 at 10:55 AM, E2 Director of Nurses (DON) stated, E11 should have called the doctor to clarify the orders if she did not agree with them. The facility Policy and Procedure for Pressure Ulcers last revised 2/17, documents, POLICY: It is the practice of this facility to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection and prevent new ulcers from developing. PR(NAME)EDURE: 1.) Upon identification of a pressure ulcer (arterial, venous or neuropathic), regardless if developed in-house or upon admission, the area is to be documented on the Wound Evaluation form or in electronic format. 4.) Initiate appropriate treatment per treatment protocol and physician order. 6.) Documentation of wound status will occur at least once a week. This weekly evaluation will be documented electronically or on the Wound Evaluation Form/Skin Condition Form as appropriate. 7.) The physician is to be notified if there is no improvement in area, signs and symptoms of infection or signs of deterioration. 10.) The Director of Nursing Services and/or designated Licensed Nurses will make pressure ulcer rounds on a weekly basis. Documentation of the area will be addressed. Resident progress or lack of progress will be evaluated. Directives may be given for further interventions and changes in plan of care. The residents current care plan will also be reviewed.

Based on observation, interview and record review, the facility failed to document timely investigations after a resident fall and failed to implement fall interventions in a timely manner to prevent future falls for one of three residents (R2) reviewed for falls in the sample of seven. These failures resulted in R2 sustaining a right wrist fracture. Findings include: An Interdisciplinary Fall Reduction/Injury Prevention Protocol dated 7/2012, documents each fall is to be investigated as soon as possible post fall, by all staff members working on that unit .the Director of Nursing Services (DNS) and the Interdisciplinary team (IDT) to discuss each fall in the daily meeting .notify the team of the fall and new intervention implemented in the morning meeting. A summary of each fall should be written in the IDT notes by the DNS/designee during the safety meeting, which is to include a description of the fall, causative factors and interventions implemented. R2's Care Plan dated 2/5/16, documents R2 is at risk for falls due to a history of falls and a [DIAGNOSES REDACTED]. R2's Minimum Data Set assessment dated [DATE], documents R2 has moderately impaired cognitive skills and requires extensive assistance of one staff member for transfers and ambulation. A Resident Incident Report dated 4/7/16 at 12:45 p.m., documents R2 was found sitting on the floor next to wheelchair. An IDT Note dated 4/13/16 (6 days after R2's fall), documents interventions which include, non slip strips in front of bed. A Resident Incident Report dated 6/12/16 at 11:50 p.m., documents R2 was found on the floor at foot of bed. R2 complained of right hand pain. An x-ray report dated 6/13/16, documents R2 sustained a right distal radius fracture. At approximately 10:30 AM on 6/30/16, no non slip strips were present by R2's bed. On 6/30/16 at 12:45 p.m., E10 (Certified Nurse Aide) verified R2's room did not have any non slip strips on any side of R2's bed. On 7/5/16 at 11:36 a.m., E3 (Director of Nursing Services) verified R2's room did not have non slip strips in place on 6/30/16. A Resident Incident Report dated 3/23/16 at 7:30 p.m., documents R2 was found on the floor next to the bed. A Post-Incident Actions report dated 3/23/16, documents Immediate Post-Incident Action was Gripper socks placed on feet. Therapy to screen. A weekly fall safety meeting dated 4/8/16 (16 days after R2's fall), documents resident was trying to take pants off, went to sit on the bed, missed the bed and fell . A Resident Incident Report dated 4/22/16 at 6:30 a.m., documents R2 was found on the floor between the bed and doorway. R2 received a 9 centimeter skin tear to the left elbow. A Post Incident Actions form dated 4/22/16, documents therapy to screen R2. A Therapy Screening form dated 4/22/16, documents R2 fell out of bed and a therapy evaluation is recommended. A Physical Therapy Plan of Care dated 5/16/16 (24 days after therapy evaluation was recommended), documents R2 was started on Physical Therapy Services. On 7/5/16 at 12:10 p.m., E3 (DNS) stated R2's physician was on vacation and the facility was waiting on the order to evaluate R2 for therapy. E3 stated R2's physician does have a Physician's Assistant in the office and E3 does not know why an order was not received or why the facility did not pursue an order. A Physical Therapy Plan of Care dated 5/16/16, documents R2 requires moderate assistance with transfers and moderate assistance in gait with wheeled walker due to an exacerbation of Dementia. A Resident Incident Report dated 5/18/16 at 6:15 p.m., documents R2 got out of bed and walked to doorway and R2 stated she slipped. An IDT note dated 6/1/16 (fourteen days after R2's fall), documents R2 was changed to stand by assist. On 7/5/16 at 11:36 a.m., E3 (DNS) verified R2's IDT note dated 6/1/16 documents R2 was changed to stand by assist even though R2's therapy notes document R2 required moderate assist with transfers and ambulation. E3 also verified E3 has a hard time getting safety meetings done in a timely manner and changes need to be made to the fall investigation process.

