Every finding on record at Golden Hill Post Acute

Based on observation, interview and record reviews, the facility failed to provide timely medical evaluation and treatment for a resident who reported right arm pain following an incident when repositioned by another staff member for one of four sampled residents (Resident 1).As a result, Resident 1 experienced an approximate 12-hour delay in receiving necessary medical evaluation and treatment for right arm pain associated with a confirmed right radial head fracture (A break in the upper part of the forearm bone near the elbow). The delay also postponed the use of a sling per hospital discharge summary orders to protect the fractured arm from further complications. Cross-Reference (F609) Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Functional Quadriplegia (completely immobile due to severe disability or frailty without physical injury or damage to the brain or spinal cord). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/24/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A clinical chart review was conducted on Resident 1's History and Physical (H&P) dated 7/12/25 at 22:36 (11:36 P.M.), indicated Thisresident [sic]: Has the capacity to understand and make decisions Reason: Alert and oriented. A clinical chart review was conducted on Resident 1's Nurse Practitioner (NP) progress note Physician's Progress Note dated 7/27/26 at 10:49 A.M., indicated . she wanted to go to the hospital where the care is better. Could not say a medical reason for going to the hospital. Then said she's been delirious all weekend and the staff hurt her R [right] arm during a turn, so she should go. A clinical chart review was conducted on Resident 1's Change in Condition/s on 7/27/26 at 20:41 (8:41 P.M.) eINTERACT SBAR Summary for Providers indicated .Situation: The Change In Condition/s reported on this CIC [change in condition] Evaluation are/were: Altered mental status [occurs when illnesses, disorders and injuries affect brain function]. A clinical chart review was conducted on Resident 1's progress note dated 7/27/26 at 22:55 (11:55 P.M.) Nursing indicated .Family expressed concern that resident was experiencing hallucinations [sensing things such as visions, sounds, or smells that seem real but are not] and an altered mental status from baseline. At the family request, the resident was transferred to the emergency department for further evaluation. A clinical chart review was conducted on Resident 1's progress note dated 7/28/2026 at 15:00 (3 P.M.) Nursing indicated .Resident return back from [Hospital Name]. A clinical chart review was conducted on Resident 1's NP notes dated 7/29/2026 at 11:37 A.M., Physician Progress Note indicated .Follow up after a day in the ER [emergency department] at [Hospital Name].R [right] radial head fx [fracture]found on repeat imaging with order for RUE [right upper extremity] sling. Hospital dc [discharge] order for sling, nursing following up with Therapy department to obtain RUE sling . A clinical chart review was conducted on Resident 1's Activities of Daily Living (ADL- include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care plan date initiated 7/29/25, indicated .REQUIRES TWO-PERSON ASSIST WITH ADL'S - REPOSITIONING, TRANSFERS, SHOWER, PERI-CARE AND AS NEEDED.RUE SLING AT ALL TIMES. On 8/11/26 at 12:26 P.M., an observation and interview was conducted with Resident 1, in Resident 1's room. Resident 1 was observed lying in bed watching television. Resident 1 stated that she had a fracture on her right arm due was the result of one staff member who had handled her rough during repositioning in bed. Resident 1 stated this person moved me roughly by themselves and my arm started to hurt really bad from it. Resident 1 refused to name or describe the staff member out of fear of retaliation (revenge) from the staff member. Resident 1 further stated she could normally feed herself but was unable to do so because her right arm remained weak and painful. During the interview, Resident 1 required assistance from at least two Certified Nursing Assistant (CNA 1 and CNA 2) for repositioning and refused to move her right arm because of pain. On 8/11/26 at 12:29 P.M., an observation was conducted with Resident 1, in Resident 1's room. CNA 1 and CNA 2 repositioned Resident 1 upright in bed for lunch. Resident 1 attempted to feed herself using her left hand. During repositioning, Resident 1 did not move her right arm and stated that it was painful. CNA 1 removed Resident 1's left hand splint and no sling was observed on Resident 1's right upper arm (RUA). On 8/11/26 at 12:36 P.M., an observation and interview was conducted with CNA 2, in Resident 1's room. CNA 2 assisted Resident 1 with feeding by cutting up meat on her lunch tray and helped Resident 1 with feeding. CNA 2 stated that Resident 1 was a two-person assistance for repositioning and transfers because Resident 1 was bed bound for safe transfers. Resident 1's RUA sling was not applied. On 8/11/26 at 1:30 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated that when a resident (any facility resident) reports the onset of new pain, the nurse should assess for bruising or injury and ask how the injury occurred. After reviewing NP's note (7/29/26 at 11:37 A.M.) which had documented Resident 1's right arm pain and report that staff member hurt her during reposition, LN 1 stated, it should have been reported. LN 1 stated Resident 1 should have been assessed and sent to the hospital sooner, a fracture was later identified. On 8/11/26 at 1:56 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). After reviewing the NP's note (7/27/26 at 11:37 A.M.) that Resident 1 reported a staff member hurt her arm when repositioned, the ADON stated, Resident 1 should have been sent out for medical evaluation when the NP identified the right arm pain. The ADON stated he was unable to find documentation showing it had been previously reported or investigated. The ADON stated he was unsure if Resident 1 was sent out earlier than the documented time noted on 7/27/26 at 11:55 P.M. On 8/12/26 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated pain is anything that the resident says it is. The DON stated Resident 1's report of right arm pain (after a staff hurt her right arm during a turn) should have been reported and further assessed when the NP documented it (7/27/26 at 11:37 A.M.). The DON stated she should have been sent out earlier as Resident 1 was requesting to go to the hospital when she reported her right arm pain to the NP and/or had recommendations from NP to get some images done or pain consult. The DON further stated Resident 1's pain could have been worsened while waiting to get properly evaluated. The DON stated two staff members should assist with repositioning Resident 1 and that the hospital's discharge orders for sling use should have been followed to prevent further complications and delay in care. A review of the facility's policy and procedure titled, Policy/Procedure-Nursing Administration Section Care and treatment Accident Intervention dated 6/2025, indicated .facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents .Assess resident fully.

Based on observation, interview and record review the facility failed to identify and report a possible allegation of abuse as required for one of four sampled residents (Resident 1) when Resident 1 reported to the Nurse Practitioner (NP) that she had experienced pain in her right arm after a staff member hurt her while turning her in bed. This deficient practice placed Resident 1 at risk for continued harm and delayed investigation and failed to protect Resident 1 and other residents from possible abuse. Cross-Reference (F684)Findings:A record review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Functional Quadriplegia (completely immobile due to severe disability or frailty without physical injury or damage to the brain or spinal cord). A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/24/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A clinical chart review was conducted on Resident 1's History and Physical (H&P) dated 7/12/25 at 22:36 (11:36 P.M.), indicated Thisresident [sic]: Has the capacity to understand and make decisions Reason: Alert and oriented. A clinical chart review was conducted on Resident 1's NP progress note Physician's Progress Note dated 7/27/26 at 10:49 A.M., indicated . she wanted to go to the hospital where the care is better. Could not say a medical reason for going to the hospital. Then said she's been delirious all weekend and the staff hurt her R [right] arm during a turn, so she should go. A clinical chart review was conducted on Resident 1's NP notes dated 7/29/2026 at 11:37 A.M., Physician Progress Note indicated .Follow up after a day in the ER [emergency department] at [Hospital Name].R [right] radial head fx [fracture]found on repeat imaging with order for RUE [right upper extremity] sling. Hospital dc [discharge] order for sling, nursing following up with Therapy department to obtain RUE sling . A clinical chart review was conducted on Resident 1's Activities of Daily Living (ADL- include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) care plan date initiated 7/29/25, indicated .REQUIRES TWO-PERSON ASSIST WITH ADL'S - REPOSITIONING, TRANSFERS, SHOWER, PERI-CARE AND AS NEEDED.RUE SLING AT ALL TIMES. On 8/11/26 at 12:26 P.M., an observation and interview was conducted with Resident 1, in Resident 1's room. Resident 1 was observed lying in bed watching television. Resident 1 stated that she had a fracture on her right arm due to one staff member had handled her rough during repositioning in bed. Resident 1 stated this person moved me roughly by themselves and my arm started to hurt really bad from it. Resident 1 refused to name or describe the staff member out of fear of retaliation (revenge) from the staff member. Resident 1 further stated she could normally feed herself but was unable to do so because her right arm remained weak and painful. During the interview, Resident 1 required assistance from at least two Certified Nursing Assistant (CNA 1 and CNA 2) for repositioning and refused to move her right arm because of pain. On 8/11/26 at 12:30 P.M., an interview was conducted with Resident 1, in Resident 1's room after CNA 1 and CNA 2 left Resident 1's room. Resident 1 stated I still don't feel safe because of that one person who hurt me on my right arm. It still really hurts. They usually need at least 2 people to reposition me cause I'm bedbound. They said if I told they'd be really mad at me. On 8/11/26 at 1:04 P.M., an interview was conducted with CNA 3. CNA 3 stated any report from any facility residents that had concerns with rough handling should be reported immediately to the Administrator who is also the abuse coordinator. CNA 3 stated any allegations of abuse cannot wait so we can provide safety for our residents. On 8/11/26 at 1:18 P.M., an interview was conducted with CNA 5. CNA 5 stated that abuse included physical acts that caused injury or emotional harm. CNA 5 stated, any new injuries we observe or symptoms of pain could indicate abuse, and we need to report it. CNA 5 further stated she would immediately report suspected abuse to the charge nurse and administrator to protect all facility residents. On 8/11/26 at 1:20 P.M., an interview was conducted with CNA 4. CNA 4 stated the Administrator was the abuse coordinator and stated, any type of abuse should be reported immediately. CNA 4 further stated that bruising, being hit, or new or worsening pain after rough handling with care could indicate possible abuse and should be reported. On 8/11/26 at 1:30 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated that when a resident (any facility resident) has reports of new pain, the nurse should assess for bruising or injury and ask how the injury occurred. LN 1 stated, for suspected abuse I would report that to our administrator. LN 1 further stated suspected abuse should be reported within two hours. LN 1 stated after she had reviewed NP's note (documentation Resident 1's right arm pain and the report that staff member hurt her during reposition), it should have been reported. LN 1 stated Resident 1 should have been assessed and sent to the hospital sooner because a fracture was later identified. LN 1 stated suspected abuse should be reported no more than 2 hours. LN 1 further stated the allegation should have been investigated and other residents should have been interviewed to ensure their safety. On 8/11/26 at 1:56 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated the NP was a mandated reporter (legally required to report) and should have reported the allegation to the facility's abuse coordinator so it could be investigated. The ADON further stated Resident 1 should have been sent out for medical evaluation when the NP identified the right arm pain. The ADON stated he was unable to find documentation showing it had been previously reported or investigated. The ADON stated he was unsure if Resident 1 was sent out earlier than the documented time noted on 7/27/26 at 11:55 P.M. progress note per family request. On 8/12/26 at 4:06 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the NP was a third-party contractor. After discussing Resident 1's report that a staff member hurt her arm during repositioning, the ADM stated, regardless, the NP is a mandated reporter. The ADM confirmed that the NP should have reported the allegation to the facility so it could be investigated and Resident 1 could be protected from further potential abuse. On 8/12/26 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated pain is anything that the resident says it is. The DON stated Resident 1's report of right arm pain (after a staff hurt her right arm during a turn) should have been reported and further assessed when the NP documented it (7/27/26 at 11:37 A.M.). The DON stated she should have been sent out earlier as Resident 1 was requesting to go to the hospital when she reported her right arm pain to the NP and/or had recommendations from NP to get some images done or pain consult. The DON further stated Resident 1's pain could have been worsened while waiting to get properly evaluated that later lead to a right arm fracture. The DON stated two staff members should assist with repositioning Resident 1 and that the hospital's discharge orders for sling use to be followed to prevent further complications and delayed care. A review of the facility's policy and procedure titled, Policy/Procedure - Nursing Administration Section Resident's Rights Abuse Reporting, Resident, Staff and Family dated 06/2025, indicated .Any person(s) witnessing or having knowledge of potential or actual abuse must report the incident to the Administrator and/or designee immediately .The report is to be submitted to the Administrator or designee within twenty-four (24) hours for further investigation.

