Every finding on record at Fairview

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #103) reviewed for pressure injury, the facility failed to ensure a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment so that services provided maintain the resident's highest practicable physical, mental and psychosocial well-being and included any specialized services or specialized rehabilitative services. The findings include:Resident #103 was admitted to the facility on [DATE] with diagnoses that included acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, abnormalities of gait and mobility, cognitive communication deficit and dementia.Physician's orders dated 11/29/24 directed a sodium restriction diet of regular texture and thin liquids consistency.Resident #103's care plan dated 12/2/24 identified Resident #103 had a self-care deficit related to activities of daily living (ADLs) related to activity intolerance. Care plan interventions directed an assist of one for bed mobility and transfers and indicated Resident #103 was non-ambulatory. The care plan interventions were dated 9/24 and were carried over from a previous admission and failed to reflect the occupational and physical therapy assessment dated [DATE].The admission MDS assessment dated [DATE] identified Resident #103 had moderately impaired cognition, was dependent on staff for toileting hygiene, shower/ bathing, transfers, position changes and mobility in the wheelchair. It further identified the resident was frequently incontinent of bowel and bladder, was at risk for developing pressure ulcers/injuries but did not have any pressure injuries and did not have any ulcers, wounds or skin problems, had a pressure reducing devices for wheelchair and bed. The assessment further identified Resident #103 was taking anticoagulant and diuretic medications. The assessment reflected that the care areas triggered included nutritional status, pressure ulcer, cognitive loss/dementia, ADL functional/rehabilitation potential and urinary incontinence. Mobility:The Braden Scale for predicting pressure ulcer risk evaluation dated 11/28/24 at 12:40 PM and completed by LPN#1 identified Resident #103 had a score of 16, which indicated Resident #103 was assessed a mild risk for developing a pressure injury. The Braden scoring identified Resident #103 had no sensory impairment, was occasionally moist, was chair fast and made frequent though slight changes in body or extremity position independently. The scoring included Resident #103 probably had inadequate nutrition and that friction and shear was a potential problem.The nursing clinical admission progress note dated 11/28/24 at 12:45 PM identified Resident #103 had two skin issues: right shin abrasion, buttocks red/blanchable wound present on admission and noted edema to the bilateral lower extremities (BLE). The physical therapy recommendation dated 11/29/24 directed Resident #103 to be transferred with a mechanical lift with 2 staff assist and to ambulate with therapy only. Additionally, the PT evaluation and plan of treatment identified Resident #103 was dependent with an assist of 2 for sit to lying, lying to sitting on side of bed and sitting to standing. The assessment indicated transfers were not attempted due to medical condition. The Occupational Therapy Evaluation and plan of treatment dated 11/29/24 identified Resident #103 was dependent for transfers with a mobility performance score of 0 out of a range of 0 to 12; 12 being the highest function. OT encounter note identified Resident #103 participated in bed mobility requiring moderate assist of 2 for bed mobility and indicated an assist of 2 was provided for sit to stand, indicating Resident #103 reported BLE discomfort and demonstrated poor functional activity tolerance requiring seated rest periods due to fatigue and decreased O2 saturation to 86% on 3L via nasal canula and required a mechanical Hoyer lift for transfers out of bed with staff.Resident #103's care plan dated 12/2/24 identified Resident #103 had a self-care deficit related to activities of daily living (ADLs) related to activity intolerance. Care plan interventions dated 12/16/24 directed an assist of one for bed mobility, transfers, bathing/showering, dressing, and indicated Resident #103 was non-ambulatory. The care plan interventions failed to reflect Occupational and physical therapy assessments dated 11/29/24 which identified Resident #103 was an assist of 2 for bed mobility and assistance for care. The care plan meeting note dated 12/2/24 at 1:48 PM identified Resident #103 used a Hoyer lift for transfers. However, this was not reflected in the care plan.The nurse aide care card (don't have a date) directed Resident #103 was an assist of 1 for care and mobility and transfers to and from bed.The nursing progress note dated 12/16/24 at 3:29 PM identified nursing was approached by physical therapy due to Resident #103's refusal to get out of bed and indicated Resident #103 had mild back pain and was tired but refused pain medication and denied pain to nursing.The occupational therapy treatment note dated 12/19/24 identified Resident #103 required an assist of 2 for safety during car transfers and indicated Resident #103's son was educated on need for rolling walker due to Resident #103's new level of ability and fatigue and shortness of breath with just a transfer.The occupational therapy treatment note dated 12/21/24 at 3:46 PM identified Resident #103 had increased coughing and malaise with decreased tolerance to functional activities and indicated a Covid positive test.Resident #103's care plan failed to identify the resident need for assistance of 2 people for transfers, mobility and care related to Resident #103's inability to move due to fatigue and shortness of breath with activity.The facility policy for comprehensive care plans directed the facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The policy indicated that all areas triggered by the MDS will be considered in developing the plan of care in addition to other factors identified by the interdisciplinary team. The policy identified the care plan will include measurable objectives and timeframes to meet the resident needs and alternate interventions will be documented as needed. The policy further identified qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.The facility policy for pressure injury prevention identified risk assessments and other risk factors would be used to develop a care plan that includes measurable goals for prevention with appropriate interventions. The policy further identified the ADNS was responsible for reviewing all relevant documentation regarding skin assessments, pressure injury risks and compliance and indicated that interventions would be modified as needed. Skin condition:The Braden Scale for predicting pressure ulcer risk evaluation dated 11/28/24 at 12:40 PM and completed by LPN#1 identified Resident #103 had a score of 16, which indicated Resident #103 had a mild risk for developing a pressure sore. The Braden scoring identified Resident #103 had no sensory impairment, was occasionally moist, was chairfast and made frequent though slight changes in body or extremity position independently. The scoring included Resident #103 probably had inadequate nutrition and that friction and shear was a potential problem.Nursing clinical admission progress notes dated 11/28/24 at 12:45 PM identified Resident had skin issues that included: a right shin abrasion, buttocks red/blanchable wound present on admission. wound is new, left breast mastectomy, right front axilla bruising, left shin bruising, and edema to BLE. The nursing progress note dated 11/29/24 at 7:31 AM identified Resident #103 was incontinent with bladder and upper and lower extremities were swollen and indicated Resident #103's legs were kept elevated.The physician's progress note dated 11/29/24 at 1:56 PM identified Resident #103 was assessed in bed, had no dermatitis, had bilateral upper extremity pitting edema and bilateral lower extremity edema.Resident #103's care plan dated 12/2/24 identified Resident #103 was at risk for potential impairment to skin integrity related to impaired mobility and significant edema. Care plan interventions directed ACE wraps as tolerated to keep skin clean and dry, provide pressure relieving/reducing mattress, turn and reposition resident frequently as tolerated, encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. The care plan failed to identify Resident #103 had open skin areas and was being treated by the wound doctor, was generalized and not individualized, failed to be individualized to represent Resident #103's open wounds being treated by the wound MD and failed to direct appropriate interventions for care.Wound care specialist's initial assessment note dated 12/4/24 at 1:45 PM identified skin problem to the right lower leg identified and provided wound care. The note identified a right lower leg wound with measurements 0.7cm x 0.3 cm x 0.1 cm with treatment recommendation to cleanse wound, apply silver hydrogel to base of the wound, secure with dry clean dressing and change every other day and as needed for soiling, saturation or accidental removal.The Braden Scale for predicting pressure ulcer risk evaluation dated 12/5/24 at 12:53 PM identified Resident #103 had a score of 17 indicating a mild risk for developing pressure injury. The assessment identified Resident #103 had no sensory impairment, was occasionally moist, chairfast and made frequent though slight changes in body or extremity position independently. The assessment further indicated Resident #103's nutrition was adequate and that friction and shear was a potential problem.Based on the admission assessment, Physical therapy assessment, occupational assessment and nursing notes my Braden scale assessment for Resident #103 scored a score of 10, which indicated Resident #103 was a high risk for pressure injury development. Nursing notes identified Resident #103 was not able to feel when he/she had a bowel movement or incontinence, indicated Resident #103's extremities were +3 pitting edema with some open areas and requiring ace wraps to BLE and BUE would indicate a very limited sensory perception (2). Resident #103 would have occasionally moist moisture indicating skin is occasionally moist requiring a linen change once daily (3). Based on physician notes identifying Resident #103 was bedfast, the activity level would be Bedfast (1). Based on occupational therapy and physical therapy notes Resident #103's mobility is very limited (2) and makes occasional slight changes in body or extremity position but is unable to make frequent or significant changes independently. Resident #103's nutrition is probably inadequate (2) and friction and shear is a problem (1) and required moderate to maximum assistance in moving as identified in the PT and OT assessments dated 11/29/24. This would indicate a Braden score of 11 which identified Resident #103 was a high risk for pressure injury development. The wound physician's note dated 12/18/24 at 2:36 PM identified Resident #103 was being treated for a right lower leg excoriation and indicated the assessment and plan to include a registered dietician consultation to optimize nutrition and avoid friction/sheer/traumatic forces.The nursing advanced skilled evaluation dated 12/24/24 at 10:37 PM identified Resident #103 had a skin issue that had not been evaluated to the right coccyx moisture associated skin damage that was painful and burning and directed interventions of change in position. The wound measurements were documented as 1.3 cm x 1.5 cm. The note identified an additional skin issue to the left coccyx moisture associated skin damage that was painful and burning with measurements of 2.1 cm x 1.7 cm.The nursing progress note dated 12/25/24 at 11:13 PM identified Resident #103 had a skin issue that had not been evaluated to the right coccyx moisture associated skin damage that was painful and burning and directed interventions of change in position. The wound measurements were documented as 1.3 cm x 1.5 cm. The note identified an additional skin issue to the left coccyx moisture associated skin damage that was painful and burning with measurements of 2.1 cm x 1.7 cm with intervention of position change. The note additionally indicated Resident #103 was bedfast at all or most of the time.The wound physician's note dated 12/27/24 at 4:50 PM identified Resident #103 was seen for a coccyx wound and indicated it was a stage 3 pressure wound. The note identified Resident #103 had edema and pressure associated signs and symptoms indicating pain in the new wound, Covid positive, incontinent and with decreased activity. Measurements of the coccyx wound were 2.7 cm x 3.2 cm x 0.3 cm with exposed subcutaneous tissues with a moderate amount of serosanguineous exudate. The note further directed wound care to cleanse wound, apply triad to peri wound, calcium alginate with silver to base of the wound, secure with dry clean dressing and change daily and as needed for soiling, saturation or accidental removal. Additional recommendations for a registered dietician consultation to optimize nutrition and pressure redistribution mattress per facility protocol.Resident #103's care plan identified Resident #103 was at risk for skin alteration and was not revised to include the development of wounds that required additional interventions or daily care.Interview with MDS#2 on 4/13/26 at 10:19 AM identified she was responsible for the short-term rehab admissions, completing assessments, putting in care plans and setting up the admission in the computer. MDS#2 indicated she got her skin information from the clinical admission and further indicated that all residents at the facility is at some risk for pressure and every resident gets a care plan for the potential impairment to skin integrity. MDS#2 identified she looks for skin tears, surgical wounds or pressure injuries and completes the baseline care plans and, based on the assessment, fills out the comprehensive care plan. MDS#2 indicated that RN supervisors were supposed to start the care plans and MDS adds additional information. MDS#2 further identified that open areas and residents seen by the wound MD should be reflected in the care plan designating wound care but that she doesn't always add the intervention. MDS#2 indicated that care plans can't be too pigeonholed and are vague and the items in the care plan direct the Kardex information. MDS#2 could not identify why Resident #103's wounds and mobility status were not updated. MDS#2 indicated that although her partner (MDS#1) was more diligent about updating the care plans, she was not.Interview with RN#2, RN supervisor, on 4/13/26 at 10:57 AM identified that care plans can be added to by nursing and interventions should be based on the needs of the resident. RN#2 indicated that interventions in the care plan carry over to the Kardex for direction of care for the NAs. RN#2 identified that all care should be verbally discussed with staff in the event there are changes.Interview with MDS#1 on 4/13/26 at 11:56 AM identified that she was responsible for the long-term residents. MDS#1 indicated that she adds the specific wound, date of occurrence and interventions for care. MDS#1 identified care plans should be specific to the resident.Interview with the ADNS on 4/13/26 at 2:01 PM identified that on further review of Resident #103's clinical record, the Braden assessments were not accurate. And indicated the score should have been a lower score identifying a higher risk for pressure injury development. The ADNS would not identify what an accurate score would have been. The ADNS indicated that there were inconsistencies in Resident #103's documentation was conflicting. The ADNS further identified that although the care plan directed turning and repositioning and assist for mobility, the interventions did not align with the assessments and that interventions for mobility would be directed by therapy. The ADNS identified MDS was primarily responsible for care planning but indicated that nursing had the ability to amend them.The facility policy for comprehensive care plans directed the facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The policy indicated that all areas triggered by the MDS will be considered in developing the plan of care in addition to other factors identified by the interdisciplinary team. The policy identified the care plan will include measurable objectives and timeframes to meet the resident needs and alternate interventions will be documented as needed. The policy further identified qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.The facility policy for pressure injury prevention identified Interventions for prevention and to promote healing and indicated that after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention with appropriate interventions. The policy identifies basic or routine care interventions to include redistribute pressure such as repositioning or offloading, minimize exposure to moisture and keep skin clean, provide appropriate, pressure redistributing support surfaces, provide non-irritating surfaces and maintain or improve nutrition and hydration status. The policy further identified the ADNS was responsible for reviewing all relevant documentation regarding skin assessments, pressure injury risks and compliance and indicated that interventions would be modified as needed.The facility policy for skin integrity identified interventions for prevention and promote healing identified categories of interventions to consider included to provide a safe environment, maintain nutrition and hydration, and protect from self-inflicted injury or injury incurred during routine care. The policy further directed that interventions will be modified in a resident's plan of care as needed and indicated considerations for needed modifications may include changes in medical condition or factors affecting the risk, new onset or recurrent, changes in the resident's goals and preferences.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for the only sampled resident (Resident #103) reviewed for pressure injuries, the facility failed to ensure accurate assessments were completed to direct care and failed to ensure the Braden assessments were reviewed by an RN when completed by an LPN. The findings include:Resident #103 was admitted to the facility on [DATE] with diagnoses that included acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, abnormalities of gait and mobility, difficulty in walking, cognitive communication deficit and dementia.The Braden Scale for predicting pressure ulcer risk evaluation dated 11/28/24 at 12:40 PM and completed by LPN#1 identified Resident #103 had a score of 16, which indicated Resident #103 was a mild risk for developing a pressure injury. The Braden scoring identified Resident #103 had no sensory impairment, was occasionally moist, was chairfast and made frequent though slight changes in body or extremity position independently, had inadequate nutrition and friction and shear were a potential problem. The assessment was completed by LPN #1.The physical therapy recommendation dated 11/29/24 directed Resident #103 to be transferred with a mechanical lift with 2 a person assist and to ambulate with therapy only. Additionally, the PT evaluation and plan of treatment identified Resident #103 was dependent with an assist of 2 for sit to lying, lying to sitting on side of be and sit to stand. The assessment indicated transfers were not attempted due to medical conditions.The nursing progress note dated 11/29/24 at 7:31 AM identified Resident #103 was incontinent of bladder and the upper and lower extremities were swollen.The physician's progress note dated 11/29/24 at 1:56 PM identified Resident #103 was assessed in bed, had no dermatitis, had bilateral upper extremity pitting edema and bilateral lower extremity edema.The nursing advanced skilled evaluation dated 11/30/24 at 10:42 PM identified Resident #103 was bedfast most of the time and was incontinent of urine and used adult briefs and the bedpan.The physical therapy treatment encounter note dated 11/30/24 at 11:25 AM identified Resident #103 used a bed pan with NA assistance and indicated limited memory recall of using the bed pan and needed reminders on a variety of things like using the call bell. The note further indicated Resident #103 was easily short of breath with minimal exertion and remained in bed.The care plan meeting note dated 12/2/24 at 1:48 PM identified Resident #103 used a Hoyer lift for transfers.Resident #103's care plan dated 12/2/24 identified Resident #103 had a self-care deficit related to activities of daily living (ADLs) related to activity intolerance. Care plan interventions directed an assist of one for bed mobility and transfers and indicated Resident #103 was non-ambulatory. Care plan interventions were dated 9/24 and were carried over from a previous admission. The interventions failed to reflect the recommendation of physical therapy for mechanical lift transfers (Hoyer), and bed mobility with the assistance of two staff members.The admission MDS assessment dated [DATE] identified Resident #103 had moderately impaired cognition, was dependent on staff for toileting hygiene, showers/bathing, transfers, position changes and mobility in the wheelchair, was frequently incontinent of bowel and bladder. The assessment further identified Resident #103 was at risk for developing pressure ulcers/injuries but did not have any pressure injuries and did not have any ulcers, wounds or skin problems and utilized a pressure reducing device for chair and bed. The occupational therapy recommendations dated 12/5/24 directed Resident #103 to transfer from bed to wheelchair and back, wheelchair to commode and back, bed to commode and back using the etac stander with an assist of 2 and to ambulate only with therapy. The Braden Scale for predicting pressure ulcer risk evaluation dated 12/5/24 at 12:53 PM identified Resident #103 had a score of 17 indicating a mild risk for developing pressure injury. The assessment identified Resident #103 had no sensory impairment, was occasionally moist, chairfast and made frequent slight changes in body or extremity position independently. The assessment further indicated Resident #103's nutrition was adequate and that friction and shear were potential problems. This was completed by LPN#1.Resident #103's care plan dated 12/5/24 identified Resident #103 was at risk for potential impairment to skin integrity related to impaired mobility and significant edema. Care plan interventions directed to keep skin clean and dry, provide pressure relieving/reducing mattress, turn and reposition resident frequently as tolerated, encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible.The nursing progress note dated 12/8/24 at 3:17 AM identified Resident #103 had plus 3 pitting edema in all extremities and was encouraged to keep extremities elevated. The Braden Scale for predicting pressure ulcer risk evaluation dated 12/19/24 at 2:47 PM identified Resident #103 had a score of 16 which indicated a mild risk for developing a pressure injury.Based on the admission assessment, Physical therapy assessment, occupational assessment and nursing notes my Braden scale assessment for Resident #103 scored a score of 10, which indicated Resident #103 was a high risk for pressure injury development. Nursing notes identified Resident #103 was not able to feel when he/she had a bowel movement or incontinence, indicated Resident #103's extremities were +3 pitting edema with some open areas and requiring ace wraps to BLE and BUE would indicate a very limited sensory perception (2). Resident #103 would have occasionally moist moisture indicating skin is occasionally moist requiring a linen change once daily (3). Based on physician notes identifying Resident #103 was bedfast, the activity level would be Bedfast (1). Based on occupational therapy and physical therapy notes Resident #103's mobility is very limited (2) and makes occasional slight changes in body or extremity position but is unable to make frequent or significant changes independently. Resident #103's nutrition is probably inadequate (2) and friction and shear is a problem (1) and required moderate to maximum assistance in moving as identified in the PT and OT assessments dated 11/29/24. This would indicate a Braden score of 11 which identified Resident #103 was a high risk for pressure injury development. Interview with the DNS on 4/9/24 at 1:20 PM identified LPNs are able to complete the Braden assessments because they are not assessments, but evaluations and do not require a co-sign by an RN. The DNS indicated that the admission assessment is co-signed by the RN.Interview with LPN#1 on 4/10/26 at 11:22 AM identified LPN#1 was the nurse who completed the admission assessment and the Braden scales dated 11/28/24 and 12/5/24. LPN #1 identified that a lower Braden score would increase interventions that would have included a positioning plan for getting out of bed more frequently, skin barrier protection and turning and repositioning. LPN#1 identified that recommendations from providers would be handled by the nursing supervisor. LPN #1 indicated that the admission assessment is signed off by the supervisor but other assessments, including the Braden scale, are completed and locked by the nurse completing them and do not have to be co-signed by the RN.Interview with the Assistant Director of Nursing (ADNS) on 4/10/26 at 2:47 PM identified that the ADNS identified the facility does frequent skin checks and NA's check the skin with all care provided. The ADNS reviewed Resident #103's Braden score and admission assessment and declined to comment on whether the assessments were accurate, indicating she was unable to remember. The ADNS indicated that Resident #103 was admitted to the facility several times and that the ADNS would need to review the clinical record. The ADNS identified that a resident who was at moderate or high risk for pressure injury would have an overlay mattress or an air mattress depending on presentation and further indicated that Resident #103 had a pressure-reducing mattress, not an overlay or an air mattress.Interview with RN#2, RN supervisor, on 4/13/26 at 10:57 AM identified she reviewed the admission assessment and co-signed the document and presented any concerns to the MD. RN#2 indicated that Braden scale assessments did not need to be co-signed and further indicated that she did not review the LPN documentation for accuracy or consistency.Interview with the ADNS on 4/13/26 at 2:01 PM identified that on further review of Resident #103's clinical record, the Braden assessments were not accurate. The ADNS would not identify what an accurate score would have been but indicated that the score would have been lower and Resident #103 would be at greater risk for pressure injury development. The ADNS indicated that there were inconsistencies in Resident #103's documentation was conflicting. The ADNS identified the score on the Braden scale assessment directs interventions for prevention of pressure injury. The ADNS further identified that Braden scale assessments were not reviewed or co-signed by the RN, when completed by the LPN and that she would expect the Braden to reflect the resident's status.The facility policy for pressure injury prevention and management identified licensed nurses will conduct a pressure injury risk assessment, using the Braden, on all residents upon admission/re-admission, weekly x 4 weeks, then quarterly or whenever the resident's condition changes significantly.According to the State of CT General Statutes Volume 7 Title 20 chapter 387 Section 20-87a (4) (c) The practice of nursing by a licensed practical nurse is defined as the performing of selected tasks and sharing of responsibility under the direction of a registered nurse or an advanced practice registered nurse and within the framework of supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total health care regimen and executing the medical regimen under the direction of a licensed physician, physician assistant, podiatrist, optometrist or dentist. A licensed practical nurse may also execute dietary orders written in a patient's chart by a certified dietitian-nutritionist.The CT LPN Practice Act identified that LPNs are properly allowed to participate in all phases of the nursing process under the direction of a registered nurse (RN) and indicated that an LPN can contribute to the nursing assessment by collecting, reporting, and recording subjective and objective patient-related data in an accurate and timely manner. But an LPN cannot perform the assessment independently.