Based on interview and record review, the Facility failed to follow their policy and failed to implement fall interventions consistent with the residents Plan of Care to prevent injury during a transfer for 1 of 3 residents (R1) reviewed for transfers in the sample of 6. This failure resulted in R1 falling during a transfer, resulting in a left proximal tibia fracture and left proximal fibula fracture. Findings include: R1's Physician admission orders [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 with 15 being the highest cognition level. R1 requires extensive assistance of 2 people for transfer on and off the toilet and that R1 is not steady, she is only able to stabilize with staff. On 2/20/14 at 10:30 AM, R1 was interviewed regarding the fall that took place on 2/13/14. R1 stated, "the Certified Nurses Aide (CNA) helped me onto the toilet when she tried to help me up from the toilet we both fell on the floor." R1 stated that help came quickly to get her off of the floor, her left leg was hurting and swelling, she was sent to the local emergency room for treatment, and now her left leg is broke in 2 places. R1 stated that she is unsure of which CNA it was but, she does know the CNA did not use the gait belt for the transfer, and that her left leg immobilizer was not on. R1 stated that she has always had 2 staff members transfer her with the gait belt and her left leg immobilizer on except for this time. On 2/20/14 at 10:35 AM, E4, CNA, stated, at the time of the fall R1 was touch toe weight bearing on the left leg, R1 required 2 people with a gait belt for transfers, and her left leg brace on. On 2/20/14 at 1:20 PM, E6 Physical Therapy Director stated, R1 had received a new order from the Physician on 2/7/14 to wean R1 off of the brace over 2 weeks with weight bearing as tolerated with walker. E6 stated Physical Therapy was in charge of the weaning process, the nursing staff was educated on R1's continued need for her leg brace when R1 was out of bed, and that R1 may have brace off in bed only. On 2/20/14 at 1:50 PM, E2 Director of Nurses (DON) stated, I was not here at the time of the fall but from what I understand the CNA got R1 up by herself with no gait belt or left leg brace on. R1's Nurses Note dated 2/13/2014 at 10:44 PM documents, Resident was transferring from toilet to chair and left leg buckled and resident fell to floor. Complaint of pain to left knee and left ankle. No other areas noted. Resident did not hit head. Full range of motion to arms and right leg. The Physician was notified and new order received to send to emergency room for evaluation and treatment Director of Nurses notified and Power of Attorney. R1's Nurses Note dated 2/14/13 at 3:11 AM documents, "Resident arrived back to Facility via ambulance, [DIAGNOSES REDACTED]." R1's Care Plan initiated on 1/15/14 documents under Problem: "Resident is at risk of falls due to has had falls at home in the past. She has back pain and needs assist of 2 with a gait belt for transfers. She is nonweight bearing to left leg and needs to pivot on Right leg when transferring. The approaches documented are, in part, 2 person assist with gait belt and nonweight bearing to left leg/pivot on right leg. An approach for hygiene/continence documented left leg brace off only when bathing." The undated Resident Incident Report documents: time of fall 8:00 PM, Resident was being transferred from toilet and residents knees gave out and resident fell . Complaint of pain to left knee and ankle and leg began to swell. Resident assessed for pain and injury sent to emergency room for evaluation. The Fall Witness Statement dated 2/13/14 documented by E13 CNA documents, What did the resident say caused the fall? E13 documentd, "She (R1) was slipping off the toilet I tried helping her and her knee gave out she fell ." The Facility investigation of the fall that E1 (Administrator) conducted documents, "Writer called to facility at approximately 8:45 PM on 2/13/14 after learning of Residents fall at facility. Spoke with C.N.A. (E13), regarding "what happened". (E13) recalled incident readily as follows: "Stated resident was on toilet and fell when trying to get off of toilet. She stated she transferred resident without a gait belt, without brace, and alone. (E13) stated she did not use her pocket care guide. She stated she knew she made a mistake". This document is signed by E1. R1's Morse Fall Scale dated 1/8/14 documents R1 having a score of 75. Any score of 46 or greater requires an action of implementing high-risk fall prevention interventions. The Facility's Interdisciplinary Fall Reduction / Injury prevention Protocol dated 7/12 documents: "Nursing to complete a fall risk evaluation upon admission, re-admission, quarterly and with significant change. If the total score places the resident at risk, determine appropriate interventions. Once selected implement the interventions and then add to the resident's plan of care and pocket care guide. Nursing staff to wear gait belts as part of their uniforms or per facility policy." The Facility's Policy on Transfer Belts/ Gait Belts dated 10/09 documents Procedure as:" 1. A gait belt is used if indicated on the care plan and Nursing Assistant worksheet."