Based on interview and record review, the facility failed to develop and implement a care plan for one of three residents (Resident 1) to ensure the safety of Resident 1 was maintained while Out On Pass (OOP) due to a previous motor vehicle accident (MVA) which occurred while OOP. The lack of care plan development posed a potential risk for Resident 1 and the resident's significant other (SO) to have a repeat MVA situation to occur.On [DATE] at 9:15 A.M., an onsite investigation was conducted to investigate a Facility Reported Incident (FRI) reporting Resident 1 was involved in a MVA when her SO was driving the vehicle on [DATE].A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with aphasia (difficulty with speaking caused by brain damage) and right-sided weakness caused by a stroke.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated [DATE], indicated the resident's BIMS (Brief Interview for Mental Status) was 13 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On [DATE] at 10:17 A.M., an observation and interview was conducted with Resident 1. The resident was sitting in her wheelchair in the facility's courtyard. Resident 1 stated her SO was driving at the time of the MVA. Resident 1 stated her SO had a history of seizure (a sudden surge of uncontrolled electrical activity in the brain that causes temporary changes in behavior, movement, or awareness) and was taking medications. Resident 1 was observed with her face grimaced and shaking her head while discussing the accident. Resident 1 stated the accident made her feel scared and her SO should not drive her anymore.A review of the emergency room record dated [DATE] indicated, .Patient was the passenger in the car.The driver from the car fled the scene and left the patient in the car. The record indicated Resident 1 sustained no injuries from the MVA and she was determined to be safe for discharge.A review of Resident 1's IDT dated [DATE] indicated the facility was unable to reach Resident 1 after the hours allowed to be OOP expired and received a call from the emergency room that the resident was in a MVA. Resident 1 returned to the facility on [DATE]. Upon return, the IDT was conducted with recommendations for a care conference to be arranged with Resident 1 and her SO. However, the facility was not able to reach the SO. There was no recommendation to develop and implement a care plan for Resident 1's OOP safety.On [DATE] at 1:05 P.M., an interview and record review was conducted with the Charge Nurse (CN). The CN reviewed and stated Resident 1 was on appropriate OOP visit with her SO, when they had a MVA. The CN reviewed Resident 1's care plan and stated the care plan did not address protection of the resident from the potential future MVA with her SO. The CN stated that she and other nurses discussed the facility should not allow Resident 1 to be in the vehicle driven by her SO anymore. The CN stated this should have been discussed among the facility's leadership and nursing staff and should have been addressed in the resident's care plan so that all nursing staff were aware.On [DATE] at 4:22 P.M., an interview was conducted with the Administrator (ADM), the Assistant Director of Nursing (ADON), and Social Services Director (SSD). The SSD stated she planned a care conference with Resident 1 and her SO but the attempts had been unsuccessful since the SO had not responded back to her calls. The ADM and ADON stated the SO should not drive Resident 1 for her safety and this should have been addressed as one of the interventions in Resident 1's care plan.

Based on observation and interviews, the facility failed to ensure resident rights were treated with respect and dignity for one of two resident 's (Resident 1) when the facility staff searched Resident 1's personal belongings without her permission.As a result, Resident 1 was observed anxious and stated she felt disrespected. On 4/20/26 at 9:15 A.M., an onsite investigation was conducted to investigate a Facility Reported Incident (FRI) reporting Resident 1 was involved in a MVA when her SO was driving the vehicle on 3/28/26.A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with aphasia (difficulty with speaking caused by brain damage) and right-sided weakness caused by a stroke.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 3/19/26, indicated the resident's BIMS (Brief Interview for Mental Status) was 13 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 4/20/26 at 10:17 A.M., an observation and interview was conducted with Resident 1. The resident was sitting in her wheelchair in the facility's courtyard. During the interview, Resident 1 saw a male Certified Nursing Assistant (CNA) 1 walk by, stopped him and pointed to visible nearby buildings around her. Resident 1 looked at CNA 1 and said ok, and waved her hand gesturing she did not need his help anymore and CNA 1 walked away. On 4/20/26 at 10:40 A.M., CNA 1 came back towards Resident 1 with a piece of paper and pen so Resident 1 could communicate in writing. Resident 1 refused to communicate with CNA 1 via paper and pen.On 4/20/26 at 10:50 A.M., an observation of Resident 2, the roommate of Resident 1, was conducted. Resident 2 was observed talking to Resident 1 in their room. Resident 2 stated a female and a male staff were searching Resident 1's personal belongings a few minutes ago. After hearing Resident 2, Resident 1 was shaking her head with her hand on her forehead and her face was grimaced. Resident 1 repeated no, and said why? Resident 1 was moving in her wheelchair anxiously in the room.On 4/20/26 at 11:02 A.M., an interview was conducted with the CNA 1. CNA 1 stated he was searching Resident 1's belongings looking for her communication board with the Social Services Director (SSD). CNA 1 stated he should have asked Resident 1 for her permission before going through her personal items.On 4/20/26 at 11:11 A.M., an interview was conducted with the SSD. The SSD stated Resident 1 had a communication device in her room and she and CNA 1 were looking for it in Resident 1's room. The SSD stated she should have gotten a permission from Resident 1 before searching through Resident 1's personal belongings. On 4/20/26 at 11:19 A.M., a follow-up interview was conducted with Resident 1. Resident 1 stated she felt disrespected but was feeling okay after CNA 1 and the SSD apologized to her.On 4/20/26 at 4:22 P.M., an interview with the Assistant Director of Nursing (ADON), the Administrator (ADM), and the SSD was conducted. The ADON, ADM, and SSD stated that staff should obtain a permission from a resident before searching through personal belongings.A review of the facility policy titled Resident Rights undated indicated, .The Resident has the right 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview, and record review, the facility failed to implement new, effective fall preventative measures after each fall incident for two of five residents reviewed for falls (Residents 1 and 2). These failures resulted in Resident 1 falling 13 times, sustaining two broken bones in her face and a broken rib.Findings:1. A review of Resident 1's undated Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool) dated 7/23/25, indicated a score of 0, or severely impaired cognition. A review of Resident 1's Nurse Practitioner/Physician's Assistant (NP/PA) progress note, dated 7/25/25, indicated Resident 1 had, evidence of severe cognitive impairment.indicating severe dementia. She is completely disoriented, unable to recall or repeat words, perform basic calculations, follow commands, or recognize objects. The NP/PA indicated Resident 1 did not speak, make eye contact or engage while being evaluated. A review of Resident 1's Physician's History and Physical Note, dated 8/17/25, indicated Resident 1 did not have the capacity to understand and make decisions. An observation of Resident 1 was conducted in her room on 3/10/26 at 10:15 A.M. Resident 1's name was outside of the room with a gold star (an indicator of fall risk) next to her name. Resident 1 was seated in a wheelchair, in her room. Resident 1 did not respond to questions asked. Resident 1 was not wearing a yellow wristband (an indicator of fall risk). A mattress with the edges built up was on the bed, and a fall mat was leaning against the wall. Resident 1's room was located approximately 10 feet from the nurse's station. A review of Resident 1's Nursing Progress Notes, Change in Condition Evaluations (COC, a form to evaluate a clinically significant change from the resident's normal levels of health) and care plan indicated the following incidents of fall and fall preventative measures initiated after each incident of a fall:Fall #1: The COC, dated 7/31/25, indicated the fall occurred on 7/31/25 at 2:18 A.M. The COC summarized that Resident 1 was found sitting on the floor in her room.A review of Resident 1's care plan, dated 7/31/25 indicated new fall preventative measures implemented were to ensure the bed was lowered to the floor, and monitor Resident 1 for any new problems as a result of the fall. Fall #2: The COC, dated 8/3/25, indicated Resident 1 had fallen on 8/3/25 at approximately 1 P.M. in her room. The COC summarized that Resident 1 was found sitting on the floor near her bed. Resident 1's care plan, dated 8/3/25, indicated new fall