Based on clinical record review, review of facility policy and staff interview, for one sampled resident (Resident #1) with a diagnosis of heart failure and reviewed for edema, the facility failed to ensure resident's weight was assessed and/or monitored for weight gain and for one sampled resident (Resident #47) reviewed for skin condition, the facility failed to ensure the skin condition was assessed and followed upon appropriately. The findings include:Resident #47 was admitted to the facility in March/2025 with diagnoses that included malignant neoplasm of female breast, exocrine pancreatic insufficiency and hearing loss. Observation on 4/7/26 at 11:00AM identified Resident #47 was in his/her room sitting in the wheelchair on the right of the bed and noted to the left upper cheek a raised area on the skin appearing like a skin growth that was approximately 2 centimeter (cm) in length by 1.5 cm in width. The area to the left upper cheek noted to have a discoloration at the base of the raised area. Resident #47 identified that it hurt when touched and he/she had reported it to the staff. The annual MDS assessment dated [DATE] identified Resident #47 was cognitively intact, required maximal assistance with personal hygiene, lower body dressing, and moderate assistance with toileting transfer, bed mobility and ambulation of 10 feet. The assessment further identified Resident #47 did not have any skin conditions. The care plan dated 3/30/26 identified #47 had a risk for potential impairment to skin integrity related to impaired mobility, muscle wasting/atrophy with interventions that included weekly skin check and identify or document potential causative factors and eliminate/resolved where possible. However, the care plan failed to reflect an actual/potential problem related to the resident having skin growth on face or any other areas on his/her body. The physician's order for the period of February 2026 through April 8, 2026, failed to identify an order directing treatment, monitoring or referral for the skin growth on the left upper cheek. The admission nursing assessment dated [DATE] under the skin section in the note identified Resident #47 had a right-side mastectomy, callus to the right foot, mole to the mid back, dry patch on right shin and right upper arm elevated dry patch. The weekly skin checks for the period of February/2026 through April/2026 failed to identify an area to the left upper cheek. Interview with the Charge Nurse (LPN #3) on 4/8/26 at 1:32 PM identified she had observed the lesion to the resident's left cheek and would have to check the treatment orders to see if there was any treatment for the area as it was her first time working on the day shift on the unit. LPN #3 reviewed the clinical records and failed to identify any orders directing care for the left cheek. LPN #3 indicated that she will have to find out from the supervisor regarding the left cheek as she may know more as she was new to the day shift. LPN #3 looked at the area to the left cheek when Resident #47 told the nurse it hurt when touched. LPN #3 left the room to report to the supervisor when Resident #47 identified he/she has had this lesion for some time now and when the aides provide care to his/her face it hurts Interview and review of clinical records with the Supervisor for the unit (LPN #4) and Unit Secretary #1 on 4/8/26 at 1:50 PM identified a ruled paper with handwritten information in the front of the chart indicated a note with an asterisk writing in a lighter ink a spot on left upper cheek hurts a lot per Resident #47. The Unit Secretary #1 and LPN #4 identified that they were unable to tell who and when the note was written regarding the resident left cheek. Unit Secretary #1 identified there is a binder on the unit which contains names of residents who request to be seen by the dermatologist and upon review of the binder it failed to indicate Resident #47 was signed up for the in-house dermatologist. They further reviewed the resident's record and identified he/she does not have consent for dermatology visit. LPN #4 indicated that she would have to call the resident's responsible party. Interview with Person #2 in the presence of LPN #4 on 4/8/26 at 2:05 PM identified Resident #47 had a care conference in March/2026 when Resident #47 expressed concern about ear and the lesion on his/her left cheek. LPN #4 indicated to Person #2 that the ear was addressed, and she was not aware of the concern with the cheek. LPN #4 then asked Person #2 for consent for a dermatology in which Person #2 provided. Interview with NA #1 on 4/9/26 at 10:48 AM identified Resident #47 would provide care to his/her face and had not complained about any pain in the area. She further identified she was a float nurse aide and had seen the area to the left cheek today and was about to report the area when she saw the other nurses and the surveyor already looking at the area. Interview with Unit Secretary #2 on 4/9/26 at 10:24 AM identified in house dermatology services was recently added in December of 2025 and Resident #47 did not have consent for such service until 4/8/26. She further identified that she was present at the care conference held on 3/31/26 for Resident #47 when she remembered the issue behind the ear was discussed and the resident could have discussed the left cheek, but she cannot remember exactly and the MDS coordinator would know more as she usually takes notes. A review of the Dermatology Service dates at the facility for the period of October 1, 2025, through April 8, 2026, identified that the Dermatologist was at the facility for a total of 5 visits. Observation and interview on 4/9/26 at 2:15PM with RN #5 (Infection Preventionist and Wound Nurse) identified Resident #47 was seated in his/her wheelchair and noted to have a raised skin growth to the left upper cheek with irritation to the base of the area. RN #5 asked Resident #47 if the area to the left cheek hurt and if it was mentioned at the care conference with the MDS coordinator when the resident responded yes, he/she had told them about the ear and the cheek. Resident #47 then further identified it hurts when touched. RN #5 indicated she will have the wound physician to look at the area. Interview with MDS Coordinator (RN #3) on 4/9/26 at 2:30 PM identified Resident #47 had a care conference in March/2026 when resident placed hand over left side of face and ear stating it hurt. She then asked if the ear hurts as the resident wears hearing aid and glasses. RN #3 identified that she could not recall if the resident had mentioned the left cheek but there was excoriation to the ear which she had addressed. Interview with RN #5 on 4/10/26 at 11:11AM identified the wound physician saw the resident on 4/9/26 and did not think it would be something that he could treat and gave a verbal recommendation for the in-house physician/APRN to evaluate and for dermatology consult. Interview with MD #1 on 4/10/26 at 1:04 PM identified the area to the resident left cheek was not new and recommendations were made for the resident to see dermatology, which was brought to the resident's family's attention and they did not want to do anything given that it was one dermatology in the New Haven that could see the resident. MD #1 was asked where this was documented, there was a pause in the conversation when he indicated that he was reviewing the notes. MD #1 then, responded that he was unable to locate the note. He further identified the area to the left cheek is a squamous cell which will need to be shaved off and biopsied, and he recommends a dermatologist consult in which the family is now in agreement. Interview with the DNS on 4/10/26 at 2:20 PM identified she is unsure as to when the area to the left upper cheek started. The DNS identified she expects that if the area was identified it should be reported. The DNS further identified that she can't recall the area to the left upper cheek being discussed in morning report. Interview on 4/13/26 at 10:33 AM with Person #2 identified when Resident #47 was admitted to the facility the area to the left cheek was a tiny red dot and within a month it got crusty and he/she had brought it to the nurse's attention in which the nurse indicated it was skin growing and will keep an eye on the area. Person #2 further identified he/she was present at the care conference when Resident #47 told the staff at the meeting about the area on the left cheek that it hurt when touched and his/her ear. Person #2 further identified he/she had never declined any dermatology consult nor did anyone at the facility spoke to him/her regarding the need for Resident #47 to have a dermatology consult. Person #2 further identified the area to the left cheek has gotten bigger recently. Interview with Charge Nurse LPN #6 on 4/13/26 at 11:11AM identified skin checks are done on shower days where the nurse would check the skin for any new open area, redness, and any abnormal skin issues. LPN #6 identified the area to the resident left cheek was not new, hence why it would not be indicated on the weekly skin checks. Review of the Pressure Injury Prevention and Management policy identified Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and as needed. Findings will be documented in the medical record. The policy further identified the nursing assistant will inspect skin during bath and will report any concerns to the resident's nurse immediately after task. Resident #1 had diagnoses that included heart failure, hypertension, and atrial fibrillation. The current monthly physician's orders dated 8/19/25 directed staff to obtain monthly weights on the day shift and to administer furosemide (diuretic medication) 60 mg by mouth once daily, lisinopril (antihypertensive medication) 2.5 mg by mouth once daily, and metoprolol succinate extended release (antihypertensive medication) 25 mg by mouth once daily. The Resident Care Plan (RCP) dated 8/20/25 identified that Resident #1 was taking a diuretic medication related to hypertension. The care plan interventions directed staff to administer the diuretic medication as ordered by the physician, to monitor for desired weight loss and adjust the dose as needed to achieve the desired effects while minimizing adverse effects, and to monitor and document any adverse reactions to diuretic therapy. The quarterly MDS assessment dated [DATE] identified that Resident #1 had severe cognitive impairment and required extensive assistance with toileting, personal hygiene, dressing, transfers, and ambulation. Further review of the assessment showed that the resident weighed 198 pounds and had no documented weight loss or weight gain. The monthly weight record identified the following documented weights for Resident #1: On 11/4/25 at 6:52 AM, the resident weighed 200.8 pounds. On 12/3/25 at 11:29 AM, the resident weighed 208.8 pounds, an increase of 8 pounds from 11/4/25. On 1/2/26 at 12:31 AM, the resident weighed 210.8 pounds, an increase of 10 pounds from 11/4/25. On 2/3/26 at 1:37 PM, the resident weighed 217.8 pounds, an increase of 17 pounds from 11/4/25. The weight comparison recorded on 11/4/25 (200.8 pounds) and 2/3/26 (217.8 pounds) showed a weight increase of 17 pounds, which represented an 8.5 percent weight gain in three months. The nurse's notes dated 2/17/26 at 11:22 AM identified that Resident #1 was observed with severe abdominal pain and shortness of breath. The resident's pulse oximetry was 80 percent on room air. The resident was placed on oxygen at 3 liters per minute via nasal cannula, and the pulse oximetry increased to 91 percent. APRN #1 assessed the resident and recommended that the resident be sent to the hospital for further evaluation. The family was also notified. The clinical record identified that Resident #1 was out of the facility from 2/18/26 through 2/23/26. The hospital Discharge summary dated [DATE] identified that Resident #1 was discharged from the hospital with a diagnosis of pleural effusion (excess fluid buildup in the lung). Interview with APRN #1 on 4/9/26 at 10:26 AM identified that she was aware of Resident #1's heart failure diagnosis and that the resident was sent to the hospital on 2/17/26 related to shortness of breath and low oximetry reading. She identified that the resident was admitted with pleural effusion. She identified that the plan of care for a resident with heart failure was individualized based on the resident's symptoms. She identified that nursing staff and/or the dietitian would inform her if there were concerns related to the resident's weight. Review of Resident #1's weight record from 11/4/25 to 2/3/26, she identified that the resident had significant weight gain that should have been evaluated. She identified that she would have instructed nursing staff to obtain another weight to ensure accuracy, monitor the resident's weight more frequently, and order a laboratory work-up. She identified that she was not aware of the resident's 17 pound weight gain. She further identified that she could not say whether Resident #1's hospitalization could have been prevented in relation to the weight gain. Interview with LPN #5 on 4/9/26 at 11:30 AM identified that the nurse aide was responsible for obtaining a resident's weight and that the charge nurse recorded the resident's weight in the vital sign section of the electronic record. She identified that the charge nurse was responsible for analyzing and assessing the resident's weight for significant weight loss or gain. She identified that when there was a significant weight discrepancy, the charge nurse would reweigh the resident to ensure the weight was accurate. She identified that Resident #1 had a diagnosis of heart failure and that any weight gain of 2 pounds in one day and/or 5 pounds in one week required physician notification. She identified that she was not able to identify what would be considered significant weight gain for a monthly weight for resident with a heart failure diagnosis. Interview with dietician #1 on 4/9/26 at 12:15 PM identified that she was responsible for reviewing resident weight changes at least monthly. She identified that she monitored residents for both weight loss and weight gain, and that a change of 5 percent in one month, 7.5 percent in three months, or 10 percent in six months would constitute a significant weight change requiring evaluation. Review of Resident #1's weights from 11/4/25 to 2/3/26 showed a 17 pound gain (8.5 percent in three months), which would have required evaluation to determine whether the gain was clinically appropriate. The dietician was uncertain whether she had been aware of the resident's significant weight gain or whether the resident was on a physician directed weight gain regimen. Interview with the DNS on 4/10/26 at 10:30 AM identified that the facility obtained monthly weights unless the physician indicated that weights should be obtained more frequently. She identified that the facility conducted weekly risk assessment meetings to discuss weight loss and weight gain. She identified that the facility did not have a policy specific to heart failure. She identified that Resident #1's 17 pound weight gain would not constitute significant weight gain but that the weight gain could have been evaluated by the physician to ensure that it was intentional. Interview with MD #1 (medical director) on 4/10/26 at 11:00 AM identified that he was aware of Resident #1's diagnosis of heart failure. He identified that the facility's practice was to assess residents with heart failure on an individual basis. He identified that Resident #1 would be monitored for significant weight gain, lung sounds, and effectiveness of medication related to heart failure. Review of Resident #1's weights from 11/4/25 to 2/3/26, he identified that the resident had a 17 pound weight gain; however, he identified that he was not sure whether he expected the nursing staff to notify him about the weight gain. The facility's Weight Monitoring policy required staff to ensure residents maintained acceptable nutritional parameters, including appropriate weight ranges and electrolyte balance. The policy identified weight as a primary indicator of nutritional status and specified that significant unintended weight changes defined as a 5 percent change in one month, 7.5 percent in three months, or 10 percent in six months were to be recognized and addressed in accordance with facility protocol.

Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #103) reviewed for pressure injury, the facility failed to accurately assess the resident's risk for pressure injury development, and failed to implement measures to prevent the development of a pressure injury to the sacrum resulting in the development of a stage 3 pressure ulcer to the sacrum. The findings include:Resident #103 was admitted to the facility on [DATE] with diagnoses that included acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, abnormalities of gait and mobility, difficulty in walking, cognitive communication deficit and dementia.The Braden Scale for predicting pressure ulcer risk evaluation dated 11/28/24 at 12:40 PM completed by LPN#1 identified Resident #103 had a score of 16, which indicated Resident #103 had a mild risk for developing a pressure sore. The Braden scoring identified Resident #103 had no sensory impairment, was occasionally moist, was chairfast and made frequent though slight changes in body or extremity position independently. The scoring included Resident #103 probably had inadequate nutrition and that friction and shear was a potential problem.Nursing clinical admission progress notes dated 11/28/24 at 12:45 PM identified Resident had skin issues to #1 right shin abrasion, 2 buttocks red/blanchable wound present on admission. wound is new. #3 left breast mastectomy, 4 right front axilla bruising, #5 Left shin bruising. Edema to BLE. Physician's orders dated 11/29/24 directed a sodium restriction diet of regular texture, thin liquids consistency.The physical therapy recommendation dated 11/29/24 directed Resident #103 to be transferred with a mechanical lift with 2 people assist and to ambulate with therapy only. Additionally, the PT evaluation and plan of treatment identified Resident #103 was dependent with an assist of 2 for sit to lying, lying to sitting on side of be and sit to stand. The assessment indicated transfers were not attempted due to medical conditionsThe Occupational Therapy Evaluation and plan of treatment dated 11/29/24 identified Resident #103 was dependent for transfers with a mobility performance score of 0 out of a range of 0 to 12; 12 being the highest function. OT encounter note identified Resident #103 participated in bed mobility requiring moderate assist of 2 for bed mobility and indicated an assist of 2 was provided for sit to stand indicating Resident #103 reported BLE discomfort and demonstrated poor functional activity tolerance requiring seated rest period due to fatigue and decreased O2 saturation to 86% on 3L via nasal canula and required a mechanical Hoyer lift for transfers out of bed with staff.The nursing progress note dated 11/29/24 at 7:31 AM identified Resident #103 was incontinent with bladder and upper and lower extremities were swollen and indicated Resident #103's legs were kept elevated.The physician's progress note dated 11/29/24 at 1:56 PM identified Resident #103 was assessed in bed, had no dermatitis, did have bilateral upper extremity pitting edema and bilateral lower extremity edemaThe nursing advanced skilled evaluation dated 11/30/24 at 10:42 PM identified Resident #103 was bedfast most of the time and was incontinent of urine and used adult briefs and the bedpan.The physical therapy treatment encounter note dated 11/30/24 at 11:25 AM identified Resident #103 used a bed pan with NA assistance and indicated limited memory recall of using the bed pan and needing reminders on a variety of things like using the call bell. The note further indicated Resident #103 was easily short of breath with minimal exertion and remained in bed.Resident #103's care plan dated 12/2/24 identified Resident #103 had a self-care deficit related to activities of daily living (ADLs) related to activity intolerance. Care plan interventions directed an assist of one for bed mobility and transfers and indicated Resident #103 was non-ambulatory. The care plan interventions were dated 9/24 and were carried over from a previous admission and failed to reflect the current therapy recommendations or resident status.The care plan meeting note dated 12/2/24 at 1:48 PM identified Resident #103used a Hoyer lift for transfers.The dietary progress note dated 12/4/24 at 9:46 AM identified nutrition interventions for Resident #103 were to continue cardiac sodium restricted diet and provide follow up diet education and support as indicated and monitor need for fluid restriction.The Braden Scale for predicting pressure ulcer risk evaluation dated 12/5/24 at 12:53 PM identified Resident #103 had a score of 17 indicating a mild risk for developing pressure injury. The assessment identified Resident #103 had no sensory impairment, was occasionally moist, chairfast and made frequent slight changes in body or extremity position independently. The assessment further indicated Resident #103's nutrition was adequate and that friction and shear was a potential problem.The admission MDS assessment dated [DATE] identified Resident #103 had moderately impaired cognition, was dependent for toileting hygiene, shower/bathing, transfers, position changes and mobility in the wheelchair, was frequently incontinent of bowel and bladder. The assessment further identified Resident #103 was at risk for developing pressure ulcers/injuries but did not have any pressure injuries and did not have any ulcers, wounds or skin problems and did utilize a pressure reducing device for chair and bed and was receiving an application of nonsurgical dressings other than to feet. The assessment further identified Resident #103 was taking anticoagulant and diuretic and indicated that the care areas triggered included nutritional status, pressure ulcer, cognitive loss/dementia, ADL functional/rehabilitation potential and urinary incontinence.The occupational therapy recommendations dated 12/5/24 directed Resident #103 to transfer from bed to wheelchair and back, wheelchair to commode and back, bed to commode and back using the etac stander with an assist of 2 and to ambulate only with therapy. Treatment encounter notes this day identified Resident #103 was incontinent of bowel without being aware and required extra time due to the resident's cognitive status.Resident #103's care plan dated 12/5/24 identified Resident #103 was at risk for potential impairment to skin integrity related to impaired mobility and significant edema. Care plan interventions directed to keep skin clean and dry, provide pressure relieving/reducing mattress, turn and reposition resident frequently as tolerated, encourage good nutrition and hydration in order to promote healthier skin and identify/document potential causative factors and eliminate/resolve where possible. The care plan failed to identify Resident #103 had open skin areas and was being treated by the wound doctor, was generalized and not individualized.The nursing progress note dated 12/8/24 at 3:17 AM identified Resident #103 had all extremities with 3 plus pitting edema and was encouraged to keep elevated. The note further indicated that Resident #103 was sleeping in long naps.The occupational therapy recommendation dated 12/10/24 directed Resident #103 to transfer with assist of 2 with grab bar or rolling walker and to ambulate only with therapy.The nursing progress note dated 12/16/24 at 3:29 PM identified nursing was approached by physical therapy due to Resident #103's refusal to get out of bed and indicated Resident #103 had mild back pain and was tired but refused pain medication and denied pain to nursing The occupational therapy treatment encounter note dated 12/21/24 at 3:46 PM identified Resident #103 had increased coughing and malaise with decreased tolerance to functional activities and indicated a Covid positive test. The nursing advanced skilled evaluation dated 12/24/24 at 10:37 PM identified Resident #103 had a skin issue that had not been evaluated that consisted of moisture associated skin damage (MASD)to the right coccyx that was painful and burning. An intervention to change position was implemented. The wound measurements were documented as 1.3 cm x 1.5 cm. The note further identified Resident #103 also had moisture associated skin damage that was painful and burning with measurements of 2.1 cm x 1.7 cm to the left coccyx.The physician's order dated 12/24/24 directed to cleanse the coccyx/buttocks (MASD) area with normal saline and pat dry, apply triad paste every shift followed by a foam dressing for 7 days and then re-evaluate.The nursing progress note dated 12/25/24 at 11:13 PM identified Resident #103 had a skin issue that had not been evaluated to the right coccyx moisture associated skin damage that was painful and burning and directed interventions of change in position. The wound measurements were documented as 1.3 cm x 1.5 cm. The note identified an additional skin issue to the left coccyx moisture associated skin damage that was painful and burning with measurements of 2.1 cm x 1.7 cm with intervention of position change. The note additionally indicated Resident #103 was bedfast at all or most of the time.The wound physician's note dated 12/27/24 at 4:50 PM identified Resident #103 was seen for a coccyx wound and indicated it was a stage 3 pressure wound. The note identified Resident #103 had edema and pressure associated signs and symptoms indicating pain in the new wound, Covid positive, incontinent and with decreased activity. Measurements of the coccyx wound were 2.7 cm x 3.2 cm x 0.3 cm with exposed subcutaneous tissues with a moderate amount of serosanguineous exudate. The note further directed wound care to cleanse wound, apply triad to peri wound, calcium alginate with silver to base of the wound, secure with a dry clean dressing and change daily and as needed for soiling, saturation or accidental removal. Additional recommendations for a registered dietician consultation to optimize nutrition and pressure redistribution mattress per facility protocol.The physician's order dated 12/27/24 directed use of an air mattress.The physician's order dated 12/30/24 directed an air mattress and a function check every shift to maintain pressure reduction and evaluate for bottoming out with hand check.The physical therapy recommendations dated 12/31/24 directed transfers with mechanical lift with an assist of 2 and identified Resident #103 was non-ambulatory.The dietician progress note dated 1/14/25 at 10:55 AM identified Resident #103's nutritional interventions to continue diet as ordered and monitor wights as ordered and Prostat (liquid protein) 30 ml every day.Interview with the dietician on 4/9/26 at 12:15 PM identified she was responsible for monitoring weight, intake and wounds, whether or not they need a nutritional intervention. The dietician indicated that she should be notified when something is non-blanchable and should have been notified of Resident #103's stage 3 wound. The dietician indicated that wounds are on a report to be seen more frequently and indicated she was not aware of the wound MD's request for a dietary consultation. The dietician identified that interventions for wounds would include additional protein and monitoring intake, output and weights.Interview with the DNS on 4/9/26 at 1:20 PM identified the criteria for referral to the wound MD for care is the clinical judgement of the nurse and indicated the facility did not have a policy that directs the referral. The DNS identified the ADNS was the wound nurse and could better answer the questions.Interview with LPN#1 on 4/10/26 at 11:22 AM identified LPN#1 was the nurse who completed the admission assessment and the first two Braden scales dated 11/28/24 and 12/5/24. LPN#1 was not able to access the resident clinical record on her computer and utilized mine for review. LPN #1 identified that a lower Braden score would increase interventions that would have included a positioning plan for getting out of bed more frequently, skin barrier protection and turning and repositioning. LPN#1 indicated that turning and repositioning was not documented but was considered a standard of care and was unable to identify who was responsible for ensuring it was completed. LPN#1 identified that recommendations from providers would be handled by the nursing supervisor or for wounds, the wound nurse.Interview with the Assistant Director of Nursing (ADNS) on 4/10/26 at 2:47 PM identified that turning and repositioning was not documented at the facility and indicated that it was considered a standard of care and that the nurses were responsible for making sure it was being completed. The ADNS identified the facility does frequent skin checks and NA's check the skin with all care provided. The ADNS reviewed Resident #103's Braden score and admission assessment and declined to comment on whether the assessments were accurate, indicating she was unable to remember. The ADNS indicated that Resident #103 was admitted to the facility several times and that the ADNS would need to review the clinical record. The ADNS identified that a resident who was at moderate or high risk for pressure injury would have an overlay mattress or an air mattress depending on presentation and further indicated that Resident #103 had a pressure-reducing mattress, not an overlay or an air mattress.Interview with MDS#2 on 4/13/26 at 10:19 AM identified she was responsible for the short-term rehab admissions, completing assessments, putting in care plans and setting up the admission in the computer. MDS#2 indicated she got her skin information from the clinical admission and further indicated that all residents at the facility is at some risk for pressure and every resident gets a care plan for the potential impairment to skin integrity. MDS#2 identified she looks for skin tears, surgical wounds or pressure injuries and completes the baseline care plans and, based on the assessment, fills out the comprehensive care plan. MDS#2 indicated that RN supervisors were supposed to start the care plans and MDS adds additional information. MDS#2 further identified that open areas and residents seen by the wound MD should be reflected in the care plan designating wound care. MDS#2 indicated that care plans can't be too pigeonholed and are vague and the items in the care plan direct the Kardex information. MDS#2 could not identify why Resident #103's wounds and mobility status were not updated.Interview with MDS#1 on 4/13/26 at 11:56 AM identified that she was responsible for the long-term residents. MDS#1 indicated that she adds the specific wound, date of occurrence and interventions for care. MDS#1 identified care plans should be specific to the resident.Interview with the wound MD, MD#2, on 4/13/26 at 1:05 PM identified he was not in a position to review a specific resident record but answered general questions. MD#2 identified the facility is responsible for interpreting the Braden score and implementing interventions according to facility policy. MD#2 indicated that skin deteriorates for all sorts of reasons medically and it would be the responsibility of the facility to ensure residents were evaluated accurately and appropriate interventions were put in place. MD#2 identified that edema may effect mobility in addition to tissue that has been deprived of oxygen and presence of toxic metabolites all contribute to developing a wound.Interview with the ADNS on 4/13/26 at 2:01 PM identified that on further review of Resident #103's clinical record, the Braden assessments were not accurate. The ADNS would not identify what an accurate score would have been. The ADNS indicated that there were inconsistencies in Resident #103's documentation was conflicting. The ADNS further identified that although the care plan directed turning and repositioning, the clinical record documentation failed to demonstrate turning and repositioning was being completed and indicated that a lower Braden score would have prompted a discussion for implementation of an overlay mattress or air mattress.The facility policy for pressure injury prevention and management identified the facility shall establish and utilize a systematic approach for pressure injury prevention and management. The policy further identified that licensed nurses would conduct a pressure injury risk assessment, using the [NAME], on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. The policy indicated the tool will be used in conjunction with other risk factors not captured by the risk assessment. Examples of risk factors include but are not limited to: Impaired/decreased mobility and decreased functional ability, Co-morbid conditions such as diabetes mellitus, Impaired diffuse or localized blood flow, cognitive impairment, exposure of skin to urinary and fecal incontinence, nutrition and hydration deficits and presence of a previously healed pressure injury. The policy identified Interventions for prevention and to promote healing and indicated that after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention with appropriate interventions. The policy identifies basic or routine care interventions to include redistribute pressure such as repositioning or offloading, minimize exposure to moisture and keep skin clean, provide appropriate, pressure redistributing support surfaces, provide non-irritating surfaces and maintain or improve nutrition and hydration status. The policy further identified the ADNS was responsible for reviewing all relevant documentation regarding skin assessments, pressure injury risks and compliance and indicated that interventions would be modified as needed. The facility failed to ensure Resident #103 was assessed correctly. The care plan that directs care was vague and did not represent Resident #103's actual status and ability, therefore the Kardex was not complete and did not direct care as needed. Referrals made by the wound MD failed to be implemented. The facility was unable to demonstrate turning and repositioning and as Resident #103's condition deteriorated, there were not additional interventions put in place to address the increased immobility, confusion, incontinence and potential for pressure injury development. Had the assessments been accurate and/or reviewed for accuracy, the interventions would have been in place to minimize development of the pressure injury.

Based on review of facility documentation, review of facility policy/procedures and interviews for the facility reviewed for sufficient staffing, the facility failed to ensure performance reviews were completed for nursing staff annually. The findings included:Review of five employee files (3 nurse aides, 1 LPN and 1 RN) on 4/10/26 at 2:30 PM identified employee performance reviews were not present in the employee files. The most recent performance evaluation reviewed was from 2019 for one employee.Interview with the Director of Human Resources (HR) on 4/10/26 at 2:45 PM identified there were not any performance evaluations for the nursing department that had been given to the human resources office. The Director of HR indicated that the performance evaluations were not being completed and that the Director of Nursing Services (DNS) was responsible for completing the nursing department evaluations.Interview with the DNS on 4/10/26 at 3:00 PM identified that nursing staff participate in the annual training and that the performance was reviewed at that time by observing the skill competencies. The DNS indicated that other than the training documentation, there were no performance evaluations completed for employees' work performance. The DNS identified the performance evaluations were a back burner item.Interview with the Director of Human Resources on 4/13/26 at 3:00 PM identified that the employee handbook indicates that employees will receive annual performance evaluations and identified that she sends out monthly emails to the department heads and the administrator to notify them of when employees would require a performance evaluation. The Director of Human Resources indicated she did not follow up with whether they were completed or not and could not identify if there was a policy.Interview with the Administrator on 4/13/26 at 3:10 PM identified that the expectation is that the performance evaluations are completed annually.The employee handbook in section 5.8 Performance Reviews identified that generally, performance reviews are conducted annually on or about your anniversary date and indicated factors considered include, but are not limited to, the quality of job performance, attendance, meeting the requirements of the job description, dependability, attitude and cooperation, compliance with company employment policies, disciplinary actions, and year to date improvement in overall performance.The job description for the Director of Nursing identified, under personnel functions, that the DNS was responsible for ensuring the completion of performance evaluations for the nursing department.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews for two of five sampled residents (Resident #2 and #!2) reviewed for unnecessary medication, the facility failed to follow up on the consultant pharmacist's recommendations. The findings include:Resident # 12's diagnoses included Alzheimer's disease, major depressive disorder, and anxiety. The physician's orders dated 11/20/25 directed staff to administer the following medications: bupropion extended release (anti-depressant) 150 mg by mouth once daily related to depression; escitalopram oxalate (anti-depressant) 15 mg by mouth once daily related to depression and quetiapine fumarate (anti-psychotic) 100 mg by mouth at bedtime related to Alzheimer's disease. The pharmacy recommendation dated 11/21/25 directed staff to monitor orthostatic blood pressure weekly for four weeks related to the use of quetiapine fumarate. The physician signed and agreed to the pharmacy recommendation on 11/26/25. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #12 had severe cognitive impairment and was independent with transfers and ambulation, utilizing a rolling walker. The assessment further identified the resident was receiving anti psychotic and anti depressant medications. The psychiatrist's initial consultation dated 11/26/25 identified that Resident #12 had been evaluated for restlessness and for a review of the medication regimen. The resident had been admitted from home to the facility for long term care due to the need for a higher level of care. The psychiatrist documented that Resident #12 had persistent forgetfulness, episodes of depressive behavior, and anxiety. The recommended plan included: checking orthostatic blood pressure weekly and then monthly thereafter. monitoring behavior for combativeness. monitoring behavior for depression. The physician's orders dated 11/26/25 directed staff to check orthostatic blood pressure. The orders instructed staff to take the resident's blood pressure while the resident was lying down for five minutes, have the resident stand for a minimum of one minute, and then retake the blood pressure. When a resident was unable to stand, the orders directed staff to take the blood pressure in a sitting position. The orders further instructed staff to document the blood pressure readings in the vital sign progress notes, review the orthostatic blood pressure results, and notify the physician when applicable. The December 2025 Medication Administration Record (MAR) showed that weekly orthostatic blood pressures were signed as completed on 12/4/25, 12/11/25, 12/18/25, and 12/25/25; however, review of the resident's vital sign records identified no corresponding orthostatic blood pressure measurements were documented on those dates. This resulted in four missed opportunities to obtain and record the ordered orthostatic blood pressures. The Resident Care Plan dated 12/10/25 identified that the resident was receiving psychotropic medications. Care plan interventions directed staff to administer medications as ordered, monitor and document behaviors, consult with the psychiatrist and consider gradual dose reduction, monitor for adverse reactions, and complete laboratory monitoring per physician orders. The physician's orders dated 2/9/26 directed staff to check orthostatic blood pressure. The orders instructed staff to take the resident's blood pressure while the resident was lying down for five minutes, have the resident stand for a minimum of one minute, and then retake the blood pressure. When a resident was unable to stand, the orders directed staff to take the blood pressure in a sitting position. The orders further instructed staff to document the blood pressure readings in the vital sign progress notes, review the orthostatic blood pressure results, and notify the physician when applicable. The February 2026 Medication Administration Record (MAR) showed that weekly orthostatic blood pressures were signed as completed on 2/12/26, 2/19/26, and 2/26/26; however, review of the resident's vital sign records identified no corresponding orthostatic blood pressure measurements were documented on those dates. This resulted in three missed opportunities to obtain and record the ordered orthostatic blood pressures. Interview with LPN #3 on 4/8/26 at 12:27 PM identified that the charge nurse was responsible for obtaining orthostatic blood pressure readings. She identified that orthostatic measurements include blood pressures taken while the resident is lying, sitting, and standing, and that these values are to be recorded in the resident's electronic vital sign record. She identified that the physician's order for orthostatic blood pressures was used to monitor for adverse reactions to antipsychotic medications. She also identified that the charge nurse signs off completion of the task on the MAR. Review of the December 2025 and February 2026 MARs with LPN #3, she confirmed that the charge nurse had signed off all weekly orthostatic blood pressures as completed. She identified that the corresponding lying, sitting, and standing blood pressure readings should have been recorded in the resident's vital sign record. LPN #3 reviewed the record and confirmed that no orthostatic blood pressures were documented on 12/4/25, 12/11/25, 12/18/25, 12/25/25, 2/12/26, 2/19/26, or 2/26/26. She identified that Resident #12 was independent with transfers and ambulation with a rolling walker and could participate in orthostatic blood pressure assessment. She was unable to identify why the readings were not documented despite being signed off as completed on the MAR. Interview with the DNS on 4/8/26 at 1:00 PM identified that the charge nurse on the nursing unit was responsible for assessing the resident's orthostatic blood pressure. She identified that orthostatic blood pressure measurements include readings taken while the resident is lying and standing, and if the resident is unable to stand, measurements would be taken while the resident is sitting. She identified that the charge nurse signs off the task in the MAR and that the corresponding blood pressure readings were recorded in the resident's electronic vital sign record. Review of the December 2025 and February 2026 MARs with the DNS, she confirmed that the orthostatic blood pressures for Resident #12 were signed off as completed by nursing staff. She identified that she would expect the blood pressure readings to be recorded in the resident's vital sign record. A policy for orthostatic blood pressure monitoring was requested but was not available for review. Resident #2 diagnoses included insomnia, depression, and Post-Traumatic Stress Disorder (PTSD). The quarterly MDS assessment dated [DATE] identified Resident #2 was cognitively intact, had no behavior, and was dependent for bed mobility, transfers, and personal hygiene. The assessment further identified that the resident utilized a wheelchair for mobility. The care plan dated 7/25/25 identified Resident #2 has potential for mood problems related to a history of PTSD, and depression. The resident sees psych services via the Veteran's administration. Interventions included, administer medications as ordered, monitor/document for side effects and effectiveness, behavioral health consults as needed, educate the resident/family/caregivers regarding expectations of treatment concerns with side effects and potential adverse effects, evaluation, and maintenance. Review of the drug regimen review dated 8/11/25 identified a recommendation to evaluate and consider a trial taper of Trazadone 150mg at bedtime for insomnia to Trazadone 100mg at bedtime or document the inability to do so. The drug regimen review did not have indication that the recommendation was reviewed by the physician or APRN. Review of the drug regimen review dated 4/22/24 identified a recommendation to check the valproic acid level but did not have indication that the recommendation was reviewed by the physician or APRN. Review of the clinical record failed to identify a change in the Trazadone 150mg at bedtime following the next psych appointment on 8/22/25. Review of the consult sheet from the 8/22/25 visit for psych services did not identify any request to review the Trazadone dosage following the pharmacy recommendation on 8/11/25. Interview on 4/9/26 at 9:00AM with the Director of Nurses identified the medication reviews are received monthly from the pharmacy consultant via email. Once received they are given to the nurse supervisor who then follows up with the appropriate action. If the recommendation is to be reviewed by a provider, they will provide that information to them. However, this recommendation was not followed up on because Resident #2 is seen by psych services from the Veteran's Affairs department and they manage this medication. Interview on 4/9/26 at 9:30AM with the APRN#1 identified she receives reviews monthly and occasionally in between the monthly pharmacy consultant visits due to new admissions. She will review the recommendation and then mark agree or disagree with the recommendation and sign the review. If the medication is managed by an outside provider she would write on the recommendation to please review at the next visit with the provider, or she herself would call the provider directly if it was something she wanted to discuss immediately. The only time the medication regimen review would not be filled out would be if the resident was no longer in the facility. Review of Drug Regimen Review Policy directed the facility to act upon all recommendations according to procedure to address medication regimen review irregularities.

Based on observation, staff interview, and facility policy, the facility failed to ensure medication carts were locked when unattended and narcotics were secured properly. The findings include:An observation on 4/08/2026 from 8:23 AM to 8:34 AM identified an unattended and unlocked medication cart in the hallway on the first-floor nursing unit between rooms [ROOM NUMBERS].An interview with LPN #2 on 4/8/2026 at 8:34 AM identified that he did not lock the medication cart before entering a Resident room at the opposite end of the hallway to provide routine care because he forgot, and that the cart contained narcotic medications. He indicated he was aware of the facility policy to lock medication carts when not in use, not in view, and unattended and that narcotic medications required a double lock for safety.Interview on 4/8/2026 at 9:45 AM with RN #1 identified nurses are expected to lock their medication carts any time they walk away from the cart. Additionally, she indicated the unit has a number of residents who wander and an unlocked cart poses a safety risk to them. RN #1 identified that when a medication cart is unlocked, the narcotics stored within them are not double locked per facility policy.Interview on 4/8/2026 at 10:20 with the DNS identified that her expectation was that nurses lock their medication carts any time they turn away from the cart. Additionally, she stated LPN #2 should have locked his medication cart before leaving it unattended.Review of the facility's Administration Procedures for all Medications policy identified in part that Medications will be administered in a safe and effective manner. All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.

Based on review of clinical record, review of facility documentation, facility policy and interviews, for one of two residents (Resident #46) reviewed during a review of the antibiotic stewardship program, the facility failed to ensure that an antibiotic time out was completed for a resident on an antibiotic timely. The findings include:Resident #46's diagnoses included type 2 diabetes mellitus, peripheral vascular disease, coronary artery disease, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #46 had severely impaired cognition. The assessment further identified the resident was taking an antibiotic with an indication noted. The physician's order dated 3/26/26 directed Doxycycline Hyclate 100 milligrams (mg) twice daily for left foot toe infection. However, the order failed to identify a stop date for the Doxycycline Hyclate. Further review of the physician orders identified Doxycycline Hyclate 100mg was directed by the physician on the following dates:On 12/27/2024 twice daily for infection for 14 days On 6/6/2025 twice daily for osteomyelitis of left great toe hallux for 14 [NAME] 6/20/2025 twice daily for osteomyelitis of left great toe hallux until 7/18/25 On 7/19/2025 twice daily for osteomyelitis prophylaxis until 3/19/26 The review further identified that Ciprofloxacin 500mg by mouth was directed by the physician on the following dates:On 6/6/2025 for twice daily for osteomyelitis for 14 days On 6/20/2025 twice daily for osteomyelitis until 7/18/25 On 3/19/2026 twice daily for left great toe infection and to reevaluate in 2 weeks with a stop date of 4/3/26 On 4/3/2026 twice daily for left great toe infection with a stop date of 4/23/26 A review of the assessment section of the resident's clinical record in the electronic medical record system identified an antibiotic timeout completed on 3/26/26 and on 12/29/24 which was incomplete. The records failed to identify an antibiotic timeout that was completed when an antibiotic was prescribed by the physician. The Antibiotic timeout dated 3/26/26 completed by the Infection Preventionist (RN #5) identified Resident #46 was on oral antibiotic treatment for sign or symptoms of cellulitis of left great toe wound with exposed bone in place at the request of the family who did not want an extensive diagnostic testing or intravenous antibiotics. The notes further identified that dual therapy of doxycycline and ciprofloxacin to continue and ciprofloxacin order to be re-evaluated next week. Interview and review of the clinical record with RN #5 on 4/9/26 at 1:00 PM failed to identify an antibiotic timeout completed for the doxycycline that was ordered on 3/26/26 as well as the other dates when antibiotics were prescribed by the physician. RN #5 identified she will review the records as the antibiotic time out are in the system and review the order for a stop date for the recent doxycycline order.The wound physician's note dated 4/9/26 at 8:37 PM identified on 3/26/26 facility staff reports patient power of Attorney have been updated and decline intravenous antibiotics and surgical intervention and primary team treating with oral ciprofloxacin and erythema has decreased. The note further identified on 4/9/26 the primary team treating with oral antibiotics for left great toe return to baseline and the plan is to continue lifelong suppressive antibiotic therapy.Subsequent to surveyor's inquiry a physician's order directed Doxycycline Hyclate 100mg by mouth two times daily for suppression therapy against osteomyelitis. Interview with RN #5 on 4/10/26 at 11:23 AM identified she was responsible to complete the antibiotic timeout within 48 to 72 hours after a resident is started on an antibiotic. RN #5 identified the antibiotic timeout is completed to ensure the culture results were reviewed and the order has indication for usage, dosage and duration. She identified the antibiotic timeout should have been completed for the doxycycline and whenever an antibiotic is ordered. RN #5 identified the resident should have had a stop date for the antibiotic and should have reviewed the order instead of assuming as the ciprofloxacin was completed and had a stop date. RN #5 further identified Resident #46 is not always on a prophylactic antibiotic as his/her antibiotics are stopped and restarted at different times. RN #5 further identified she was unable to find the other antibiotic timeout completed in the system for the previous antibiotic orders. Interview with the DNS on 4/10/26 at 2:17 PM identified that antibiotics when prescribed should have a stop date if they are not ordered prophylactic. Review of the Antibiotic Stewardship Program policy identified nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. The policy further identified new or changed orders for antibiotics based on the antibiotic time out recommendations will be obtained from the practitioner.

Based on review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #10) reviewed for pre-admission screening and resident review PASARR, the facility failed to ensure a resident with a new psychotic disorder diagnosis was submitted for a Level II screening. The findings include:Resident #10's diagnoses included unspecified psychosis not due to a substance or known physiological condition, excoriation (skin picking) disorder, depression, and anxiety disorder.The quarterly MDS assessment dated [DATE] identified Resident #10 was cognitively intact, required partial to moderate assistance with bed mobility and personal hygiene, was dependent on staff for transfers, and utilized a wheelchair for mobility.The care plan dated 10/17/25 identified Resident #10 had depression and anxiety with interventions that directed to arrange for a psychiatric consult, administer medications as ordered, monitor and document for side effects and effectiveness, monitor, record, and report to the physician any risk for harming others, increased anger, or agitation. The physician's order dated 10/21/25 directed to administer Abilify (antipsychotic) 2mg by mouth every day for delusions. The psychiatry provider note dated 10/21/25 directed the start of Abilify for delusions related to unspecified psychosis. A review of Resident #10's current diagnoses as of 4/7/26 identified the diagnosis of unspecified psychosis disorder was added on 10/22/25. Interview on 4/8/26 at 12:33 PM with RN #3(MDS Coordinator) identified that the psychiatric APRN provides a report every few months (last one in February 2026) that contains the current psychiatric diagnoses. RN#3 further identified that she reviews the list and updates the diagnoses in the residents' medical record; however, the last report did not identify a new diagnosis of psychosis for Resident #3. Additionally, she noted that the resident was still receiving Abilify. She also noted that information on new diagnoses is also received in morning report or when the MDS Coordinator reviews the clinical record. Interviews with Social Worker #1 (SW #1) on 4/9/26 at 11:45AM and 1:15PM identified that she is made aware of residents' diagnoses at the time of admission, through the psychiatric services provider or during morning report. SW #1 further identified that if a resident had diagnoses that include major depressive disorder, bipolar or schizophrenia, she would be prompted to request that the resident have a level II PASARR assessment completed. She further noted that she was not sure if a diagnosis of psychosis would be a qualifying diagnosis that would require a level II PASARR assessment. SW #1 further identified that she was unaware of Resident #10's diagnosis of psychosis, so she had not submitted it for consideration for a level II PASARR assessment. Interview with the Lead Level II Coordinator for Maximus/Ascend on 4/9/26 at 12:21 PM identified that a diagnosis of unspecified psychosis not due to a substance or known physiological disorder should be submitted for a Level II review as there is a good chance they would trigger for a positive Level II. Interview with the psychiatric APRN on 4/13/26 at 10:08 AM identified that when a resident is diagnosed with a new psychiatric diagnosis, it is placed in the daily visit report, and it is placed on the bottom of the provider note. He noted that when he submitted the last diagnoses report to the DNS, he had not included Resident #10's new diagnosis of psychosis. Additionally, he noted that the diagnosis was a chronic condition for Resident #10.The PASARR policy directed to submit an updated Level I screen in assessment PRO within 14 days of a significant change in status or change in serious mental illness, intellectual disability, a related condition, or a condition that suggests a Level II resident review is needed.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of five (5) residents (Resident #1) reviewed for falls, the facility failed to ensure a safe transfer for Resident #1 resulting in a fall with a closed head injury.The findings include: 1. Resident #1's diagnoses included paraplegia (paralysis/inability to voluntarily move the lower half of the body and the ability to walk), chronic pain, weakness and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition (Brief Mental Interview for Mental Status (BIMS) score of 13) and required partial assistance for bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 2/20/25 identified Resident #1 was at risk for falls related to paraplegia. Interventions included providing assistance with transfers and mobility as ordered. Review of the clinical record identified that on 3/7/25, Resident #1 weighed 76.6 pounds. Review of the facility Reportable Event (RE) dated 4/12/25 identified that at 11:00 AM Resident #1 was being transferred with the mechanical lift (A machine used to safely lift and move a person who can't stand or move on their own) by two (2) staff when he/she began to slide out of the sling (A fabric seat or support used with a mechanical lift to safely hold and move a person who cannot stand or walk on their own. It wraps around the person and attaches to the lift to help transfer them, such as from a bed to a chair) attached to the mechanical lift and the staff attempted to lower Resident #1 to the floor. The RE identified Resident #1 complained of moderate pain to the right backside of his/her head and was assessed by Registered Nurse (RN) #2 and the Medical Director (MD #1), was noted to have a small bump to the head and was observed to be at baseline. The RE identified that fifteen (15) to thirty (30) minutes later, Resident #1 was observed to have a change in Level of Consciousness (LOC), was evaluated by MD #1 and was transferred to the Emergency Department (ED) for evaluation. The RE identified that initial CT scans (imaging that uses x-rays to create detailed cross-sectional images) were negative for acute injury but that a follow-up CT scan of the head that same evening revealed a small subdural hematoma. A nurse's note dated 4/12/25 at 12:26 PM identified Resident #1 was observed laying on the floor next to his/her bed with the mechanical lift in front of him/her, with two (2) Nurse Aides (NAs) present and that initial neurological vital signs were stable. The note identified that Resident #1 was complaining of moderate pain to the right back side of the head, a small bump was noted, and a skin tear was noted to the left fourth finger. A nurse's note dated 4/12/25 at 12:57 PM identified that thirty (30) minutes after Resident #1 was observed on the floor, he/she was noted to be unresponsive, both eyes were slightly dilated (larger than normal) and he/she was not speaking or responding per baseline. The note identified MD #1 and the family were notified, Comfort Measures Only (CMO) status was discontinued and Resident #1 was sent to the ED. A physician's progress noted dated 4/12/25 identified he was called to Resident #1's bedside after staff reported Resident #1 was dropped from the mechanical lift and hit his/her head on the left lower support of the mechanical lift. The note identified that upon entering the room, Resident #1 was observed on the floor, his/her head nearly under the bed, laying perpendicular to the middle of the bed, he/she was awake and alert, and a small contusion was noted to the right posterior (backside) skull with no bleeding. The note identified that the assessment was negative, Resident #1 appeared to be at his/her baseline and ice was ordered to be applied to the area. About 15 to 20 minutes later, Resident #1 was unresponsive to voice and deep sternal rub. The hospital CT of the head dated 4/12/25 at 12:56 PM, performed due to head trauma, identified no acute intracranial abnormality. The hospital CT of the head dated 4/12/25 at 10:18 PM, performed due to mental status change, identified there was a new acute left frontal subdural hematoma. The facility Summary Report dated 4/16/25 identified that following the 4/12/25 incident, both NA #1 and NA #2 were sent home pending an investigation. The report identified both NAs stated Resident #1 had been positioned properly on the small standard mechanical lift sling (standard sling) and while transferring Resident #1, he/she became fidgety, and his/her right side began to slip out of the right side of the standard sling. The report identified both NAs denied witnessing Resident #1 hitting his/her head but further identified NA #1 reported she quickly removed the standard sling leg strap from the mechanical lift bar and the mechanical lift bar may have struck the back of Resident #1's head. The report identified NA #1 could not locate the small full body mechanical lift sling (full body sling), as directed for use on the resident care card (RCC), so Resident #1 was instead transferred with a standard sling. Following the incident and Resident #1's transfer to the ED, Resident #1's hospital diagnoses included a right frontal subdural hematoma. The facility summary identified past non-compliance. Following the incident, an audit was conducted to ensure all residents who required mechanical lift transfer equipment had the proper transfer equipment indicated on the RCC and that the slings were available for use. The summary identified that NA and licensed staff education was initiated on 4/12/25 to include ensuring proper mechanical lift transfers and identified that hooks would be added to the back of resident room doors to provide a standard location for the mechanical lift slings. Random weekly audits were to be completed to ensure that the proper slings were being utilized for residents requiring mechanical lift transfers for sixty (60) days . Review of the RCC on 5/5/25 identified that Resident #1 required a mechanical lift with a small full body mechanical lift sling for transfers . Interview with NA #1 on 5/5/25 at 1:03 PM identified that although she was aware that the RCC directed Resident #1 be transferred using the full body sling, she could not locate the full body sling and did not ask for assistance, she instead located a standard sling and thought it would be adequate. She identified that she placed the standard sling under Resident #1 in bed, attached the loops to the clips on the mechanical lift and then requested assistance from NA #2. NA #1 reported that she thought Resident #1 was positioned correctly in the standard sling, and NA #2 controlled the mechanical lift. As NA #2 lifted Resident #1 up, she (NA #1) guided Resident #1 and as they prepared to position him/her over the chair, Resident #1 started to slide out of the right side of the standard sling. NA #2 lowered Resident #1 but was unable to lower him/her in the chair. Instead, NA #2 lowered Resident #1 to the floor as she (NA #1) unclipped the right bottom hook from the loop to release Resident #1 and then tried to hold and lower Resident #1 to the floor. NA #1 identified she did not use the correct sling for the transfer which was the reason Resident #1 fell from the mechanical lift. Interview with NA #2 on 5/5/25 at 1:08 PM identified that on 4/12/25, NA #1 requested her assistance with transferring Resident #1 from the bed to the chair and identified that she (NA #2) was not familiar with Resident #1. She identified there was a red sticker outside of the room door indicating a size small sling was to be used for transfers and when she entered the room, the sling under Resident #1 was already hooked to the mechanical lift and had a red ribbon, so she assumed the correct sling was in place. She identified she was operating the mechanical lift with the controller and as she lifted Resident #1 off the bed, she turned the mechanical lift to face the chair (between the two beds) and while Resident #1 was suspended over the floor, Resident #1 was observed to be crooked in the sling and his/her right side began to slide out of the sling. She identified there was no safe way to lower Resident #1 into the chair so they lowered Resident #1 to the floor. She identified that she lowered Resident #1 quickly as NA #1 guided him/her down by the sling to the floor and that NA #1 detached one of the loops from the right side of the mechanical lift. She identified she should have ensured the correct sling was in pace prior to transferring Resident #1. Interview with the DNS on 5/5/25 at 1:47 PM identified that both NA #1 and NA #2 should have ensured that the correct mechanical lift sling was utilized prior to transferring Resident #1 and reported that the facility had since provided education to staff on mechanical lift transfers, installed hooks on the back of residents room doors to store the slings and that the color of the sling to be used for each resident and whether it is a standard or full body sling is notated on the RCC. Review of the Mechanical Lift Transfer Policy, revised 4/2025 identified that it is the responsibility of the NAs using the mechanical lift to ensure the proper sling size for the resident is being used and that the loops of the sling straps are securely in place before attempting the transfer and during the transfer. The proper sling size will be indicated on the resident's care card and a red sling is used for residents weighing between 75 and 124 pounds. The mechanical lift should be operated by a minimum of two staff members when safely transferring the resident.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for pressure injuries (ulcers), the facility failed to ensure a physician's order directing the settings for a pressure redistribution air mattress. The findings include: Resident #2's diagnoses included dementia with behavioral disturbances, weakness, pain, glaucoma (an eye condition that damages the optic nerve and can cause vision loss or blindness) and anxiety disorder. A physician's order dated 10/28/24 directed to check function of the air mattress every shift to maintain pressure reduction and evaluate for bottoming out with hand check every shift. A physician's order dated 12/31/24 directed to check low air loss mattress function every shift to maintain pressure reduction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 2) and was dependent on staff for bed mobility and transfers. The MDS identified Resident #2 was at risk for pressure ulcers/injuries and that a pressure reducing device was in place to the bed. The Resident Care Plan (RCP) dated 4/10/25 identified Resident #2 had actual/potential impairment to skin integrity related to impaired mobility and agitation/combativeness. Interventions included an air mattress to Resident #1's bed and staff to check the function every shift to maintain pressure reduction and evaluate for bottoming out with hand check every shift. A Wound Care Specialist note dated 5/1/25 identified Resident #2 had 2 new unstageable wounds to the right medial foot and to the left medial foot. Observation and interview with the DNS on 5/5/25 at 10:34 AM identified Resident #2 sitting in the wheelchair to the left of his/her bed. A scoop air mattress was in place to the bed and the air mattress was set to normal pressure with the settings knob between 160 and 240, positioned slightly above 160. There were no markers to identify the exact air mattress setting. The DNS reported that although there were no markers to identify the exact setting of the air mattress, the air mattresses were to be set to the resident's weight, and staff estimate where the dial should be turned to. Review of the clinical record on 5/5/25 identified a weight of 122.2 pounds on 3/27/25. Re-interview with the DNS on 5/5/25 at 12:36 PM identified that the providers order should include air mattress settings according to the resident's weight to ensure the air mattress is set accurately each shift. She indicated that the air mattress was set to above 160 pounds and could not provide documentation to identify the settings were being checked by licensed staff. The DNS identified that the facility was currently having licensed staff push down on the air mattress every shift to ensure that the bottom of the bed could not be felt, which would indicate that the air mattress was inflated. Interview with the ADNS on 5/5/25 at 12:40 PM identified that inaccurate air mattress settings would put a resident at risk for skin breakdown. Review of the Fairview Use of Support Surfaces policy dated 4/1/24 directed, in part, that support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Except for the facility's standard mattresses and wheelchair cushions, support surfaces will be utilized in accordance with physician's orders. For powered devices, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and/or inflation. Guidelines for support surface selection may be utilized in obtaining physician's orders. The guidelines are to be used to assist in treatment decision making, but do not supersede physician clinical judgement or orders. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. The effectiveness of support surfaces will be monitored through ongoing assessment of the resident and/or wound.