preventative measures of moving Resident 1 closer to the nurse's station, and a physical therapy consult for strength and mobility. The care plan indicated unnamed facility staff would, .determine and address causative factors of the fall. No documentation of causative factors were identified in the record review. Fall #3: The COC, dated 8/4/25, indicated Resident 1 fell on 8/4/25 at approximately 3:35 A.M. in the hallway outside of her room. Resident 1 was sent to the hospital for tests and returned to the facility. Resident 1's care plan, dated 8/4/25, indicated new fall preventative measures of adding floor mats next to the bed, and a pharmacist consult to evaluate Resident 1's medications. Fall #4: The COC, dated 8/11/25, indicated Resident 1 fell at approximately 7:30 A.M. in an unknown location. No new fall preventative measures were identified in Resident 1's 8/11/25 care plan. Fall #5: The COC, dated 9/18/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room. Resident 1 was sent to the hospital for tests due to, Small knot noted to right side of head. Resident 1 later returned to the facility.Resident 1's care plan, dated 9/18/25, indicated new fall preventative measures identified were a physical therapy consult for strength and mobility, and to move Resident 1 closer to the nurses station. Fall #6: The COC, dated 10/9/25, indicated Resident 1 fell at approximately 2:20 P.M. in the facility dining room. Resident 1's care plan, dated 10/9/25, indicated new fall preventative measures identified were increased monitoring of the resident during the evening shift, and offering toileting prior to bedtime. Fall #7: The COC, dated 10/17/25, indicated Resident 1 fell at approximately 7:37 A.M. in the hallway near the resident's room and the nurse's station. Resident 1's care plan, dated 10/17/25, indicated new fall preventative measures identified were to assist Resident 1 when walking, and when transferring from one place to another. Fall #8: The COC, dated 11/14/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room. No new care plan fall preventative measures were identified. Fall #9: The COC, dated 11/18/25, indicated Resident 1 fell at approximately 3:50 A.M. in her room. Resident 1's care plan, dated 11/18/25, indicated new fall preventative measures of offering toileting assistance before bedtime, and increased visually checking on the resident during the evening shift. Fall #10: The COC, dated 12/12/25, indicated Resident 1 fell at approximately 4:57 P.M. in her room. X-rays were ordered by the physician.Resident 1's care plan, dated 12/12/25, indicated new fall preventative measures identified were to increase Restorative Nursing Assistant (RNA, a type of rehabilitative care to help restore independence) frequency, and to maintain needed items, such as water and the call light within reach. Fall #11: The COC, dated 1/2/26, indicated Resident 1 fell at approximately 7 P.M. outside of her room. Resident 1's care plan, dated 1/2/26, indicated new fall preventative measures of scheduled toileting (a technique used to manage bowel and bladder issues by having the resident use the toilet at regular intervals) and a physical therapy evaluation. Fall #12: The COC, dated 1/11/26, indicated Resident 1 fell at approximately 6:55 A.M. inside of her room. Resident 1's care plan, dated 1/11/26, indicated new fall preventative measures of obtaining a urine test for possible infection. Fall #13: The COC, dated 2/1/26, indicated Resident 1 fell at approximately 11 A.M. inside of her room. According to the COC, the bed was raised to a high position. Resident 1 was sent to the hospital due to discoloration on the left side of her face. A review of Resident 1's hospital imaging results, dated 2/1/26, indicated that Resident 1 had sustained a broken rib, a left zygomaticomaxillary complex fracture (the cheekbone), and an orbital fracture (one or more bones surrounding the eye, or the eye socket). Resident 1's care plan, dated 2/1/26, indicated new fall preventative measures of a scoop mattress (a special mattress with raised edges around the perimeter to prevent the user from rolling off the bed). An interview and concurrent review of Resident 1's medical record was conducted with the Director of Nursing (DON) on 3/10/26 at 2:45 P.M. The DON stated all falls that occurred at the facility were tracked for patterns and discussed with leadership. The DON stated Resident 1's family member (FM) visited daily and monitored her due to her dementia and Parkinson's Disease. The DON stated if the FM was not present, staff placed Resident 1 at the nurse's station or in the activities area so they could monitor her for safety. According to the DON, the facility tried to do everything they could to prevent additional falls and keep Resident 1 safe. The DON stated she was not aware of how many falls Resident 1 had sustained. The DON provided an undated document titled Investigative Summary, which included details of Resident 1's fall that occurred on 2/1/26. The document indicated, Staff that were involved in the treatment and care of [Resident 1] were interviewed regarding their observations and interactions with the residents. Four staff members were listed. Licensed Nurses (LN) 1, 2, and 3, and Certified Nursing Assistant (CNA) 1. An interview was conducted with LN 1 on 3/10/26 at 3:03 P.M. Per LN 1, he was aware of Resident 1 falling several times. LN 1 stated he was familiar with Resident 1, and dementia was probably the reason Resident 1 tried to get out of bed or up from her wheelchair without assistance. LN 1 stated staff tried to keep eyes on Resident 1 to prevent injuries. Per LN 1, Resident 1's FM was very attentive, but staff were not always patient. LN 1 stated he had heard staff giving directions to Resident 1 even though she had dementia and would not understand the directions given. LN 1 stated, a one to one (1:1, a staff member assigned to monitor the resident at all times) may have worked to prevent more falls. Obviously with 11 falls, our staff did not prevent further falls. An interview was conducted with LN 2 on 3/10/26 at 3:15 P.M. LN 2 stated she had started her shift 2/1/26 at 3 P.M. and heard from another nurse Resident 1 had fallen and gone to the hospital. LN 2 stated she had called the hospital to get a report and to find out if Resident 1 was returning to the facility. LN 2 stated the hospital informed her Resident 1 had two facial fractures and would return to the facility. LN 2 stated she was informed Resident 1 had fallen from LN 3, who was the assigned nurse on 2/1/26. LN 2 stated Resident 1 had had previous falls, the most recent fall approximately two weeks earlier. LN 2 stated staff tried to keep Resident 1 from falling by keeping her engaged in activities. Per LN 2, We're trying everything for her, but it's not effective. An interview was conducted with Director of Staff Development (DSD, staff responsible for education and training of facility CNAs) on 3/10/26 at 4:07 P.M. Per the DSD, she was not aware how many falls Resident 1 had experienced. Per the DSD, Resident 1 had, .fallen quite a bit, maybe five to six times. The DSD stated Resident 1 needed something to do with her hands to keep her occupied. Per the DSD, the intervention to keep Resident 1 busy would not work during nighttime hours as Resident 1 needed to sleep. The DSD stated she was not aware of whether a 1:1 observation of Resident 1 had been attempted to keep her safe. The DSD stated staff should be familiar with Resident 1's diagnosis of dementia and how to provide care specific to the diagnosis. An observation of Resident 1 was conducted on 3/16/26 at 12:21 P.M. Resident 1 was seated in a wheelchair in the dining room, with the FM assisting her with the meal. An interview was conducted with CNA 2 on 3/16/26 at 12:21 P.M. CNA 2 stated he knew Resident 1 well. CNA 2 stated Resident 1 did not listen to staff, and .she does what she wants to.she falls often.she doesn't understand us. I'm not sure what her diagnosis is, or why she acts that way. Per CNA 2, Resident 1 usually fell at night. CNA 2 stated, When her [FM] is with her she doesn't seem to fall. If her [FM] would stay maybe she wouldn't fall. A telephone interview was conducted with CNA 1 on 3/17/26 at 11:15 A.M. CNA 1 stated he was assigned to provide care to Resident 1 on 2/1/26, the day of her fall with an injury. CNA 1 stated he often worked with Resident 1 and was familiar with her care. CNA 1 stated he had observed Resident 1 in bed, with her bed low to the floor at about 10:50 A.M., then went to break. CNA 1 stated when he returned from break, he saw many staff in Resident 1's room and saw her sitting on the floor with her cheek appearing red. CNA 1 stated he noticed the bed was positioned as high as it could go. CNA 1 stated he assisted getting Resident 1 back into bed, then prepared her to go to the hospital. CNA 1 stated it was difficult to work with Resident 1, even though he spoke the same language she did. CNA 1 stated, It's hard to get her to do things. She doesn't like to listen. CNA 1 stated he did not know what medical condition made Resident 1 act that way. CNA 1 stated he had received education on dementia in the past but did not know if Resident 1 had dementia. CNA 1 stated Resident 1 had fallen before but he did not know how many times, only that it was more than other residents, .maybe three falls. CNA 1 stated the facility should have implemented other things to prevent falls, like possibly having a CNA sit with her at all times. A telephone interview was conducted with LN 3 on 3/17/26 at 11:45 A.M. LN 3 stated she was assigned to Resident 1 on 2/1/26. LN 3 stated the FM for Resident 1 came to her and asked for help in the room. LN 3 stated she went to the room and saw Resident 1 sitting on the floor by her bed, hugging her legs. Per LN 3, Resident 1's bed was raised up to its highest level. LN 3 stated she saw a reddened area and swelling on Resident 1's face. LN 3 stated she assessed the resident, then called the physician. Per LN 3, Resident 1 was only aware of her own self, and was not oriented to the time, date, or her current location or situation. LN 3 stated she was not aware of Resident 1's diagnosis. Per LN 3, other staff told her Resident 1 was a fall risk, and she had assumed Resident 1 had fallen a few times, possibly two to three times. LN 3 stated nobody informed her of how many times Resident 1 had fallen. 