Based on the tour of the Dietary Department, staff interviews, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure food was served under sanitary conditions, and failed to ensure correct dishwasher temperatures. The findings included: Tour of the Dietary Department on [DATE] at 10:42 AM with the Assistant Dietary Manager identified the following: 1a. The windowsill, across from the walk-in freezer, was noted to have a heavy accumulation of dirt, dust, and a dead insect was present. b. The window tracking on the window outside of the walk-in refrigerator was noted to have a heavy accumulation of dirt, dust, and dead bugs. c. A brown substance was noted splattered on the door frame in between the kitchen and dish room and on the ceiling tiles in the dish room. d. The fan pointing over the 3 bay sink area was noted with a heavy accumulation of dust. e. The fan over a clean dish rack where clean items were stored (2 ladles, 1 hotel pan, 2 serving spoons, a scooper and a small pan) was noted with a heavy accumulation of dust. f. The inside of a Convection oven on the side of the tray line was noted to have an accumulation of crumbs and a dried splattered substance on the sides and bottom of the oven. g. A 10-gallon bin of flour was noted to have a heavy accumulation of a dried white substance on the lid. h. A 1-gallon jug of molasses stored on a tray with spices was noted to have a brown, sticky substance all over the outside of the container. i. The walk-in freezer was noted to contain an opened 3-pound bag of hash browns (that was ,d+[DATE] full), an opened 2-pound bag of french fries (that was ,d+[DATE] full), an opened 2-pound bag of blueberries (that was ,d+[DATE] full), and an opened 10-pound bag of tilapia fish (that was ,d+[DATE] full) with no open date or expiration date identified. j. The walk- in refrigerator was noted to contain an opened 5-pound bag of mozzarella cheese (that was ,d+[DATE] full) with no open date or expiration date. k. On [DATE] at 12:39 PM observation of the dry storage room with the Assistant Dietary Manager identified an opened 10-pound bag of macaroni noodles (that was ,d+[DATE] full), an opened bag of nuts (that was ,d+[DATE] full) and an opened ,d+[DATE] bag of coconut flakes with no open date or expiration date. Interview with the Assistant Dietary Manager at that time identified that the staff member who opened the food items should have labeled the food item with a date when opened, as well as when items should have been discarded or expired. She also identified that it was her responsibility to do spot checks in the freezer, refrigerator, and dry storage room to ensure open items were dated and labeled correctly at least weekly but must have overlooked the non-dated items. Review of the Date Marking for Food Safety policy dated [DATE] directed, in part, that food should be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food should be responsible for the date marking the food at the time the food is opened or prepared. The marking system should consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. The Dietary Manager, or designee, should spot check refrigerators weekly for compliance, and document accordingly. Additionally, the Assistant Dietary Manager identified there was a cleaning schedule for cleaning equipment and areas of the Dietary department, she was responsible for ensuring areas were clean and did not identify the soiled areas. 2a. On [DATE] at 12:17 PM dishwasher temperature logs were reviewed with the Assistant Dietary Manager for [DATE], [DATE], [DATE] and [DATE], which identified the wash and rinse temperatures were low. On [DATE], [DATE], [DATE], and [DATE] the rinse temperatures were recorded at 160 degrees Fahrenheit, (should be 180 degrees Fahrenheit or above but not exceed 194 degrees Fahrenheit, per manufactures guidelines). On [DATE], [DATE], and [DATE] the wash temperatures were recorded at 140 degrees Fahrenheit, (should be 150 to 165 degrees Fahrenheit, per manufactures guidelines). The temperature logs failed to reflect any follow up regarding the low temperatures. Interview with the Assistant Dietary Manager at that time identified the temperatures were taken by Dietary Aide (DA) #1 for the dishwasher, which were inaccurate because he must have been reading the wrong dial on the dishwasher, however, DA #1 did not report obtaining low temperatures, so the reason for low temperatures could be identified. She identified that she noticed the incorrect temperature readings in the logs on [DATE] and notified the dishwasher company at that time to come out and assess the dishwasher. Additionally, she identified DA #1 should have reported obtaining low temperatures at the time he took them. Subsequent to surveyor inquiry of low dishwashing temperatures, Dietary staff were in-serviced on how to take dishwashing temperatures and the dials on the machine have been labeled according to the in-service instructions. On [DATE] at 1:06 PM interview with DA #1 identified that he documented the dishwashing temperatures on [DATE], [DATE], [DATE] and [DATE] and he was unsure of which gauge to look at to record the temperatures for the wash and rinse cycle. He stated that he was not aware of what the correct temperatures should be and that was the reason he did not notify the Assistant Dietary Manager of the low readings. 2b. On [DATE] at 9:55 AM observation with the Assistant Dietary Manager identified a plastic tray of metal cutlery being put through the dishwasher by DA #2. The wash temperature was 126 degrees Fahrenheit (normal temperature should be 150 to 165 degrees Fahrenheit) and the rinse temperature reading was 160 degrees Fahrenheit (normal temperature should be 180 to 194 degrees Fahrenheit) DA #2 did not note the low temperatures during or after the tray of utensils passed through the dishwasher and proceeded to load a plastic tray with lid covers through the machine even after a low wash cycle reading. Interview on [DATE] at 10:00 AM with the Assistant Dietary Manager identified that the wash and rinse temperatures were low and DA #2 should have checked the temperatures at the start of the dishwashing process and documented on the log. She identified that DA #2 should have been checking the temperatures throughout the process of running the machine and should have stopped the dishwashing and notified her of the low temperature, and she would have contacted the dishwasher company. She stated that they would put the cutlery through the sanitizing solution. Interview on [DATE] at 10:04 AM with DA #2 identified that he saw the temperatures were reading low and that he was going to tell the Assistant Dietary Manager later, but continued to pass items through the dishwasher. Review of the Dishwasher Temperature Policy identified the correct wash temperature should be ,d+[DATE] degrees Fahrenheit and the final rinse temperature should be 180 degrees Fahrenheit. Policy identified if the dishwasher is not working properly to notify the cook, supervisor, and the maintenance department. Corrective action for temperatures below the final rinse temperature (180 degree F) All dishes after being washed through the dishwasher will be submerged in premeasured sanitizer for greater than 30 seconds and racked to air dry. Corrective action taken for dishwasher being out of service would be All dishes would be scraped, washed, rinsed, and sanitized (submerged in premeasured sanitizer for greater than 30 seconds and racked to air dry) in a three-compartment sink. Another Corrective action for dishwasher being out of service would be to serve meals on all paper products until dishwasher is operational.

Based on review of the clinical record, facility policy, and interviews for 2 of 6 sampled residents (Resident #23 and Resident #48) who were reviewed for unnecessary medications, the facility failed to ensure timely responses to pharmacy recommendations for the use of psychotropic medications. The findings include: 1. Resident #23's diagnoses included Alzheimer's disease, dementia and received hospice services. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired and required maximal assistance with eating and was totally dependent for toilet use, upper/lower body dressing and personal hygiene. The MDS further identified Resident #23 was on Antidepressant and Opiod medication. The Resident Care Plan identified Resident #23 used antidepressant medication related to depression, and poor appetite with interventions that include administering antidepressant medications as ordered by the physician monitoring/documenting side effects, and effectiveness every shift, educate the resident/family/caregivers about risks, benefits, and the side effects and or toxic symptoms. Additional interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy and change in behavior/mood/cognition. Physician orders dated 3/31/24 directed Trazodone (an antidepressant) 25 milligrams (mg) every 8 hours as needed for anxiety and agitation, but failed to identify a stop date. Medication Administration Records (MAR) for as needed (PRN) medications for April 2024 through 7/15/24 identified Trazodone 25 mg every 8 hours as needed for anxiety/restlessness was signed off as being administered on 4/1/24, 4/16/24, 4/18/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/26/24, 4/29/24 and 4/30/24 (10 times in April 2024). The MAR further identified Resident #23 received PRN Trazodone 25 mg on 5/1/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/21/24, 5/23/24, and 5/27/24 (9 times in May 2024) and 6/21/24, 6/25/24 and 6/27/24 (3 times in June 2024). The MAR further identified Resident #23 received PRN Trazodone once (7/5/24) in July 2024. Pharmacy review dated 4/29/24 recommended including a stop date for the PRN psychotropic medication (Trazodone) due to The Centers for Medicare and Medicaid (CMS) guidelines not allowing open-ended orders for PRN psychotropics on medication profiles. Further review identified hospice patients were not excluded from this regulation. Physician orders failed to reflect a stop date, after the pharmacy recommendation dated 4/29/24. A progress note dated 5/30/24 identified another medication review was completed by the pharmacy consultant, although no recommendations for the prescriber were documented on this visit, an interview with Pharmacist #1 on 7/15/24 at 1:15 PM identified that the pharmacist spoke to the DNS verbally on 5/30/24 about the Medication Review (MRR) for Resident #23 not being addressed from 4/29/24 regarding including a stop date for PRN Trazodone. An additional pharmacy recommendation dated 6/27/24 was identified with another recommendation for the prescriber to include a stop date for the PRN psychotropic medication (Trazodone) identifying that hospice patients were not excluded from this regulation. The further review identified on 7/3/24 the Advanced Practice Registered Nurse (APRN) responded to a pharmacy recommendation that was made on 6/27/24 and directed Trazodone 25 mg every 8 hours PRN anxiety/restlessness for 30 days. A progress note dated 6/28/24 identified that the APRN had an encounter with Resident #23 however did address the addition of the stop date for the PRN Trazodone in the note. Further review identified another progress note dated 7/4/24 of an encounter by MD #1 and ordered Trazodone 25 mg orally every eight hours as needed for anxiety with no stop date indicated. An interview with the Director of Nursing Services (DNS) on 7/15/24 at 12:25 PM identified that there was no specific time frame for addressing pharmacy recommendations on their facility policy, she did not have a copy of the pharmacy policy for MRRs, and that she did not remember if the pharmacy policy for MRR included an expected time frame for addressing their recommendations. An interview with Pharmacist #1 on 7/15/24 at 1:15 PM, identified that the expectation for addressing pharmacy recommendations was within 14 days. The interview further identified the 4/29/24 MRR for Resident #23 was not addressed and they spoke verbally to the DNS on 5/30/24 to reiterate the April 2024 recommendation for adding a stop date to the PRN Trazodone. The interview further identified the prescriber had still not addressed the recommendation by the 6/27/24 MRR so a third recommendation was made. The pharmacist was due to return for the July 2024 MRR at the end of the month. Facility policy for Medication Regimen Review (MRR) identified facility staff shall act upon all MRR recommendations according to procedures for addressing MRR irregularities; however, the policy is not specific to the facility staff's responsibility for ensuring the recommendations are brought to the prescriber's attention or the expected timeframe for addressing the pharmacy recommendations. 2. Resident #48's diagnoses included generalized anxiety disorder, depression, and insomnia. The admission baseline Resident Care Plan dated 1/24/24 identified Resident #48 received an anti-anxiety medication related to an anxiety disorder. Interventions included administering anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift, and to monitor the resident for safety. The admission Minimum Data Set assessment dated [DATE] identified Resident #48 was cognitively intact, required setup or clean-up assistance with eating, supervision or touching assistance with personal hygiene, and supervision or touching assistance with chair/bed-to-chair transfers. APRN's orders dated 1/22/24 directed to administer Hydroxyzine (Atarax) 25 milligrams (mg) by mouth every 8 hours as needed for anxiety/insomnia and to administer Trazodone 25 mg by mouth nightly as needed for insomnia/sleep. A pharmacy consultant note dated 1/23/24 at 11:40 AM identified recommendations were made for Resident #48's medication regimen for the prescriber to review. Review of the pharmacist recommendations dated 1/23/24 included to either provide a stop date for the as needed medications (Atarax and Trazodone) or consider discontinuing the medication(s) (Atarax and Trazodone) per Centers for Medicare and Medicaid Services guidance. The recommendation was not noted to be addressed. Further review of the clinical record identified a second request from the pharmacy consultant dated 3/29/24 (66 days following the initial request) for the prescriber to, again, either provide a stop date for the as needed medications (Atarax and Trazodone) or consider discontinuing the medication(s) (Atarax and Trazodone). Review of the psychiatric APRN orders dated 4/23/24 (91 days after the original request) directed to discontinue the as needed Trazodone and add a stop date to the Atarax medication for 90 days. Review of the Medication Regimen Review policy dated 3/12/2024 directed, in part, the pharmacist shall communicate any irregularities to the facility; written communication to the attending physician, the facility's Medical Director, and the Director of Nursing; and facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. 51183