2. A review of Resident 2's undated Face Sheet indicated Resident 2 was readmitted to facility on 10/28/25 with diagnoses to include encephalopathy (a group of conditions that cause brain dysfunction) and history of falling. A review of Resident 2's BIMS score, dated 10/29/25, indicated a score of 7, or severely impaired cognition. A review of Resident 2's Physician's History and Physical exam, dated 10/29/25, indicated Resident 2 had no memory of recent events, and had significant memory difficulty. The physician indicated Resident 2 had a past medical history of dementia and brain injury. An interview and observation of Resident 2 was conducted on 3/16/26. Outside of the room, Resident 2's name was posted, with a gold star next to it. Resident 2 was in bed, and the bed was low to the floor. Gray landing mats were next to the bed on the floor. Resident 2 was not wearing a yellow wristband. Resident 2 stated he was admitted for seizures. Resident 2 stated he fell at home about a week ago. Resident 2 stated he believed he was at a hospital due to the fall. A review of Resident 2's Nursing Progress Notes, Change in Condition Evaluations and care plans indicated the following incidents of fall and fall preventative measures initiated after each incident of a fall: Fall #1: The COC, dated 11/6/25, indicated an injury to Resident 2 had occurred at approximately 10:30 P.M. in Resident 2's room.A Nursing Progress Note, dated 11/6/25, indicated Resident 2 had been seen by his roommate crawling to the bathroom in their room.Resident 2's care plan for 11/6/25 did not indicate any new fall preventative measures had been implemented. Fall #2: The COC, dated 11/10/25, indicated the fall occurred in the morning. No specific time was documented. According to the COC, Resident 2 fell in his room, next to the bed.Resident 2's care plan, dated 11/10/25, indicated new fall preventative measures implemented were to ensure Resident 2's bed was in the lowest position. Fall #3: The COC, dated 11/23/25, indicated the fall occurred at approximately 6:09 A.M. in Resident 2's room. Resident 2 was found on the floor, seated near the bed. Resident 2 had dislodged a foley catheter (a device inserted into the bladder for urine collection) and had bleeding from the site. Resident 2's care plan, dated 11/23/25, indicated new fall preventative measures implemented were increased visual checks on the resident, and offering toileting assistance while awake. The care plan listed a pharmacist consult to review Resident 2's medications for potential contributors to falls. Fall #4: The COC, dated 11/25/25, indicated the fall occurred at night. No exact time was indicated. Resident 2 was found on his knees next to the bed.Resident 2's care plan, dated 11/25/25, did not identify any new fall preventative measures implemented. Fall #5: The COC, dated 12/19/25, indicated Resident 2 fell at approximately 7 A.M. and was found sitting on the floor next to the bed.Resident 2's care plan, dated 12/19/25, indicated no new fall preventative measures were implemented. Fall #6: The COC, dated 12/27/25, indicated Resident 2 fell in his room and was found on the floor next to his bed. The COC did not identify the exact time of the fall, only that it occurred at night.Resident 2's care plan, dated 12/27/25, did not identify any new fall preventative measures implemented. Fall #7: The COC, dated 1/7/26, indicated Resident 2 fell at night, no exact time was indicated. The COC indicated Resident 2 had a reddened area on his lower back from the fall.Resident 2's care plan, dated 1/7/26, indicated new fall preventative measures of scheduled toileting. Fall #8: The COC, dated 1/8/26, indicated a fall occurred in the morning. No exact time was indicated. Resident 2 was found sitting on the floor near his bed.Resident 2's care plan, dated 1/8/26, indicated a new fall preventative measure implemented was a psychiatric evaluation. Fall #9: The COC, dated 1/19/26, indicated Resident 2 was found on the floor in his room. The COC did not identify a specific time, and only specified morning.Resident 2's care plan, dated 1/19/26, indicated a new fall preventative measure of moving the resident to a room closer to the nurse's station for higher visibility and monitoring. Fall #10: The COC, dated 1/25/26, indicated Resident 2 fell in the afternoon, although no specific time was identified. Resident 2 was found on the floor outside of the door to his room.A Nurses Progress Note, dated 1/25/26, indicated Resident 2 had sustained a bruise on his hip and a skin tear on his forearm.Resident 2's care plan, dated 1/25/26, indicated a new fall preventative measure of ordering lab tests to assess for infection. Fall #11: The COC, dated 2/1/26, indicated Resident 2 fell at approximately 3:15 P.M. Resident 2 was found sitting on the floor near his bed. Resident 2's care plan, dated 2/1/26, indicated a new fall preventative measure of a scoop mattress. Fall #12: The COC, dated 2/12/26, indicated Resident 2 had fallen in the afternoon, no exact time was indicated. Resident 2 was found sitting on the floor next to his bed.Resident 2's care plan, dated 2/12/26, indicated a new fall preventative measure of positioning the bed against the wall. Fall #13: The COC, dated 2/19/26, indicated Resident 2 had fallen in the afternoon. No specific time was indicated. Resident 2 was found seated on the floor next to his bed.Resident 2's care plan, dated 2/19/26, indicated new fall preventative measure of getting Resident 2 up in a wheelchair during the day. An observation of Resident 2 and concurrent interview with CNA 4 was conducted on 3/18/26 at 5 P.M. Resident 2 was in bed, eating dinner. CNA 4 was seated next to Resident 2's bed. CNA 4 stated she usually sat outside the room to observe several residents who had a history of falling. CNA 4 stated she was aware Resident 2 had fallen before, but she did not know how many times or whether he had sustained any injuries. CNA 4 stated any residents who were at risk for falls had a gold star outside of their room by their name and wore a yellow wrist band . CNA 4 stated that it was important so that all staff could be aware that Resident 2 was at risk for falls, and they could monitor him and keep him safe. Resident 2 was asked if he had a wrist band on. He looked at his wrist, which did not have a wrist band, and replied, Nope. Nothing here. A telephone interview was conducted on 3/18/26 at 6:15 P.M with the facility's Medical Director (MD 1). MD 1 stated he was very familiar with Residents 1 and 2. MD 1 stated the Quality Assurance Performance Improvement committee (QAPI) discussed all falls monthly, and the facility goal was to reduce the number of falls, particularly falls with injury. MD 1 stated the ultimate intervention was to provide 1:1 supervision, although they always tried to maintain the residents' independence and quality of life. When asked whether providing earlier interventions of scoop mattresses or 1:1 supervision might prevent injuries, MD 1 stated, That's a fair assessment. A concurrent interview and record review with the DON was conducted on 4/2/26 at 3:10 P.M. The DON acknowledged that despite adding care plan interventions for Residents 1 and 2, both residents continued to have falls. The DON stated the COCs should have included more information in order to identify trends, such as time of day and location where the fall occurred and implement changes to keep the residents from falling. The DON stated each care plan should be updated to meet the individual needs of the residents. The DON stated if residents were at risk for falls, the facility placed a gold star outside of the resident room, and placed a yellow wristband so staff could identify residents who were at risk for falls. The DON was unable to explain why Resident 2 was not wearing a yellow wristband. Per an undated facility policy, titled Falls, It is the policy of this facility to evaluate extent of injury after a fall and prevent complications.observe for cause of the fall, e.g., wet floor, obstructed pathway. Per an undated facility document, titled Fall System, In the Event of a Fall.Individualized interventions initiated.

Based on observation, interview, and record review, the facility failed to ensure care plans for fall prevention were revised and updated with specific resident-centered interventions for two of five residents reviewed for falls (Residents 1 and 2). This failure had the potential to result in additional falls, and an increased risk for injuriesFindings: 1. A review of Resident 1's undated Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and Parkinson's Disease (a movement disorder of the nervous system that worsens over time). A review of Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool) dated 7/23/25, indicated a score of 0, or severely impaired cognition. A review of Resident 1's Nurse Practitioner/Physician's Assistant (NP/PA) progress note, dated 7/25/25, indicated Resident 1 had, evidence of severe cognitive impairment.indicating severe dementia. She is completely disoriented, unable to recall or repeat words, perform basic calculations, follow commands, or recognize objects. The NP/PA indicated Resident 1 did not speak, make eye contact or engage while being evaluated. A review of Resident 1's Physician's History and Physical Note, dated 8/17/25, indicated Resident 1 did not have the capacity to understand and make decisions. An observation of Resident 1 was conducted in her room on 3/10/26 at 10:15 A.M. Resident 1's name was outside of the room with a gold star next to her name. Resident 1 was seated in a wheelchair, in her room. Resident 1 did not respond to questions asked. Resident 1 was not wearing a colored wristband. A mattress with the edges built up was on the bed, and a fall mat was leaning against the wall. Resident 1's room was located approximately 10 feet from the nurse's station. A review of Resident 1's Nursing Progress Notes, Change in Condition Evaluations (COC, a form to evaluate a clinically significant change from the resident's normal levels of health) and care plan indicated the following incidents of fall and fall preventative measures initiated after each incident of a fall: Fall #1: The COC, dated 7/31/25, indicated the fall occurred on 7/31/25 at 2:18 A.M. The COC summarized that Resident 1 was found sitting on the floor in her room.A review of Resident 1's care plan, dated 7/31/25 indicated new fall preventative measures implemented were to ensure the bed was lowered to the floor, and monitor Resident 1 for any new problems as a result of the fall. Fall #2: The COC, dated 8/3/25, indicated Resident 1fell on 8/3/25 at approximately 1 P.M. in her room. The COC summarized that Resident 1 was found sitting on the floor near her bed.Resident 1's Fall risk assessment score, dated 8/3/25, re-evaluated her fall risk level from 16 to 13 (higher numbers indicate higher risk for falls). Resident 1's care plan, dated 8/3/25, indicated new fall preventative measures of moving Resident 1 closer to the nurses' station, and a physical therapy consult for strength and mobility. The care plan indicated unnamed facility staff would, .determine and address causative factors of the fall. Fall #3: The COC, dated 8/4/25, indicated Resident 1 fell on 8/4/25 at approximately 3:35 A.M. in the hallway outside of her room. Resident 1 was sent to the hospital for tests and returned to the facility.Resident 1's care plan, dated 8/4/25, indicated new fall preventative measures of adding floor mats next to the bed, and a consult from a pharmacist to evaluate Resident 1's medications. Fall #4: The COC, dated 8/11/25, indicated Resident 1 fell at approximately 7:30 A.M. in an unknown location.No new fall preventative measures were identified in Resident 1's 8/11/25 care plan. Fall #5: The COC, dated 9/18/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room. Resident 1 was sent to the hospital for tests due to, Small knot noted to right side of head. Resident 1 later returned to the facility.Resident 1's care plan, dated 9/18/25, indicated new fall preventative measures identified were a physical therapy consult for strength and mobility, and moving Resident 1 closer to the nurse's station. Fall #6: The COC, dated 10/9/25, indicated Resident 1 fell at approximately 2:20 P.M. in the facility dining room.Resident 1's care plan, dated 10/9/25, indicated new fall preventative measures identified were increased monitoring of the resident during the evening shift, and offering toileting prior to bedtime. Fall #7: The COC, dated 10/17/25, indicated Resident 1 fell at approximately 7:37 A.M. in the hallway near the resident's room and the nurse's station.Resident 1's care plan, dated 10/17/25, indicated new fall preventative measures identified were to assist Resident 1 when walking, and when transferring from one place to another. Fall #8: The COC, dated 11/14/25, indicated Resident 1 fell at approximately 6:40 A.M., in her room.No new care plan fall preventative measures were identified. Fall #9: The COC, dated 11/18/25, indicated Resident 1 fell at approximately 3:50 A.M. in her room.Resident 1's care plan, dated 11/18/25, indicated new fall preventative measures of offering toileting assistance before bedtime, and increased visual checks during the evening shift. Fall #10: The COC, dated 12/12/25, indicated Resident 1 fell at approximately 4:57 P.M. in her room. X-rays were ordered by the physician.Resident 1's care plan, dated 12/12/25, indicated new fall preventative measures identified was to increase Restorative Nursing Assistant (RNA, a type of rehabilitative care to help restore independence) frequency, and to maintain needed items, such as water and the call light within reach. Fall #11: The COC, dated 1/2/26, indicated Resident 1 fell at approximately 7 P.M. outside of her room.Resident 1's care plan, dated 1/2/26, indicated new fall preventative measures of scheduled toileting and a physical therapy evaluation. Fall #12: The COC, dated 1/11/26, indicated Resident 1 fell at approximately 6:55 A.M. inside of her room.Resident 1's care plan, dated 1/11/26, indicated new fall preventative measures of obtaining a urine test for possible infection. Fall #13: The COC, dated 2/1/26, indicated Resident 1 at approximately 11 A.M. inside of her room. Per the COC, .Resident's bed noted elevated above the floor level. Resident 1 was sent to the hospital due to discoloration on the left side of her face.Resident 1's care plan, dated 2/1/26, indicated new fall preventative measures of a scoop mattress (a special mattress with raised edges around the perimeter to prevent the user from rolling off of the bed). A review of Resident 1's hospital imaging results, dated 2/1/26, indicated that Resident 1 had sustained a broken rib, a left zygomaticomaxillary complex fracture (the cheekbone) and an orbital fracture (one or more bones surrounding the eye, or the eye socket). An interview and concurrent review of Resident 1's medical record was conducted with the Director of Nursing (DON) on 3/10/26 at 2:45 P.M The DON stated she was not aware of how many falls Resident 1 had sustained. The DON stated the Interdisciplinary Team (IDT, a group of healthcare professionals) met following each fall to assess for patterns, such as the time of day the fall occurred, and to update the care plan. An interview was conducted with LN 1 on 3/10/26 at 3:03 P.M. Per LN 1, he was aware of Resident 1 falling several times. LN 1 stated he was familiar with Resident 1, and dementia was probably the reason Resident 1 tried to get out of bed or up from her wheelchair without assistance. LN 1 stated staff tried to keep eyes on Resident 1 to prevent injuries. Per LN 1, Resident 1's FM was very attentive, but staff were not always patient. LN 1 stated he had heard staff giving directions to Resident 1 even though she had dementia and would not understand the directions given. LN 1 stated, a one to one (1:1, a staff member assigned to monitor the resident at all times) may have worked to prevent more falls. Obviously with 11 falls, our staff did not prevent further falls. An interview was conducted with LN 2 on 3/10/26 at 3:15 P.M. LN 2 stated she had started her shift 2/1/26 at 3 P.M. and heard from another nurse Resident 1 had fallen and gone to the hospital. LN 2 stated she had called the hospital to get a report and to find out if Resident 1 was returning to the facility. LN 2 stated the hospital informed her Resident 1 had two facial fractures and would return to the facility. LN 2 stated she was aware Resident 1 had fallen from LN 3, who was the assigned nurse on 2/1/26. LN 2 stated Resident 1 had had previous falls, the most recent fall approximately two weeks earlier. LN 2 stated staff tried to keep Resident 1 from falling by keeping her engaged in activities. Per LN 2, We're trying everything for her, but it's not effective. An interview was conducted with Director of Staff Development (DSD, staff responsible for education and training of facility CNAs) on 3/10/26 at 4:07 P.M. Per the DSD, she was not aware how many falls Resident 1 had experienced. Per the DSD, Resident 1 had, .fallen quite a bit, maybe five to six times. The DSD stated Resident 1 needed something to do with her hands to keep her occupied. Per the DSD, the intervention to keep Resident 1 busy would not work during nighttime hours as Resident 1 needed to sleep. The DSD stated she was not aware of whether a 1:1 observation of Resident 1 had been attempted to keep her safe. The DSD stated staff should be familiar with Resident 1's diagnosis of dementia and how to provide care specific to the diagnosis . The DSD stated she recently started attending the IDT meetings regarding residents who had fallen. An observation of Resident 1 was conducted on 3/16/26 at 12:21 P.M. Resident 1 was seated in a wheelchair in the dining room, with the FM assisting her with the meal. An interview was conducted with CNA 2 on 3/16/26 at 12:21 P.M. CNA 2 stated he knew Resident 1 well. CNA 2 stated Resident 1 did not listen to staff, and .she does what she wants to.she falls often.she doesn't understand us. I'm not sure what her diagnosis is, or why she acts that way. Per CNA 2, Resident 1 usually fell at night. CNA 2 stated, When her [FM] is with her she doesn't seem to fall. If her [FM] would stay maybe she wouldn't fall. CNA 2 stated he received updates on the residents during the morning huddle, but he did not review the care plans for information. A telephone interview was conducted with CNA 1 on 3/17/26 at 11:15 A.M. CNA 1 stated he was assigned to provide care to Resident 1 on 2/1/26, the day of her fall with an injury. CNA 1 stated he often worked with Resident 1 and was familiar with her care. CNA 1 stated when he returned from break, he saw many staff in Resident 1's room and saw her sitting on the floor with her cheek appearing red. CNA 1 stated he noticed the bed was as high as it could go. CNA 1 stated he assisted getting Resident 1 back into bed, then prepared her to go to the hospital. CNA 1 stated it was difficult to work with Resident 1, even though he spoke the same language she did. CNA 1 stated, It's hard to get her to do things. She doesn't like to listen. CNA 1 stated he did not know what medical condition made Resident 1 act that way. CNA 1 stated he had received education on dementia in the past but did not know if Resident 1 had dementia. CNA 1 stated Resident 1 had fallen before but he did not know how many times, only that it was more than other residents, .maybe three falls. CNA 1 stated residents who were at risk for falls had a gold star by their name outside of the room, and staff knew to check on them more often. CNA 1 stated the facility should have implemented other things to prevent falls, like possibly having a CNA always sit with her. CNA 1 stated he was aware of the care plans but did not routinely review them. A telephone interview was conducted with LN 3 on 3/17/26 at 11:45 A.M. LN 3 stated she was assigned to Resident 1 on 2/1/26. LN 3 stated the FM for Resident 1 came to her and asked for help in the room. LN 3 stated she went to the room and saw Resident 1 sitting on the floor by her bed, hugging her legs. Per LN 3, Resident 1's bed was raised up to its highest level. LN 3 stated she saw a reddened area and swelling on Resident 1's face. LN 3 stated she assessed the resident, then called the physician. Per LN 3, Resident 1 was only aware of her own self, and was not oriented to the time, date, or her current location or situation. LN 3 stated she was not aware of Resident 1's diagnosis. Per LN 3, other staff told her Resident 1 was a fall risk, and she had assumed Resident 1 had fallen a few times, possibly two to three times. LN 3 stated nobody informed her of how many times Resident 1 had fallen. LN 3 stated she could look at care plans to obtain information about the residents, but she usually heard in report from the previous shift if a fall had occurred. LN 3 stated that was her primary way to receive information about the residents. 