Based on observations, staff interviews, review of the clinical record, facility documentation, and facility policy, for the only sampled resident reviewed (Resident #43) for physical restraints, the facility failed to revise the Resident Care Plan (RCP) upon initiation of a resident's clip alarm. The findings include: Resident #43's diagnoses included vascular dementia, history of transient ischemic attack/cerebral infarction and primary open angle glaucoma. The Nurse Aide (NA) Assignment sheet, last updated on 4/8/24, failed to identify a bed/chair tab alarm under the area of Safety Devices. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired and dependent with transfers, bed mobility and toileting. The MDS further indicated that a bed alarm and chair alarm were not used and that the resident had two or more falls since his/her last assessment. The Resident Care Plan (RCP) dated 6/30/24 identified Resident #43 had a history of falls with interventions that included a floor mat on the left side of the bed and a Dycem under the wheelchair cushion. The RCP failed to identify a clip alarm was utilized as an intervention. Observations on 7/9/24 at 1:50 PM and 7/11/24 at 10:40 AM identified Resident #43 seated in his/her bedside chair with a clip alarm in place. The alarm box was placed on the side of the top drawer of Resident #43's bedside table and the alarm clip was attached to Resident #43's sweatshirt. Interview, observation and review of facility documentation with NA #4 on 7/11/24 at 10:50 AM identified Resident #43 was a fall risk and the clip alarm was used on both his/her bed and chair. NA #4 demonstrated setting off the alarm and indicated that it was attached to Resident #43's sweatshirt. Additionally, NA #4 identified that she would refer to Resident #43's NA care card to determine if Resident #43 required a clip alarm. NA #4 then reviewed Resident #43's NA care card but could not find documentation for the clip alarm. NA #4 further indicated that the NA care card should have been updated by the nursing supervisor. Interview, observation and review of facility documentation with RN #1 on 7/11/24 at 11:00 AM identified that Resident #43 had a clip alarm in place and that the alarm clip was attached to Resident #43's sweatshirt. RN #1 indicated that nursing staff would know to place the alarm on Resident #43 by reviewing the NA care card and RCP. RN #1 then reviewed Resident #43's NA care card, however could not find documentation for the clip alarm. Additionally, RN #1 identified that it would have been the responsibility of the nursing supervisor to update the NA care card and would notify the nursing supervisor to update the NA care card updated. Interview and review of facility documentation and clinical record with the DNS on 7/15/24 at 10:50 AM identified Resident #43 required a clip alarm due to a history of falls, but she was unsure of the date the clip alarm was initiated. The DNS indicated that the resident's clip alarm had been put in place to alert staff when Resident #43 was possibly getting out of his/her bed or chair unassisted. Additionally, although the DNS identified that the need to use the clip alarm for Resident #43 should have been on his/her NA care card and in his/her RCP, review of facility documentation failed to alert staff to the need for a clip alarm. The DNS was unable to state the reason the use of the clip alarm was not added to Resident #43's NA care card and RCP, but that it was the responsibility of the nursing staff who had implemented the use of the clip alarm to update the documentation to ensure all staff knew Resident #43 required an alarm. Subsequent to surveyor inquiry, Resident #43's clip alarm was removed/discontinued by the facility. Review of the facility's Comprehensive Care Plan policy, dated 4/28/22, directs that qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observations, staff interview, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #28) reviewed for activities of daily living, the facility failed to ensure Resident #28's fingernails were clean and trimmed. The findings include: Resident #28's diagnoses included unspecified dementia, cognitive communication deficit and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was moderately cognitively impaired and dependent with transfers, toileting and personal hygiene. The Resident Care Plan (RCP) dated 6/26/24 identified Resident #28 had deficits in activities of daily living (ADL's) and mobility related to weakness. Interventions included to set-up and assist resident as needed for morning/evening (am/pm) care. The RCP further identified that Resident #28 had a potential for impairment to skin integrity related to decreased mobility with interventions to avoid scratching and keep fingernails short. Observation and interview with Resident #28 on 7/9/24 at 12:48 PM identified that his/her fingernails on both hands were unclean, lengthy, and longer than he/she preferred. Resident #28 indicated that the Nurse Aides (NAs) had not cut his/her fingernails in the last few weeks and that he/she was going to ask them to cut them this week. Observation and interview with Licensed Practical Nurse (LPN) #1 on 7/10/24 at 11:30 AM identified that Resident #28's fingernails on both hands were lengthy and unclean. LPN #1 further indicated that Resident #28's fingernails should have been cleaned and trimmed on his/her last shower day and that she would make Resident #28's assigned NA aware to get them trimmed and cleaned. Additionally, LPN #1 identified that Resident #28's weekly shower day was Saturday on the 3:00 PM to 11:00 PM shift and that the assigned NA for the shower would have been responsible to trim and clean Resident #28's fingernails with his/her shower. Subsequent to surveyor inquiry, observation and interview of Resident #28 on 7/11/24 at 1:40 PM identified that his/her fingernails on both hands were clean and trimmed. Resident #28 further indicated that it was nice to finally have them cut. Interview and review of facility documentation with NA #7 on 7/11/24 at 1:49 PM identified that NA #8 was assigned to Resident #28 on Saturday 7/6/24 for the 3:00 PM to 11:00 PM shift. NA #7 further identified that NA #8 would have been responsible for Resident #28's shower and nail trimming on that shift. NA #7 further indicated she could not find documentation from NA #8 as to the reason Resident #28's fingernails were not cleaned and trimmed on the shower day of 7/6/24. Attempts to contact NA #8 were unsuccessful. Facility policy on Nail Care, dated 10/10/23, directed that routine cleaning and inspection of nails would be provided during ADL care and on an ongoing basis. In addition, the policy indicated that routine nail care, to include trimming and filing, would be provided on a regular schedule with weekly bath day.

Based on observations, interviews, facility policy, and review of the clinical record for 2 of 3 residents (Resident #6 and Resident #25) reviewed for skin conditions, the facility failed to follow physician orders regarding the application of compression stockings and heel offloading. Additionally, for 1 of 3 sampled residents (Resident #25) reviewed for pressure ulcers, the facility failed to complete weekly skin assessments 2 of 4 weeks. Also, for 1 of 3 residents (Resident #82), reviewed for nutrition, the facility failed to follow a physician's order for 1-to-1 assistance with eating for a dependent resident. The findings include: 1. Resident #6's diagnoses included cerebral infarction (stroke), hyperlipidemia, hypertension, and altered mental status. A Nurse Aide (NA) care card dated 4/19/24 directed TED (thrombo-embolic deterrent) hose to be applied on Resident #6 in the morning and to be removed in the evening. A significant change Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired, was dependent with toileting hygiene and showering/bathing self, and required partial/moderate assistance with personal hygiene. A physician's order dated 5/7/24 directed compression stockings to be applied on Resident #6 in the morning and to be removed in the evening. The Resident Care Plan dated 5/23/24 identified Resident #6 was at risk for an altered cardiovascular status related to hypertension, hyperlipidemia, embolic stroke, and the presence of a cardiac monitor. Interventions included to administer medications per physician's orders and to wear compression stockings as ordered. Observations on 7/8/24 at 12:40 PM, 7/9/24 at 11:06 AM, 7/10/24 at 12:20 PM, and 7/11/24 at 10:59 AM identified that Resident #6 was not wearing compression stockings. The Electronic Medication Administration Record (EMAR) for the month of June 2024 identified that compression stockings were signed as being applied on all dates. Review of the EMAR for 7/1/24 through 7/11/24 identified that compression stockings were signed as being applied (despite on 7/8/24, 7/9/24, 7/10/24 and 7/11/24, Resident #6 was not wearing compression stockings). Interview, clinical record review, and observation with RN #4 on 7/11/24 at 11:07 AM identified that Resident #6 was not wearing compression stockings despite having a current order for compression stockings to be worn daily. Additionally, RN #4 had signed for the application of the compression stockings on 7/11/24 despite Resident #6 not wearing any compression stockings. RN #4 identified that the NA would apply the compression stockings on Resident #6. RN #4 further indicated she would change her documentation on the EMAR for 7/11/24 since the compression stockings were not observed on Resident #6. Subsequent to surveyor inquiry on 7/11/24, compression stockings were discontinued by the physician. Although requested, a facility policy for compression stockings was not provided. Interview with the Director of Nursing Services on 7/11/24 at 1:48 PM identified that in lieu of a policy, it would be expected that compression stockings be applied per the physician's order. 2. Resident #25's diagnosis included stroke, peripheral artery disease, and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had intact cognition, required partial/moderate assistance for bed mobility, and was at risk for developing pressure injuries. The Resident Care Plan (RCP) dated 4/17/24 identified Resident #25 as having the potential for impairment to skin integrity related to impaired mobility, history of pressure wound, and diabetes mellitus. A physician's order dated 5/14/24 directed facility staff to elevate and offload Resident #25's right heel while in bed, at all times and for facility staff to not place a pillow under the left limb to prevent contracture. a. Observation on 7/9/24 at 8:55 AM identified Resident #25 in bed asleep with his/her right heel flat on the mattress. The foot of the bed was noted to be elevated. Subsequent observations on 7/9/24 at 9:20 AM, 9:33 AM, 9:48 AM, 10:03 AM, 10:15 AM, 10:28 AM, 10:43 AM, 11:00 AM, 11:15 AM and 11:30 AM, identified Resident #25's position remained unchanged. Interview with NA #5 on 7/9/24 at 11:15 AM identified the NA care card included handwritten instructions including the symbol circle with a line through it, (signifying without) but she was unaware of the meaning of the symbol. NA #5 was unaware of what the initials AATs meant after the words foot of bed flat AAT's (at all times). Further, NA #5 identified the care card did not direct offloading of Resident #25's right heel. Interview and review of the clinical record with LPN #5 on 7/9/24 at 11:25 AM identified a physician's order directing offloading of the right heel and that the NA should know offloading instructions based on the NA care card. However, review of the Resident Care Plan (RCP) and NA care card failed to indicate that Resident #25's right heel was to be off-loaded according to physician orders. LPN #5 further identified the 11:00 PM to 7:00 AM shift was responsible for updating the NA care card and the care cards were frequently not updated. An interview with the DNS on 7/9/24 at 11:35 AM identified the NA care card should be updated by the licensed nurse who notes a new order and Resident #25's care card should have been updated with the right heel offloading order. The DNS stated it was facility policy for staff to follow physician's orders. b. Review of the facility's Weekly Bath Skin Observations identified 2 out of 4 assessments missing in June of 2024. Interview with the DNS on 7/9/24 at 10:40 AM, identified skin checks were to be completed weekly. The facility Pressure Injury Prevention and Management Policy included licensed nurses will conduct a full body assessment weekly. 3. Resident #82 was admitted to the facility with diagnoses that included dementia, dysphagia (swallowing difficulty), and osteoporosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 was severely cognitively impaired, required substantial/maximal assistance for bed mobility, was dependent for toileting, and was independent for eating. The Resident Care Plan dated 6/30/24 identified Resident #82 had an Activity of Daily Living (ADL)/mobility status deficit related to dementia and included an intervention to set up and assist as needed with eating. Review of the APRN's orders and progress note dated 7/4/24 directed that Resident #82 required 1-to-1 assistance with eating. During an observation on 7/9/24 at 9:10 AM, Resident #82 was sleeping in bed, with the head of bed elevated to approximately 45 degrees. Resident #82's breakfast tray was noted in front of him/her on the over bed table and was within Resident #82's reach. The meal was noted to be covered. No staff were observed in Resident #82's room or outside the door. Subsequent observations at 9:25 AM, 9:40 AM, 9:55 AM, 10:10 AM, and 10:25 AM were unchanged. At 10:40 AM Resident #82 was up in the wheelchair and the breakfast tray had been removed. During an observation on 7/9/24 at 12:45 PM Resident #82 was seated in his/her wheelchair in the main dining room at a table with 3 other residents. Resident #82 was noted to be independently eating a toasted piece of bread. There were no staff observed in the dining room. Review of the Nurse Aid (NA) care card dated 5/2/24 identified contradictory instruction to assist Resident #82. In one area staff were directed to provide Resident #82 with supervision but in another area, the resident was totally dependent on staff to eat. Review of the NA flow sheets titled Documentation Survey Report identified staff documented Resident #82 was independent for eating (no help or staff oversight at any time) for 87 out of 90 meals in June of 2024 and 27 out of 42 meals in July of 2024. An interview with RN #3 on 7/11/24 at 10:54 AM identified that residents who were dependent with 1-to-1 assistance meant that a staff member must always be present while the resident ate. RN #3 indicated that 1 NA was assigned and required to remain in the dining room while residents were eating due to the risk of choking. Additionally, RN #3 stated Resident #82's meal tray should not have been left within his/her reach on 7/9/24. An interview with NA #6 on 7/11/24 at 12:45 PM, indicated on 7/9/24 she placed Resident #28's breakfast tray in front of him/her and left because she had 3 other residents who required assistance. NA #6 identified she should not have left the meal within the resident's reach because Resident #82 required supervision with meals but had done so because she thought another NA was going to assist Resident #82 with breakfast. Further, NA #6 also indicated facility policy was to ensure a staff member was present, at all times, in the dining room, during meals to supervise residents while eating and that a staff member should have been present on 7/9/24 when Resident #28 was observed eating his/her bread. An interview with the DNS on 7/11/24 at 1:30 PM identified that a resident who is 1-to-1 dependent or 1-to-1 supervision with meals should not be left alone with a meal tray within reach and that physician orders should be followed for supervision directed during meals. Review of the facility's Assist Level with Feeding policy dated 1/25/24 defined, in part, dependent, as a resident who required total physical assistance to safely eat an entire meal and defined distant supervision as a resident requiring staff to be within eyesight to consume meals and may need intermittent verbal cues/encouragement. 50890

Based on observation, staff interview, review of the clinical record, and facility policy for 1 of 3 residents (Resident #80) reviewed for pressure ulcers, the facility failed to maintain infection control practices during a dressing change. The findings include: Resident #80's diagnoses included Parkinson's disease, generalized muscle weakness, abnormal posture, and age-related cognitive decline. An Interdisciplinary Transfer document from the hospital (W-10) dated 4/17/24 identified Resident #80 had a stage 2 pressure injury on the coccyx. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was moderately cognitively impaired and required partial/moderate assistance. Additionally, the MDS identified that Resident #80 had an unstageable pressure ulcer. The Resident Care Plan dated 6/28/24 identified Resident #80 had an unstageable pressure ulcer (coccyx) and potential for pressure ulcer development related to a decline in mobility and bowel incontinence. Interventions included to administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report PRN any changes in skin status, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The physicians order dated 7/3/24 directed to cleanse the coccyx area with Normal Saline, pat dry, apply Triad to the peri wound, apply Silver Alginate to the wound bed, cover with foam dressing daily and as needed (prn) for excess drainage/dislodgement every evening shift for wound healing. Observations of the treatment to Resident #80's coccyx wound on 7/11/24 at 5:00 PM identified Licensed Practical Nurse (LPN) #4 appropriately donned personal protective equipment indicated for enhanced barrier precautions, removed the soiled dressing which contained a heavy amount of exudate, changed her gloves without the benefit of performing hand hygiene, applied the sterile gauze which already contained the normal saline and then cleaned the wound. LPN #4 then attempted to open the clean foam dressing with the gloved hands that she removed the soiled dressing with. The surveyor intervened to question clean dressing change technique (changing gloves and performing hand hygiene when going from dirty to clean). LPN #4 then applied the foam dressing per physician order. Facility policy for Clean Dressing Technique identified to remove the soiled dressing, remove gloves, wash your hands, and put on clean gloves.

Based on staff interviews, record review, and facility policy for 1 of 5 sampled residents, (Resident #23) who were reviewed for unnecessary medications, the facility failed to include a stop date on an as needed (PRN) psychotropic physician order. The findings include: Resident #23's diagnoses included Alzheimer's disease, dementia and received hospice services. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired and required maximal assistance with eating and was totally dependent for toilet use, upper/lower body dressing and personal hygiene. The MDS further identified Resident #23 was on Antidepressant and Opiod medication. The Resident Care Plan identified Resident #23 used antidepressant medication related to depression, and poor appetite with interventions that include administering antidepressant medications as ordered by the physician monitoring/documenting side effects, and effectiveness every shift, educate the resident/family/caregivers about risks, benefits, and the side effects and or toxic symptoms. Additional interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy and change in behavior/mood/cognition. Physician orders dated 3/31/24 directed Trazodone (an antidepressant) 25 milligrams (mg) every 8 hours as needed for anxiety and agitation, but failed to identify a stop date. Medication Administration Records (MAR) for as needed (PRN) medications for April 2024 through 7/15/24 identified Trazodone 25 mg every 8 hours as needed for anxiety/restlessness was signed off as being administered on 4/1/24, 4/16/24, 4/18/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/26/24, 4/29/24 and 4/30/24 (10 times in April 2024). The MAR further identified Resident #23 received PRN Trazodone 25 mg on 5/1/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/21/24, 5/23/24, and 5/27/24 (9 times in May 2024) and 6/21/24, 6/25/24 and 6/27/24 (3 times in June 2024). The MAR further identified Resident #23 received PRN Trazodone once (7/5/24) in July 2024. Pharmacy review dated 4/29/24 recommended including a stop date for the PRN psychotropic medication (Trazodone) due to The Centers for Medicare and Medicaid (CMS) guidelines not allowing open-ended orders for PRN psychotropics on medication profiles. Further review identified hospice patients were not excluded from this regulation. Physician orders failed to reflect a stop date, after the pharmacy recommendation dated 4/29/24. (Refer to F #756). A progress note dated 5/30/24 identified a medication review was completed by the pharmacy consultant; however, no recommendations for the prescriber were documented. An additional pharmacy recommendation dated 6/27/24 was identified with another recommendation for the prescriber to include a stop date for the PRN psychotropic medication (Trazodone) and that hospice patients were not excluded from this regulation. Review of the record from 7/3/24 identified the Advanced Practice Registered Nurse (APRN) responded to pharmacy recommendations from 6/27/24 and directed Trazodone 25 mg every 8 hours PRN anxiety/restlessness for 30 days. An interview with Pharmacist #1 on 7/15/24 at 1:15 PM, identified that the expectation for addressing pharmacy recommendations was within 14 days. The interview further identified the 4/29/24 MRR for Resident #23 was not addressed and they spoke verbally to the DNS on 5/30/24 to reiterate the April recommendation for adding a stop date to the PRN Trazodone. The interview further identified the prescriber had still not addressed the recommendation by the 6/27/24 MRR so a third recommendation was made. A review of facility policy and an Interview with the DNS on 7/15/24 at 12:15 PM did not identify a policy for including stop dates on psychotropic medications.