2. A review of Resident 2's undated Face Sheet indicated Resident 2 was readmitted to facility on 10/28/25 with diagnoses to include encephalopathy (a group of conditions that cause brain dysfunction) and history of falling. A review of Resident 2's BIMS score, dated 10/29/25, indicated a score of 7, or severely impaired cognition. A review of Resident 2's Physician's History and Physical exam, dated 10/29/25, indicated Resident 2 had no memory of recent events, and had significant memory difficulty. The physician indicated Resident 2 had a past medical history of dementia and brain injury. An interview and observation of Resident 2 was conducted on 3/16/26. Outside of the room, Resident 2's name was posted, with a gold star next to it. Resident 2 was in bed, and the bed was low to the floor. Gray landing mats were next to the bed on the floor. Resident 2 was not wearing a yellow wristband. Resident 2 stated he was admitted for seizures. Resident 2 stated he fell at home about a week ago. Resident 2 stated he believed he was at a hospital due to the fall. A review of Resident 2's Nursing Progress Notes, Change in Condition Evaluations and care plans indicated the following incidents of fall and fall preventative measures initiated after each incident of a fall: Fall #1: The COC, dated 11/6/25, indicated an injury to Resident 2 had occurred at approximately 10:30 P.M. in Resident 2's room.A Nursing Progress Note, dated 11/6/25, indicated Resident 2 had been seen by his roommate crawling to the bathroom in their room.Resident 2's care plan for 11/6/25 did not indicate any new fall preventative measures implemented. Fall #2: The COC, dated 11/10/25, indicated the fall occurred in the morning. No specific time was documented. According to the COC, Resident 2 fell in his room, next to the bed.Resident 2's care plan, dated 11/10/25, indicated new fall preventative measures implemented were to ensure Resident 2's bed was in the lowest position. Fall #3: The COC, dated 11/23/25, indicated the fall occurred at approximately 6:09 A.M. in Resident 2's room. Resident 2 was found on the floor, seated near the bed.Resident 2 had dislodged a foley catheter (a device inserted into the bladder for urine collection) and had bleeding from the site.Resident 2's care plan, dated 11/23/25, indicated new fall preventative measures implemented were increased visual checks on the resident, and offering toileting assistance while awake. The care plan listed a pharmacist consult to review Resident 2's medications for potential contributors to falls. Fall #4: The COC, dated 11/25/25, indicated the fall occurred at night. No exact time was indicated. Resident 2 was found on his knees next to the bed.Resident 2's care plan, dated 11/25/25, did not identify any new fall preventative measures implemented. Fall #5: The COC, dated 12/19/25, indicated Resident 2 fell at approximately 7 A.M. and was found sitting on the floor next to the bed.Resident 2's care plan, dated 12/19/25, indicated no new fall preventative measures were implemented. Fall #6: The COC, dated 12/27/25, indicated Resident 2 fell in his room and was found on the floor next to his bed. The COC did not identify the exact time of the fall, only that it occurred at night.Resident 2's care plan, dated 12/27/25, did not identify any new fall preventative measures implemented. Fall #7: The COC, dated 1/7/26, indicated Resident 2 fell at night, no exact time was indicated. The COC indicated Resident 2 had a reddened area on his lower back from the fall.Resident 2's care plan, dated 1/7/26, indicated new fall preventative measures of scheduled toileting. Fall #8: The COC, dated 1/8/26, indicated a fall occurred in the morning. No exact time was indicated. Resident 2 was found sitting on the floor near his bed.Resident 2's care plan, dated 1/8/26, indicated a new fall preventative measure implemented was a psychiatric evaluation. Fall #9: The COC, dated 1/19/26, indicated Resident 2 was found on the floor in his room. The COC did not identify a specific time, and only specified morning.Resident 2's care plan, dated 1/19/26, indicated a new fall preventative measure of moving the resident to a room closer to the nurses station for higher visibility and monitoring. Fall #10: The COC, dated 1/25/26, indicated Resident 2 fell in the afternoon, although no specific time was identified. Resident 2 was found on the floor outside of the door to his room.A Nurses Progress Note dated 1/25/26 indicated Resident 2 had sustained a bruise on his hip, and a skin tear on his forearm.Resident 2's care plan, dated 1/25/26, indicated a new fall preventative measure of ordering lab tests to assess for infection. Fall #11: The COC, dated 2/1/26, indicated Resident 2 fell at approximately 3:15 P.M. Resident 2 was found sitting on the floor near his bed. Resident 2's care plan, dated 2/1/26, indicated a new fall preventative measure of a scoop mattress. Fall #12: The COC, dated 2/12/26, indicated Resident 2 had fallen in the afternoon, no exact time was indicated. Resident 2 was found sitting on the floor next to his bed.Resident 2's care plan, dated 2/12/26, indicated a new fall preventative measure of positioning the bed against the wall. Fall #13: The COC, dated 2/19/26, indicated Resident 2 had fallen in the afternoon. No specific time was indicated. Resident 2 was found seated on the floor next to his bed.Resident 2's care plan, dated 2/19/26, indicated new fall preventative measure of getting Resident 2 up in a wheelchair during the day. An observation of Resident 2 and concurrent interview with CNA 4 was conducted on 3/18/26 at 5 P.M. Resident 2 was in bed, eating dinner. His bed was against the wall, and the mattress was curved upwards around the four sides. CNA 4 was seated next to Resident 2's bed. CNA 4 stated she usually sat outside the room to observe several residents who had a history of falling. CNA 4 stated she was aware Resident 2 had fallen before but did not know how many times or whether he had sustained any injuries. CNA 4 stated any residents who were at risk for falls had a gold star outside of their room by their name and wore a yellow wrist band. CNA 4 stated that it was important so that all staff could be aware that Resident 2 was at risk for falls, and they could monitor him and keep him safe. Resident 2 was asked if he had a wrist band on. He looked at his wrist, which did not have a wrist band, and replied, Nope. Nothing here. A concurrent interview and record review with the DON was conducted on 4/2/26 at 3:10 P.M. The DON acknowledged that despite adding care plan interventions for Residents 1 and 2, both residents had continued to have falls. The DON stated care plan interventions should be appropriate for the residents to ensure effectiveness. Per the DON, the purpose of the falls care plan was to implement actions that would prevent further falls and injuries. The DON stated each care plan should be updated to meet the individual needs of the residents. Per an undated facility document, titled Fall System, In the Event of a Fall.Individualized interventions initiated. A policy on updating care plans was requested but not provided by the facility.

Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three of three residents (Residents 2, 3 and 4) who filed complaints with the California Department of Public Health (CDPH, an agency responsible for regulatory compliance of healthcare facilities).This failure had the potential to negatively affect the overall health and mental wellbeing of the residents.Findings:Three consumer complaints were filed with CDPH regarding the facility's failure to answer call lights in a timely manner. An onsite investigation was conducted. An interview was conducted on 2/12/26 at 5:15 P.M. with Resident 2. Resident 2 stated she had been in two skilled nursing facilities over the last seven years, and she had never filed a complaint with CDPH prior to this incident. Resident 2 stated she often waited an hour or more for someone to respond to her call light. Per Resident 2, on 2/4/26 she waited 90 minutes for a medication. Resident 2 stated due to her physical issues, the long delay in getting a medication or getting assistance with toileting could cause serious complications to her health. Resident 2 stated she was involved in Resident Council (a meeting for residents to communicate concerns or needs), and call light response was always discussed, but no improvements had been seen. On 2/12/26, a record review was conducted. Resident 2 was admitted to the facility on [DATE] with diagnoses to include quadriplegia (paralysis to all four limbs and torso), per the Face Sheet. Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool) score was 15, indicating intact cognition. Resident Council minutes from October 2025 indicated complaints about call light response in Old Business and New Business discussions. The facility response was that the call light policy would be reviewed with staff. Resident Council minutes from November 2025 indicated complaints about long waits for call light response. The facility response was that education would occur with Certified Nursing Assistants (CNAs) to remind them to communicate with each other. Resident Council minutes from December 2025 indicated that registry staff (nurses and CNAs who work for a staffing agency rather than the facility) were not good, and call light response took too long. The facility response was that management was working on hiring permanent staff to lessen the use of registry staff. Resident Council minutes from January 2026 indicated CNAs needed to communicate when they go on break so another CNA would respond to their call lights. The facility response was that a buddy system was being instituted, and the facility would do inservices and rounds to assess whether it helped with call light response times. Resident Council minutes from February 2026 indicated it was challenging to find an available CNA during some shifts to answer call lights. The facility response was to reeducate staff. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses to include aftercare for joint replacement surgery and need for assistance with personal care, per the Face Sheet. A record review was conducted. Resident 3's BIMS score was 14, indicating intact cognition. An interview was conducted with Resident 3 on 2/17/26 at 9:25 A.M. Resident 3 stated she chose to leave the facility against medical advice (AMA, when a discharge is not approved by the physician) due to the problems she experienced there. Resident 3 stated, The worst thing was waiting for someone to answer the call light. Resident 3 stated in one instance, she waited over an hour, then when a staff member came to her room, they told her they would go get her CNA to assist her. Resident 3 stated later she found out the staff member was the CNA assigned to her. Resident 3 stated her room was near the nurses station and she could clearly hear staff seated for long periods of time just outside of her room, laughing and talking amongst themselves. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses to include need for assistance with personal care, per the Face Sheet. A record review was conducted. Resident 4's BIMS score was 13, indicating intact cognition. A consumer complaint was received by CDPH on 2/17/26. The complaint outlined a family member's (FM 1) concerns while visiting Resident 4. FM 1 documented call lights often took up to 40 minutes for a staff member to respond. FM 1 indicated she had walked to the nurses station and observed three CNAs sitting at the desk, with call lights alarming. FM 1 documented when she requested assistance, staff often responded that the assigned staff person was on break, or busy attending to other residents, and no other staff was available to assist. An observation of call light response was conducted on 2/12/26 starting at 1:30 P.M.A call light was observed on. An employee (Em 1) walked past the room with the call light and did not stop to assist. Em 1 was stopped and asked what the process was for call light response. Em 1 stated she was from the Admissions office, and all staff was supposed to answer call lights. Em 1 stated she had kept another resident waiting for about an hour, so she passed the call light to attend to that resident's needs. Em 1 stated it was the expectation that all staff respond to call lights, and she had not done so. An interview was conducted with the Activities Director (AD) on 2/12/26 at 3 P.M. The AD stated she was responsible for taking notes during the Resident Council meetings, and for obtaining responses from department heads for any concerns expressed by the Council. The AD stated she was new to the role, but she had reviewed the Council's concerns for the previous months and determined call lights were an ongoing problem. The AD stated the additional training and monitoring of staff regarding call lights did not seem to have improved the process. The AD stated it was important to answer call lights in a timely manner to ensure residents were safe, and to treat them with dignity and respect. The AD stated, We have some work to do here. An observation of Resident 5 was conducted on 2/17/26 at 11:15 A.M. Resident 5 was seated in a wheelchair at the entrance to her room. Resident 5 asked if someone could get her help going to the bathroom. The call light was hit to get staff's attention. CNA 2 responded to the room, did not look at or address Resident 5, and proceeded to walk around Resident 5 to enter the room and turn off the call light. When asked, CNA 2 stated he was a CNA, but Resident 5 requested female CNAs only so he was unable to help her. CNA 2 stated he was unable to provide assistance with toileting so he would request a female CNA report to the room. CNA 2 stated he turned off the call light because he had come to the room, but he should have left the light on since he was unable to provide the care requested. The observation continued. Resident 5's personal caregiver (CG 1) arrived and greeted Resident 5 who was still seated in her wheelchair in the doorway of her room. CG 1 stated she came in to visit Resident 5 several times a week. CG 1 stated she worked for Resident 5 when she was home, but when she was in the nursing home she came to keep her company. CNA 3 then arrived, and did not greet or make eye contact with Resident 5. CNA 3 spoke to CG 1 and asked if it was safe to take Resident 5 to the bathroom. When asked, CNA 3 stated she addressed CG 1 since she was, Always here. CNA 3 stated she should have addressed her questions to Resident 5 in order to treat her with respect and dignity. CNA 3 stated she also should have spoken to her coworkers to find out how Resident 5 toileted rather than asking CG 1. An interview was conducted with Resident 6 on 2/17/26 at 11:40 A.M. Resident 6 stated his call light was always on, because when he needed something staff would come in and turn off the light, informing him they would return or they would go get the right person. Resident 6 stated it usually took about an hour for someone to come in and provide whatever he had requested. Resident 6 stated he had learned to turn the call light back on when staff turned it off. Resident 6 stated, .when the staff finally comes to my room, they have an attitude, like they're doing me a favor. An interview was conducted with Resident 7 on 2/17/26 at 11:50 A.M. Resident 7 stated it always took too long for staff to answer her call light. Resident 7 stated, Sometimes I think I'm the only one here and nobody can see me. An interview was conducted with Resident 8 on 2/17/26 at 3:45 P.M. Resident 8 stated it took a long time for staff to come and help her clean up. Resident 8 stated she heard other residents yelling, so she knew other people needed help and she tried to be patient while waiting for help. An interview was conducted with Resident 9 on 2/17/26 at 3:52 P.M. Resident 9 stated the staff was nice but it could be an hour before someone came in to help her An interview was conducted with the Director of Staff Development (DSD) on 2/17/26 at 4:30 P.M. The DSD stated she was responsible for monitoring and training of CNAs. The DSD stated she and the managers had spoken about how to monitor call lights to ensure residents were being attended to. The DSD stated the managers conducted rounds to ask residents how things were going, and any concerns were addressed by the managers. The DSD stated she worked with the CNAs to identify how they do their work to see if they were proficient, rather than observe call light response. An interview was conducted with the Director of Nursing (DON) on 2/17/26 at 5 P.M. The DON stated call lights response was an ongoing project. The DON stated the managers met daily to discuss resident concerns, and call lights were usually discussed. The DON stated, We still have an opportunity to do better. Per a facility policy, titled Resident Council Meeting and reviewed 2/2026, It is the policy of this facility to.Provide information to the residents on action taken on recommendations made at the Resident Council meetings.Resident Council is a chance for residents to provide input into.facility policies in general.The Council allows residents to discuss any special concerns they may be having.Residents are encouraged to discuss all aspects of nursing care received. Per a facility policy, titled Dignity and Privacy, reviewed 2/2026, It is the policy of this facility that all residents be treated with kindness, dignity and respect.Staff shall display respect for resident's rights, preferences.and shall communicate with residents in a courteous, calm and professional manner. Per a facility policy, undated and titled Call Light/Bell, .Answer the light within a reasonable time.Leave the resident comfortable.

Based on interview and record review, the facility failed to administer medications as ordered by the physician for one of three residents reviewed for medication administration (Resident 4) when:Resident 4 did not receive nine of the 14 medications within 24 hours of her admission; and,Resident 4 received a medication two times when it was scheduled five times over her admission to the facility. This failure had the potential to affect the health and well-being of Resident 4.Findings:Resident 4 was admitted to the facility on [DATE] with diagnoses to include diabetes (a long-lasting health condition that affects how the body turns food into energy), high blood pressure and heart failure, per the Face Sheet.A record review was conducted on 2/23/26.Resident 4's Brief Interview for Mental Status (BIMS, an assessment tool) score was 13, indicating intact cognition.According to the physician's orders, dated 11/5/26, Resident 4 had 14 scheduled medications to be administered at specific times of day.According to the Medication Administration Record (MAR), on 11/6/26 Resident 4 received five of the 14 medications prescribed. Three of the five medications were supplements (a product added to improve the diet, such as vitamins), as well as two over the counter medications, one for pain and one for allergies.According to the MAR, on 11/6/26 Resident 4 did not receive 9 medications. Those medications included two medications for diabetes, three medications for blood pressure, a medication for cholesterol, a blood thinner, a medication for depression and eye drops. For each medication not administered, the Licensed Nurse (LN) documented that the medication was not available, and the LN was waiting for the pharmacy to deliver the medication.The nurse who was responsible for documenting the medication was not available for an interview.2. Resident 4 had a physician's order , dated 11/5/25, for dulaglutide (a once-weekly injection which helped to control blood sugar), to be administered one time a day. No day of the week was indicated.According to LN notes, dated 11/6/25 and11/13/25, the facility was waiting for the pharmacy to deliver the medication. According to LN notes, dated 11/27/25 and 12/4/25, the medication was not administered, and no explanation was provided.According to the MAR, Resident 4 was admitted to the facility for five weeks, providing five opportunities for the facility to provide Trulicity as ordered. In the five weeks of Resident 4's admission, she received dulaglutide two times.On 2/17/26 at 3 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated all medications should be available for administration to residents within eight hours of admission. The DON stated she could not explain what had occurred during November as she was not at the facility, and another DON was covering for her during that time. The DON stated if a medication was not available, nurses should have informed the current DON or Assistant DON to identify a solution. The DON stated while the LNs had documented the medications were not available, no staff resolved the issue. According to the DON, .We did not administer the medications the way we should have.The covering DON was not available for interview.Per a facility policy, revised 6/2025 and titled Admission, .Order medications from the pharmacy. Medications are to be delivered within 8 hours of admission.Per a facility policy, reviewed 2/2026 and titled Medication Administration, It is the policy of this facility to accurately prepare and administer medications as ordered.