Based on interviews, review of the clinical record, and facility documentation for the only sampled resident (Resident #1) reviewed for dental, the facility failed to follow up regarding dental treatment. The findings include: Resident #1's diagnoses included dysphagia (swallowing difficulty), paraplegia, and osteoporosis. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with eating, required setup or clean up assistance with oral hygiene, and required partial/moderate assistance with personal hygiene. The Resident Care Plan dated 2/6/24 identified Resident #1 had oral/dental health problems related to missing teeth and for denture placement. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered, and to consult with the dietitian to have the diet order changed if chewing/swallowing problems were noted. A facility agreement with a Dental service provider was effective as of 2/1/24. A Dental Consent and Problem form identified that Resident #1 indicated he/she wanted to discuss an upper denture on 2/14/24. A dental progress note dated 2/29/24 identified Resident #1 reported he/she was in the process of having his/her front teeth fixed and would like to continue treatment. The dentist referred Resident #1 to a community dentist for treatment of root tips #7 and #8. Interview with Resident #1 on 7/8/24 at 11:54 AM identified that he/she was supposed to get an upper denture at the beginning of 2024 and that he/she had scans completed, but the previous dental group left the facility. Resident #1 was seen by the facility's new dental group, (the Dental service provider from 2/1/24), however he/she was unsure what the status was of his/her upper denture. Interview with the Priority Care Supervisor at the Dental service provider on 7/15/24 at 9:45 AM identified that there was no documentation that Resident #1 wanted to receive an upper denture, however Resident #1 would need to have his/her root tips treated before he/she could receive an upper denture. The Priority Care Supervisor indicated that she would make a note of the request for an upper denture in Resident #1's chart. Interview with the Unit Secretary on 7/15/24 at 9:55 AM identified that Resident #1 was seen by a community dentist on 3/22/24, however Resident #1 preferred not to return to that specific dental provider. The Unit Secretary indicated that even though she was aware Resident #1 did not want to return to the community dental provider Resident #1 had been to on 3/22/24, she did not attempt to find an alternate dental provider, or discuss the issue with Social Services (SS) or the Director of Nursing Services (DNS). Additionally, the Unit Secretary identified that it was her responsibility to advise the facility contracted Dental service group of the residents' problems via email and was unable to confirm communication occurred via email regarding Resident #1 wanting to receive an upper denture. Interview with the DNS on 7/15/14 at 12:45 PM identified that she was not aware Resident #1 did not want to return to the community dental provider Resident #1 had been to on 3/22/24. Additionally, the DNS indicated that had she been aware, she would have discussed the issue with the interdisciplinary team and SS, and would have searched for a new dental provider after the 3/22/24 dental appointment. Subsequent to surveyor inquiry, the Unit Secretary emailed the facility contracted Dental service provider on 7/15/24 requesting information for additional dental providers. Additionally, the Unit Secretary contacted an alternative dental provider and indicated she would also discuss the need to find a different dental provider with SS.

Based on review of staff interviews, review of the clinical records, facility documentation, and facility policy for two sampled residents (Residents #50 and Resident #55) reviewed for a resident to resident altercation, the facility failed to notify Adult Protective Services (APS) of the altercation. The findings include: 1. Resident #50's diagnoses included dementia, insomnia, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 was moderately cognitively impaired, required supervision/touching assist for eating, oral hygiene, transferring, and personal hygiene, and partial moderate assist for toilet hygiene. The Resident Care Plan (RCP) dated 5/2/24 identified Resident#50 was at risk of wandering. and had insomnia. Interventions included to identify patterns of wandering, distract the resident from wandering and to communicate resident's potential for wandering to staff at the unit, try to improve sleep, preferred hours of sleep routine, decrease noise level after, and maximize daily activities. 2. Resident #55's diagnoses included dementia, contracture (prevents normal movement), and weakness. The quarterly MDS assessment dated [DATE] identified Resident #55 was severely cognitively impaired, dependent on staff for oral hygiene, eating, toileting, personal hygiene, and dressing, requiring the assist of 2 for transfers with a mechanical lift. The Resident Care Plan dated 5/15/24 identified Resident #55 was at risk for falls related to dementia, and poor safety awareness. Interventions included to anticipate and meet the resident's needs, be sure that Resident #55's call light was within reach and encourage the resident to use it. A Reportable Event form dated 5/21/24 identified at 12:45 AM, Licensed Practical Nurse (LPN) #7 heard yelling down the hall get out of my bed. LPN #7 told Nurse Aide (NA) #1 that she would be right back as she headed down the hall from the nurse's station. LPN #7 was walking by Resident #50's room and it was empty. LPN #7 followed the yelling and observed Resident #50 trying to pull Resident #55 out of bed by squeezing and shaking Resident #55's head. Resident #55 was contracted, and his/her legs were hanging off the side of the bed. LPN #7 identified that the railing held Resident #55 in bed. Both residents were immediately separated and assessed. Resident #55 had 2 discolored areas noted, 1 to his/her left eye and the other to the left side of his/her face. LPN #7 returned Resident #50 to his/her room with assistance, was placed on one-to-one supervision, Psychiatric and Social Services were provided. Interview with LPN #7 on 7/10/24 at 2:02 PM identified on 5/21/24 that Resident #50 had been wandering and that they had placed her/him near the nurse's station. LPN #7 identified that she heard yelling, and that Resident #50's room was empty and found her/him in Resident #55's room. LPN#7 identified that Resident #50 was attempting to pull Resident #55 out of bed while yelling get out of my bed. LPN #7 reported the occurrence to the supervisor and a motion sensor was placed at Resident #50's doorway. Additional review of the Reportable Event form dated 5/21/24 at 12:45 AM failed to identify Adult Protective Services were notified of the resident to resident altercation. Interview with the Director of Nursing Services (DNS) on 7/11/24 at 10:33 AM identified she did not feel the situation warranted notifying Adult Protective Services and that she had never notified Adult Protective Services in the past when the situation involved a resident to resident alteration even though the facility policy identified that the agency should be notified within 3 days. The DNS identified she was unaware of the state guidelines regarding notifying Adult Protective Services. Facility's Resident Abuse policy identified reporting requirements include notifying Adult Protective Services within 3 days.

Based on observation, review of the clinical record, facility documentation, facility policy and interview for 4 of 11 residents (Residents #29, 71, 165, and 166), reviewed for accidents, the facility failed to ensure an assistive device was used appropriately to prevent an accident with injury, and/or failed to ensure the plan of care was followed to prevent a fall and/or failed to ensure equipment was in functioning order to prevent an elopement. The findings include: 1. Resident #29's [DIAGNOSES REDACTED]. The care plan, originally dated 10/17/16, (lacking a revision date) identified Resident #29 was at risk for falls related to confusion, incontinence and unaware of safety needs. Interventions included to anticipate and meet needs, ensure the call light is in place, physical therapy evaluation and treatment as indicated and the use of a high back shower chair. A fall risk assessment dated [DATE] identified Resident #29 had a modified risk for falls. A quarterly MDS dated [DATE] identified Resident #29 had short and long term memory problems, severely impaired cognition, required extensive assistance with ADLs, was non-ambulatory and had no falls. physician's orders [REDACTED].#29 with a mechanical lift and the assistance of 2 staff using the yellow sling. The orders further directed to transfer to the adaptive wheelchair with pelvic positioning belt and roho cushion. Facility documentation dated 4/13/18 identified that during a mechanical lift transfer by NA #2 and NA #3, Resident #29 fell to the floor and hit his/her head on the metal rail of the mechanical lift. Physicians order dated 4/13/18 directed to send Resident #29 to the emergency department for evaluation. Resident #29 sustained a laceration to the back of the head that required 2 staples to close. The facility investigation dated 4/13/18 identified that although NA #3 was sure he/she attached the straps/loops to the lift properly, he/she did not check NA #2's straps/loop placement. The investigation further indicated that although the facility could not definitely identify the root cause of the accident, the documentation identified the strap/loop would have difficulty coming off the lift if it had been placed correctly. Further, the investigation identified that the staff may not have been communicating their actions effectively, and in-servicing had been implemented. A visual reminder was added to the lifts to check that sling/loops are in place. A statement by NA #3 dated 4/13/18 identified he/she and NA #2 were transferring Resident #29 on 4/13/18. NA #3 hooked up the straps/loops of the hoyer on one side, and NA #2 hooked up the straps/loops of to the hoyer on the other side. NA #3 indicated while he/she and NA #2 were transferring Resident #29, NA #3 heard one of the straps/loops move, as if it was coming off. Subsequently, Resident #29 fell head down and hit the rail of the hoyer. A statement by NA #2 dated 4/13/18 identified he/she and NA #3 were transferring Resident #29 from the wheelchair to the bed. NA #2 indicated he/she was sure that the straps/loops were attached, and as the hoyer was moving up, and Resident #29's legs swung to the side, one of the straps/loops came off from the machine. Resident #29's body was unbalanced and he/she fell quickly to the floor and hit his/her head. Facility documentation dated 4/16/18 identified an investigation related to the root cause of the incident was conducted to prevent a recurrence, and the staff members were interviewed immediately following the incident. The lift was checked and functioning properly. The reason for the fall was that 1 of the straps/loops came off the lift hanger bar. Interview with the DNS on 7/11/18 at 11:00 AM indicated a re-enactment was done without issues, and interview with the involved nurse aides indicated they knew the straps/loops were on the hooks of the lift. The DNS further indicated she thinks the bottom loop at the thigh was off and the sling could no longer hold the resident. Interview with NA #2 on 7/11/18 at 11:50 AM indicated the straps/loops were correctly placed in the hoyer hooks, and he/she was guiding Resident #29's legs to ensure they did not hit the bed when NA #2 heard NA #3 say oh my God and then saw Resident #29 fall. NA #2 indicated he/she was unsure how Resident #29 fell , but one of the straps/loops had come off the lift. Interview with NA #3 on 7/19/18 at 1:45 PM indicated that although he/she was sure the straps/loops of the sling were in the lift hooks on his/her side during the transfer from the chair to the bed, the nurse aide heard the thigh straps/loops from the sling come out, and Resident #29 fell out of the sling before he/she could get to the resident. The facility transfer lift policy indicates it is the responsibility of the nurse aide using the mechanical lift to ensure the proper sling size for the resident is being used and that the loops of the sling straps are securely in place in the lift before attempting the transfer and during the transfer. The facility staff failed to ensure the sling straps (straps/loops) were securely in place in the lift on 4/13/18 before NA #2 and NA #3 transferred Resident #29. Subsequently, the straps/loops detached from the sling, and Resident #29 fell out of the sling onto his/her head and sustained a laceration that required 6 sutures to close. 2. Resident #71's [DIAGNOSES REDACTED]. A cognitive assessment dated [DATE] identified Resident #71 was without cognitive impairment. physician's orders [REDACTED]. The 60 day MDS dated [DATE] identified Resident #71 required extensive assistance with transfers. The care plan dated 2/12/18 identified Resident #71 fell to the floor during a transfer. Interventions directed to transfer the resident with 2 staff during the 3:00 PM to 11:00 PM shift, and provide in-service education to staff. a. A nurse's note dated 2/12/18 at 10:45 PM identified Resident #71 fell between his/her wheelchair and bed during a transfer with assistance of 1 staff. Additionally, the note indicated the nurse aide received an in-serviced. The fall incident note dated 2/12/18 at 11:12 PM identified that the nurse answered the bathroom light in Resident #71's room and found the nurse aide with Resident #71 on the floor between bed and wheelchair. The reportable event form dated 2/12/18 identified Resident #71 had a witnessed fall during a transfer with assistance of 1 staff. The investigation identified that the nurse aide did not use 2 staff to transfer Resident #71, and that the resident's pants were half way down. Additionally, the nurse aide was provided an in-service. Interview with NA #6 on 7/18/18 at 1:42 PM identified that he/she was using a walker instead of a grab bar, and Resident #71's pants were down around his/her knees when he/she lowered him/her to the floor. NA #6 identified that he/she was not aware Resident #71 required 2 staff for that transfer. NA #6 identified that he/she was in-serviced regarding Resident #71's pants being around his/her knees during the transfer, however, did not recall being in-serviced on the number of staff required to assist the resident. Interview with RN #3 on 7/18/18 at 3:12 PM identified that Resident #71 should have had 2 staff during the sit to stand transfer using the roller walker, according to the care plan, and the physician's orders [REDACTED].#6 only used 1 staff, and incorrectly transferred the resident and the resident fell . b. The quarterly MDS assessment dated [DATE] identified Resident #71 required supervision with locomotion off the unit, and extensive assistance with locomotion on the unit. A cognitive assessment dated [DATE] identified Resident #71 was without cognitive impairment. The care plan dated 6/6/18 identified Resident #71 required assistance with ADL's related to mobility and weakness. Interventions included to provide encouragement and verbal cues for safety with ADL's and mobility. Observation on 7/16/18 at 11:35 AM identified Resident #71 being wheeled by a nurse aide. Resident #71 was observed to have a left lower extremity leg brace on with a sneakers on both feet. The right foot was noted to be underneath the wheelchair with the leg bent back under the wheelchair. The toe was pointed down on the floor and was dragging as it bounced up and down while Resident #71 was being pushed in the wheelchair. Interview with NA #5 on 7/16/18 at 11:40 AM identified he/she did not realize that Resident #71's foot was dragging and bouncing on the ground under the wheelchair. NA #5 identified that normally Resident #71 shuffles his/her feet when being pushed, and that the resident was sick last night. NA #5 identified that Resident #71 self-mobilizes in the wheelchair but it is the policy to use footrests when residents are not able to self-mobilize. Interview and clinical record review with the DNS on 7/17/18 at 4:10 PM identified that if the resident was dragging his/her foot while being pushed in the wheelchair, the foot rests should have been utilized. 3. Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 8/28/17 identified Resident #165 required assistance with mobility and ADL's related to dementia and weakness. Additionally, Resident #165 had periods of confusion and forgetfulness. Interventions included to cue, reorient and supervise as needed, administer medications as ordered, and keep routine consistent. A quarterly MDS dated [DATE] identified Resident #165 had severely impaired cognition, required extensive assistance for transfers, was non-ambulatory, was independent for locomotion of the unit once in the wheelchair, and had no wandering behaviors. A wander risk assessment dated [DATE] identified Resident #165 could move without assistance when in the wheelchair, had a history of [REDACTED]. The assessment identified Resident #165 was at high risk to wander. Physician orders [REDACTED]. Facility investigation dated 12/28/18 identified a staff member who was in the parking lot observed Resident #165 exit the building. A second staff member observed Resident #165 from inside the building. The staff member notified the nursing supervisor, and Resident #165 was brought back into the building. Resident #165 was outside approximately 5 minutes. Resident #165 was put on every 15 minute checks and transferred to the secured memory care unit. Interview with NA #1 on 7/10/18 at 10:50 AM indicated he/she observed Resident #165 come out of the bistro door independently while self-propelling in a wheelchair. NA #1 further indicated while he/she called into the building, Resident #165 had turned around, and a staff member came to let the resident back into the building. Interview with the DNS on 7/10/18 at 12:00 PM indicated upon investigation it was found that the secure care alarm, and the door alarm had not triggered when Resident #165 had gone out the doors. The DNS further indicated after the elopement, the secure care alarm system by the door was checked with a testing chip and it was not working. In addition, the DNS indicated staff can use the entrance to enter the unit or go up the stairs between the two doors and if someone swiped to enter the building and went up the stairs, the door alarms on both doors would disengage and the resident could have gone out behind the staff member while the door was still disengaged. Interview and review of facility documentation with the Director of Environmental Services on 7/10/18 at 12:10 PM indicated the facility's secure care door alarms had been checked monthly. Interview with Vendor #1 on 7/11/18 at 11:00 AM indicated the secure doors should be checked for function weekly using the pocket tag reader. Vendor #1 also indicated when he/she checked the system on 12/29/17, the day after the elopement, the keypad and sound wire were disconnected. The facility elopement prevention protocol included that the facility uses multi-faceted approaches to assure resident safety which include alarmed doors, alarmed bracelets and signage with interventions for wandering behaviors to include educating staff on the alarm system utilized for wandering residents. The facility policy on wanderguard system identified the wanderguard will be used for residents at risk for elopement. The wanderguard bracelets are checked for placement daily on all shifts, and weekly for function by the team nurse. Checks are documented in the EMR. 4. Resident #166's [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified Resident #166 was at moderate risk for falls. A quarterly MDS dated [DATE] identified Resident #166 had moderately impaired decision making ability, required extensive assistance with ADL's, and 1 recent fall without injury. The care plan dated 8/30/17 identified Resident #166 was at risk for falls related to gait/balance problems and psychoactive drug use. Interventions included to provide assistance of 2 for transfers. Physical therapy orders dated 9/15/17 directed to transfer with a mechanical lift and assistance of 2 staff. Facility documentation dated 9/18/17 at 7:45 PM identified Resident #166 was noted sitting on the floor at the side of the bed. Additionally, the investigation indicated NA #4 transferred Resident #166 from the bed to the wheelchair alone, without a mechanical lift or 2 staff. Resident #166's statement at the time indicated he/she wanted to go to the bathroom and the nurse aide helped him/her to the wheelchair and he/she missed the chair. Interview with NA #4 on 7/12/18 at 1:15 PM identified he/she followed the transfer directions on the assignment sheet and was unaware of the care card which identified Resident #166 required a mechanical lift.lift.

Based on clinical record reviews, interviews, review of reportable event documentation, sworn statements, and review of facility policy and procedure for six of six residents reviewed for abuse (Resident #12, R #22, R #41, R #80, R #128 and R #141), the facility staff failed to identify and report allegations of abuse to management resulting in multiple residents affected over a period of a week and/or the facility failed to take appropriate actions to ensure the residents were free from abuse resulting in a finding of substandard quality of care. The findings include: 1. Resident # 12's [DIAGNOSES REDACTED]. The significant change in status MDS dated [DATE] identified the resident had impaired cognition, and required extensive assistance with ADL's. The supervisor report dated 5/21/17 noted R #12 was weepy /confused at 8:30 PM, slept in the wheel chair at the nurses station until 11:00 PM. Facility investigation documentation dated 5/25/17 noted that NA #2 reported to RN #2 that NA #1 was mean and rude to R #12, and that R #12 reported NA #1 was disrespectful and was a bulldog. Additionally, on 5/26/17, R #12 reported to RN #2 that NA #1 was gruff with him/her. When R #12 asked NA #1 to be careful with his/her personal items, NA #1 responded then why don't you just pack it up and go somewhere else to live. Facility investigation documentation dated 5/26/17 noted that upon being asked about NA #1's behavior, LPN #1 reported that NA #1 was not nice to patients and yells loudly in the hallway talking about residents. LPN #1 identified that about a week prior, NA #1 came out of R #12's room, was throwing his/her hands up in the air and yelled down the hallway that R #12 was crying because s/he can't dress him/herself. LPN #1 reported that when s/he entered R #12's room, R #12 reported that NA #1 yelled at him/her. R #12 was upset and crying. The Reportable Event form dated 5/31/17 (five days after initial allegation) identified only an allegation of mistreatment toward R #12. The facility investigation documentation included that another NA reported that his/her co-worker (NA #1) was rough when transferring the resident and spoke loudly to the resident. Interview and review of the reportable event including the investigation with LPN #1 on 7/19/17 at 11:25 AM identified that although NA #1 could be disrespectful to co-workers and loud on the nursing unit, s/he denied being aware of any inappropriate behaviors exhibited by NA #1. Interview and review of the facility investigation documentation, including sworn statements with LPN #1 on 7/19/17 at 3:00 PM identified that on 5/26/17, a written statement signed by LPN #1 identified that approximately a week prior, LPN #1 observed NA #1 coming out of R #12's room throwing his/her hands in the air and yelling down the hallway that R #12 was in there crying because s/he can't get dressed alone. LPN #1 entered R #12's room, and R #12 reported that NA #1 yelled at him/her and that s/he does not like NA #1. Although LPN #1 initially stated during a phone interview on 7/19/17 at 11:25 AM that s/he was unaware of any negative behavior NA #1 exhibited while providing care, the written statement obtained from LPN #1 during the facility investigation documented that LPN #1 was aware that R #12 was crying, complained he/she was yelled at by NA #1 and did not want NA #1 to care for him/her anymore. LPN #1 failed to report the incident and/or document the incident in the resident's record or any other facility documentation. A sworn voluntary statement by LPN #1 on 7/19/17 at 3:15 PM documented that after NA #1 left R #12's room, NA #1 yelled in the hallway that R #12 was crying. LPN #1 entered R #12's room and noted R #12 crying and reported the bear yelled at me. Further review of the statements and investigation identified that LPN #1 did not address any inappropriate behaviors with NA #1 because s/he was fearful of retaliation. Although this information was obtained by the facility on 5/26/17, the facility failed to report the allegation immediately to the State Agency and/or initiate a further investigation and/or take corrective action to ensure such incidents did not occur again in the future except for an inservice on mandatory reporting of abuse which began on 6/1/17 and only included nursing staff. LPN #1 failed to report the incident to management staff, failed to identify NA #1's errant behaviors, and failed to protect further residents from NA #1's behaviors until 5/25/17 when NA #2 reported NA #1's behaviors to RN #2 who suspended NA #1. 2. Resident #22's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident had moderately impaired cognition, no mood or behaviors were exhibited, and required extensive assistance with ADL's. The RCP dated 3/13/17 identified the resident required assistance with ADL's and mobility related to weakness. Interventions included to assist with bed mobility as needed, transfer and ambulate with a rolling walker and assistance of one. Facility documentation dated 5/25/17 identified NA #2 reported to RN #2 that NA #1 was mean, rude and speaks disrespectfully to the residents. NA #2's written statement dated 5/31/17 (five days after initial allegation) identified NA #2 reported to RN #2 that NA #1 was observed abruptly, almost throwing R #22 while transferring R #22. NA #2 reported R #22 was crying telling NA #2 that NA#1 treats her/him badly, is mean, rude and yells at him/her. Shortly after NA #2 brought R #22 into the hallway, NA #1 approached R #22 in a threatening manner from behind and said if you don't like me, next time when you ring you will have to wait, because I am so tired of helping you. NA #2 failed to report the incident to the supervisor and/or management until 5/31/17, a week after the incident occurred. 3. Resident #41's [DIAGNOSES REDACTED]. The Reportable Event form dated 6/1/17 noted an allegation of mistreatment was reported to RN #2. The facility noted NA #2 reported that NA #1 was rough when transferring R #41. The social service notes dated 6/6/17 identified SW #1 spoke to R #41 regarding the allegation of abuse. R #41 was unable to recall the incidents and showed no signs of distress during the interview. Interview and review of facility initial interview documentation with RN #2 on 7/20/17 at 2:00 PM identified that during the facility investigation into multiple allegations of abuse by NA #1, NA #2 reported that h/she observed NA #1 transfer R #41 in a rough manner. The date of the incident was not documented. 4. Resident #80's [DIAGNOSES REDACTED]. Facility documentation dated 6/1/17 identified SW #1 spoke with R # 80 regarding an incident that occurred with NA #1. R # 80 reported that while NA #1 was providing a shower to R #80, R #80 was yelling and screaming while in the shower room. When the shower was completed R # 80 said to NA #1 you shouldn't treat me that way, I am no dummy. NA #1 responded while you are a resident here I am the boss and you need to listen to what I say The reportable event form dated 6/1/17 noted an allegation of mistreatment was reported. The facility noted that NA #2 reported that NA #1 was rough when transferring the resident, and spoke loudly to the resident. No date of the alleged incident was documented. 5. Resident #128's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified the resident had severely impaired cognition, and required extensive assistance with ADL's Facility documentation dated 5/31/17 identified NA #2 reported to RN #2 that NA #1 yelled at R #128 and was rude to him/her. The reportable event form dated 6/1/17 noted an allegation of mistreatment was reported. The facility noted that NA #2 reported that NA #1 was rough when transferring the resident, and spoke loudly to the resident. No date of the alleged incident was documented. 6. Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] identified the resident without cognitive impairment, and required extensive assistance with ADL's. The facility grievance form dated 5/26/17 identified that R #141 stated that on 5/24/17, NA #1 was rough and fresh with him/her. Social service spoke with R #141 and noted while NA #1 was providing care it felt like NA #1 was pushing his/her hands into his/her hip. The resident reported that NA #1 refused to stop even when told s/he was hurting the resident. Social service informed R #141 that NA #1 would be provided education on proper care. The facility treated the incident as a grievance and not an allegation of abuse and did not initiate a reportable event form, or conduct an investigation. Further, the State Agency and the police were not notified until 6/1/17. The facility investigation which was not initiated until 5/31/17, identified that on 5/25/17, R #141 reported to the Recreation Director that on 5/24/17 during the 3-11 shift, NA #1 was fresh and rough with him/her, squeezed his/her hip while being provided care, and when asked to stop providing care because it was hurting, NA #1 continued to provide care. The facility failed to report, and/or initiate an investigation when R #141 made an allegation of rough treatment. Interview with the RN #2 on 7/19/17 at 10:30 AM noted the allegation of rough handling was competed as a grievance because when RN #2 went to interview R # 141, s/he refused to file an official complaint. Review of the timeline during which the facility identified the incidents of verbal and/or physical abuse and/or intimidation resulted in the following fact finding whereby it was identified: that facility staff did not report witnessed abuse of residents, facility was not reporting all allegations and/or investigating thoroughly immediately, failure to conduct an analysis of how multiple staff members could be aware of resident abuse by one staff member and not report it, and/or failure to initiate a plan of correction to ensure that such incidents do not occur again until subsequent to surveyor inquiry: Timeline: 5/25/17: New admission on 5/24/17, R #141, reported to the recreation director that NA#1 was rough, hurt him/her, and didn't stop when told to. The recreation director reported that allegation immediately and NA #1 was removed from the schedule. 5/25/17: NA #2 went to RN #2's office unsolicited at the start of the 3-11pm shift to report that NA #1 was mean and rude to the residents. NA #2 reported that R #12 called him/her the bulldog and was disrespectful. NA #2 also reported that R #22 reported that NA #1 was disrespectful, rough with transfers and made him/her cry. NA #2 reported that NA #1 transferred R #22 into the wheelchair yelling and complaining that s/he was tired of helping him/her. NA #2 failed to report these incidents that occurred prior to 5/24/17 (no dates documented). NA #2's written statement which was not provided until 5/31/17 indicated NA #1 transferred resident to the wheelchair in a way abrupt and almost throwing her in the wheelchair. R #22 was on the toilet crying about how bad NA #1 treated her/him. When R #22 was brought out to hall, NA #1 was heard yelling at R #128 and R #22 stated that is why s/he doesn't want NA #1 taking care of him/her. NA #1 heard R #22's statement and then confronted R #22 and said if you don't like me, next time when you ring, you have to wait for your NA because I'm so tired of helping you. 5/26/17: LPN #1 was interviewed and stated, NA #1 was not nice to residents, yells loudly talking about residents. If you try to provide counseling, NA #1 is defensive, yells at nurse and takes it out on everyone for the rest of the shift. LPN #1 in a written, signed statement indicated that a week prior, NA #1 came out of R #12's room yelling and throwing hands up in the air complaining that resident wouldn't dress self. LPN #1 went in the room to find resident saying I don't like that girl, not my aide the other girl, the bear yelled at me. This was not reported to anyone or documented. Surveyor review of 24 hour report noted on 5/21/17 resident was weepy and slept in chair in hallway. No other documentation was available to address the incident or documented that the incident had occurred. LPN #1's statement documented that I do not discipline her for fear of retaliation. 5/26/17: LPN #2 was interviewed and stated that NA #1 is abrupt, has no patience, is short tempered and verbally impatient. Loose cannon and wouldn't want to cross him/her. Staff wants to change their weekend so they don't have to work with him/her. 5/26/17: NA#3 documented that s/he feels bad how NA #1 treats the residents. Rough and has no respect. Grabs the resident up. R #122 yells stop, stop when NA #1 cares for him/her. NA #3 also noted that NA #1 was inappropriate with him/her, rubs against him/her and tried to kiss him/her which s/he reported to nurse. No reportable event documentation or report to the police or State Agency was done until 6/1/17. On 6/1/17, the facility began conducting inservice training with nursing staff regarding mandatory reporting of abuse. No other actions were taken to ensure resident safety and/or the identification and interventions to use with staff who have burn out or other behavioral issues. Subsequent to surveyor inquiry, an immediate action plan was submitted and accepted. Facility policy and procedure for resident abuse noted all residents have the right to be free from verbal, sexual, physical, and mental abuse. If a staff member has reasonable cause to suspect resident abuse or neglect has occurred, they are mandated to report it immediately to their supervisor. All alleged violations involving mistreatment, neglect, or abuse are reported to the facilities administrator and/or designee and to other officials as required by law. Fairview will have evidence that all alleged violations are thoroughly investigated, and will prevent further potential abuse while the investigation is in progress.

Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #2) who required staff assistance for transfers in and/or out of the bed, the facility failed to ensure that an appropriate device was utilize and/or supervision was provided to prevent an accident with injury. The findings include: Resident #2's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] identified that Resident #2 had severe cognitive impairment, required extensive to total one to two person assistance with the functions of daily living and utilized a wheelchair as the primary mode of transportation. The resident care plan dated 6/26/14 identified an alteration in functional mobility related to abnormal posture and poor balance. Interventions directed to transfer the resident out of bed to the wheelchair with two person assistance via a mechanical lift. The nurse's note dated 7/9/14 at 4:15 pm identified that Resident #2's right arm became caught in the side rail of the bed while being transferred by the mechanical lift, the physician was notified and an x-ray was obtained. The nurse's note dated 7/9/14 at 10:45 pm identified the resident sustained [REDACTED]. The Reportable Event Form dated 7/9/14 at 4:10 pm identified while Resident #2 was being transferred from the bed to the custom wheelchair via the mechanical lift, the resident's right arm was caught in the side rail. The investigation identified that Resident #2's right arm was caught in the side rail during the transfer out of bed to the custom wheelchair. In a written report Nurse Aide (NA) #1 identified that the side rails were in up and that she and the other nurse aide were not aware that the side rails were supposed to be down when transferring a resident out of bed via a mechanical lift. The nurse aides lowered the resident back on the bed, removed the arm from the side rail, again lifted the resident out of the bed into the wheelchair and while NA #1 lifted the resident's right arm the resident cringed and complained of pain. Interview with NA #1 on 9/22/14 at 3:20 pm identified that the mechanical lift pad that was used to transfer Resident #2 was too small and the resident's arms were coming off the sides of the pad. NA #1 indicated that she and NA #2 were talking amongst each other while lifting the resident and then NA #2 screamed "Resident #2's arm". NA #1 identified she stopped lifting the resident and lowered the resident back onto the bed, she turned the residents right arm downward, pushed the arm out of the side rail, transferred the resident out of bed to the wheelchair and reported to the charge nurse what happened. Interview with Registered Nurse (RN) #1 on 9/22/14 at 3:35 pm identified that NA #1 and NA #2 came to her and reported that Resident #2's arm was caught in the side rail during the mechanical lift transfer and they had removed the arm. RN #1 indicated when she assessed the resident she noted the mechanical lift pad that was used to transfer the resident was too small. RN #1 identified that she notified the physician, obtained an x-ray, and stabilized the arm. In an interview with the Director of Nursing (DON) on 9/22/14 at 2:55 pm the DON identified that Resident #2 should have been secured in the sling with the arms across the chest while being transferred. The DON indicated that residents who required use of the mechanical lifts for transfers had not been evaluated for an appropriate size sling or pad, and if the staff did not know which size to use they should ask the nurse. The DON identified that the sling size was not documented on the NA assignments. Review of the facility policy and procedure for Mechanical Lift Transfers with the DON at that time failed to identify the appropriate size of the sling/ pad to be used on each resident. Subsequent to the incident the facility conducted a review and competency of the mechanical lift transfers.

Based on review of the clinical record, review of facility policies, review of facility documentation, and interviews, the facility failed to provide adequate supervision to prevent injury to one resident, Resident #2, who had a history of [REDACTED]. 1. Resident #2 (R #2) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] identified that the resident was alert with disorganized thinking and independent when ambulating in the room with a walker though required one person physical assist with toilet use. The Fall Risk assessment dated [DATE] identified that R #2 was at risk to fall (last fall was 12/8/12). Review of the care plan dated 12/26/12 identified that R #2 was at risk to fall due to a history of falls and psychotropic drug use with interventions that included ensuring that the resident had proper footwear and to provide the resident with the walker. Review of the clinical record and facility documentation dated 12/28/12 identified that R #2 was found on the bathroom floor at 9:45 PM and had sustained a laceration on the back of his/her head. Although the nursing notes dated 12/28/12 at 10:24 PM identified that R #2 was in the bathroom receiving evening care and had his/her lost balance falling backward, interview with Nursing Assistant #3 (NA #3) on 4/11/12 at 3:00 PM identified that he/she had provided evening care earlier in the shift, that the resident had gotten out of bed without calling for assistance, and went into the bathroom. NA #3 stated that after seeing the resident in the bathroom, he/she left the resident in the bathroom to get supplies to provide the resident with incontinent care. Upon her return, he/she observed R #2 fall backwards. Review of the Post Fall Investigation form dated 12/28/12 at 9:40 PM identified that R #2 had ambulated to the bathroom without assistance, without the benefit of a walker, and without the benefit of appropriate footwear in accordance with the plan of care. Review of the clinical record identified that R #2 sustained a laceration to the back of the head, was transferred to the Emergency Department (ED), and required six staples to close the head wound. Review of the Post Fall Investigation form dated 12/28/12 at 9:40 PM incorrectly identified that R #2 did not have a history of falls (last fall was 12/8/12). The investigation identified that the resident had been incontinent and displayed weakness at the time of the fall. The post fall action plan directed that non-skid socks be applied while the resident was in bed. Review of the clinical record and interview with RN #2 on 4/11/13 at 10:00 AM identified that upon the resident's return from the hospital at 2:45 AM on 12/29/12, R #2 had non-skid socks applied. RN #2 identified that R #2 remained independent to ambulate despite the earlier fall. Review of nursing notes dated 12/29/12 at 5:56 AM identified that R #2 was again found on the floor of the bathroom at 4:20 AM, one and one half hours after returning to the facility. R #2 was transferred to the ED. Review of the hospital discharge summary dated 1/1/13 identified that R #2 was subsequently diagnosed with [REDACTED].