Based on observation, interview, and record review, the facility failed to provide pharmacy services in accordance with accepted standards of practice when:1. A medication was not in stock for one of five sampled residents (Resident 5) when it was due. This failure had the potential for Resident 5 not to benefit from the full therapeutic effect of her medication. 2. Random controlled medication (medications with a high abuse potential) use audit for four out of eight sampled residents (Residents 6, 9, 37, 73) did not reconcile. The residents' medications were signed out of the controlled drug record (CDR, count sheet), but not documented on the Medication Administration Record (MAR) to indicate they were administered to the residents. This failure resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications. 3. Controlled medications for pain were not administered as ordered for two of five sampled residents (Residents 72 and 73). This failure had the potential for Residents 72 and 73 to experience harmful effects and negative health outcomes from the controlled medications. 1. During the medication administration observation on 8/25/25 at 9:41 a.m., Licensed Nurse (LN) 2 was observed preparing and administering 11 medications for Resident 5. LN 2 stated she did not have Resident 5's twelfth medication, Vitamin D 5000 international units (IU, unit of measure), in stock. LN 2 stated she cannot give the Vitamin D pending pharmacy supply.We have different Vitamin Ds, but I can't give it to her because it's a different strength. LN 2 stated that the Vitamin D would not be coming in that day (8/25/25), although nursing staff told her it was ordered last Thursday (on 8/21/25). A review of Resident 5's clinical record indicated Resident 5 had an active order since 7/22/25 for Vitamin D3 (a type of Vitamin D) oral tablet 125 micrograms (mcg, unit of measure). Vitamin D 125 mcg is equivalent to Vitamin D 5000 IU. Give 1 tablet by mouth one time a day for Vit[[NAME]] D deficiency [low Vitamin D levels]. During an interview with the Director of Nursing (DON) on 8/27/25 at 8:59 a.m., the DON stated it is not acceptable for residents to be without their medications. The DON stated, They're taking their medications for a reason.A review of the facility's policy and procedure (P&P) titled, Medication Administration and Storage, revised 3/2025, indicated, .accurately prepare, administer and document medications as per physician's order.A review of the facility's P&P titled, Pharmacist, Services of a Licensed, revised 6/2025, indicated, The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs.1.including.accurate acquiring, receiving, dispensing, and administering of drugs.6. Strive to assure.medications are requested, received, and administered in a timely manner as ordered by the physician. 2. The CDRs for eight random residents receiving PRN (as needed) controlled medications were requested for review. a) A review of Resident 6's clinical record indicated she had an order for tramadol (a controlled medication used to relieve pain) 25 milligram (mg, unit of measure) tablet - give one tablet by mouth every 8 hours as needed for moderate to severe pain, dated 6/21/25. During a concurrent interview and record review with the DON on 8/27/25 at 8:06 a.m., a review of Resident 6's CDR for tramadol 25 mg and August 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on four occasions: 8/4/25 at 6:47 a.m. and 9 p.m., 8/6/25 at 9:30 p.m. and 8/9/25 at 8:43 p.m. The DON confirmed this finding and stated, I'm missing the MAR documentation on this. There's no documentation on the MAR for tramadol on 8/4, 8/6 and 8/9. b) A review of Resident 9's clinical record indicated she had an order for oxycodone (a controlled medication and strong painkiller) 5 mg tablet - take one tablet by mouth every 6 hours as needed for severe pain, originally dated 6/24/25.During a concurrent interview and record review with the DON on 8/27/25 at 8:37 a.m., a review of Resident 9's CDR for oxycodone 5 mg and the August 2025 MAR indicated the nursing staff signed out of the CDR but did not document the medication administration on 6 occasions:8/3/25 at 4:08 p.m.8/8/25 at 9:02 p.m.8/9/25 at 6:45 a.m.8/21/25 at 9:37 p.m.8/23/25 at 8:36 p.m.8/24/25 at 8:50 p.m. The DON confirmed this deficiency and stated, I couldn't find that either, regarding any documentation on the MAR for oxycodone on 8/3, 8/8, 8/9, 8/21, 8/23 and 8/24. c) A review of Resident 73's clinical record indicated he had an order for oxycodone 5 mg, give one tablet by mouth every 6 hours as needed for moderate to severe pain, dated 6/21/25.During a concurrent interview and record review with the DON on 8/27/25 at 8:47 a.m., a review of Resident 73's CDR for oxycodone 5 mg and the July 2025 MAR indicated nursing staff signed the CDR but did not document on the medication administration on 1 occasion: 7/30/25 at 10 p.m. The DON confirmed this deficiency and could not find any documentation on the MAR on 7/30/25 for oxycodone.d) A review of Resident 37's clinical record indicated she had an order for hydrocodone-acetaminophen (a controlled medication and painkiller) 10/325 mg, give one tablet every 4 hours as needed for moderate to severe pain, dated 7/30/25. During a concurrent interview and record review with the DON on 8/27/25 at 8:47 a.m., a review of Resident 37's CDR for hydrocodone-acetaminophen 10/325 mg and the August 2025 MAR indicated nursing staff signed the CDR but did not document on the medication administration on 1 occasion: 8/24/25 at 8:47 p.m. The DON confirmed this deficiency. The DON stated, I don't see that one either.During an interview with the DON on 8/27/25 at 8:37 a.m., the DON confirmed controlled medication administration should be documented properly on the CDR and MAR. The DON stated improper documentation creates more room for errors. and increased risk of side effects for the residents. The DON stated controlled medications are tracked on a higher scale. If anything is missing, it could be a diversion and that's what we want to prevent. Even when we dispose it with the pharmacist, we make sure it's there. The DON stated, we need to know the exact administration for future administrations so we can track it appropriately and prevent diversion. A review of the facility's P&P titled, Controlled Medications, revised 6/2025, indicated, .6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered. 3. a) A review of Resident 72's clinical record indicated that she had an order for hydrocodone-acetaminophen 5/325 mg tablet, give one tablet by mouth every 6 hours as needed for severe pain (6-10 level pain out of 10, with 0 being no pain and 10 being the worst pain imaginable), originally dated 6/26/25. Resident 72 received doses, as documented on her July 2025 and August 2025 MARs, despite having a pain level less than 6 on the following dates:7/12/25 at 7:24 p.m. pain level 57/14/25 at 5:27 p.m. pain level 58/2/25 at 6:55 p.m. pain level 48/5/25 at 9:48 a.m. pain level 28/8/25 at 3:30 p.m. pain level 58/10/25 at 5:19 p.m. pain level 08/12/25 at 10:08 p.m. pain level 08/13/25 at 5:33 p.m. pain level 08/15/25 at 9:20 p.m. pain level 18/19/25 at 5:32 p.m. pain level 48/20/25 at 9:28 p.m. pain level 58/25/25 at 4:16 p.m. pain level 58/26/25 at 3:22 p.m. pain level 5During a concurrent interview and record review with the DON on 8/28/25 at 1:15 p.m., the DON confirmed the order was for severe pain (pain level 6-10). The DON also verified the entries on Resident 72's July and August 2025 MARs.A drug review of hydrocodone-acetaminophen on Daily Med (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e23d135c-7aea-405a-804e-5c4f82179e96, accessed 8/29/25), a drug resource site, updated 1/11/24, indicated side effects, such as dizziness, lightheadedness, nausea, vomiting and sedation. Signs and symptoms of overdose listed included respiratory depression (slow, shallow breathing), somnolence (excessive sleepiness), cold and clammy skin, low blood pressure, low blood sugar and coma. b) A review of Resident 73's clinical record indicated that he had an order for oxycodone 5 mg tablet, give one tablet by mouth every 6 hours as needed for moderate to severe pain (4-10 level pain out of 10), dated 6/21/25.Resident 73 received doses, as documented on his July 2025 and August 2025 MARs, despite having a pain level of 0 (no pain) on the following dates:7/27/25 at 8:03 p.m.8/7/25 at 7:39 p.m.8/8/25 at 8:47 p.m.8/25/25 at 10:00 p.m.8/26/25 at 6:03 p.m.During a telephone interview with the Consultant Pharmacist (CP) on 8/28/25 at 11:14 a.m., the CP stated, there is no reason to give [oxycodone], if there is no pain. The CP stated it is not appropriate to give the pain medication when the resident reports a pain level of 0.During an interview with the DON on 8/28/25 at 1:15 p.m., the DON confirmed oxycodone was given when the pain level was 0 on 5 occasions. The DON stated the nurse might have made documentation. I don't see it. The DON stated the pain medications should be given per the order because we don't want to overmedicate. The DON stated overmedicating could cause adverse (negative) effects from the medication itself.A drug review of oxycodone on Daily Med (https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=094b64b3-cd32-4de5-afb6-ea00d9caad74, accessed 8/29/25), a drug resource site, updated 4/24/24, indicated side effects, such as dizziness, nausea, vomiting, constipation, headache and sedation. Signs and symptoms of overdose listed included respiratory depression, somnolence, cold and clammy skin, low blood pressure, low blood sugar and coma.A review of the facility's policy and procedure (P&P) titled, Medication Administration and Storage, revised 3/2025, indicated, .accurately prepare, administer and document medications as per physician's order.

Based on observation, interview, and record review, the facility failed to assess and manage pain for one of two residents investigated for pain management (Resident 72). As a result, the deficient practice had the potential for unmanaged pain. Cross Reference F 655.Findings: Resident 72 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of right buttock (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), per the facility 's admission Record. Resident 72's H&P, dated 6/26/25, indicated Resident 72 had the capacity to make decisions. On 8/25/25, a review of Resident 72's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/2/25, indicated Resident 72's brief interview for mental status (BIMS, ability to recall) score was 15/15, which meant Resident 72's cognition was intact. On 8/25/25 at 10:04 A.M., an observation and an interview of Resident 72 was conducted in her room. Resident 72 sat up in a wheelchair watching a television show. Resident 72 stated she had problem getting her pain medications/meds over the weekend. Resident 72 stated she last received her pain meds on Friday (8/22/25). Resident 72 stated she experienced pain all over her body and was not able to perform her favorite activity which was crocheting. Resident 72 stated she informed the assigned Licensed Nurse (LN) but did not get the pain medication. Resident 72 stated she was also informed she could not get an over-the-counter pain medication because there was no physician's order. Resident 72 stated her sister brought her over the counter pain meds on Sunday (8/24/25) to help with her pain. On 8/27/25 at 9:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 72 was alert and oriented. CNA 3 stated Resident 72 would ask for pain medication on her due time. On 8/27/25 at 3:19 P.M., a joint review of Resident 72's clinical record and an interview was conducted with LN 1. LN 1 stated Resident 72 could make her needs known. LN 1 stated Resident 72 was admitted to the facility due to pressure ulcer on her right foot. LN 1 stated Resident 72 usually received her pain medication every day. LN 1 stated Resident 72 missed her pain medication dose over the weekend (8/23/25 to 8/24/25). LN 1 stated the last time Resident 72 received her pain medication was last Friday (8/22/25). LN 1 stated, When we run out of meds and the pharmacy takes a while to deliver them, we use the emergency meds from the emergency kit. LN 1 stated Resident 72's pain medication was delivered to the facility on (Tuesday) 8/26/25. LN 1 stated it was important to manage Resident 72's pain to maintain her activities of daily living (ADLs). On 8/28/25 at 8:58 A.M., a joint review of Resident 72's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated expectation was for the LNs to notify the physician if there was no over the counter pain medication for Resident 72 and to ensure pain medications were available for Resident 72 to manage he pain. A review of the facility's policy titled, Physician Orders, revised 5/2025, indicated, It is the policy of this facility that drugs shall be administered.It is the policy of this facility to.implement orders.upon the written order of a person duly licensed.

Based on observation, interview and record review, the facility failed to provide care and treatment consistently for a Midline catheter (a thin, flexible tube inserted into a vein in the upper arm) for one of one resident (Resident 23) reviewed for Intravenous therapy. This failure had the potential to cause infection and affect Resident 23's health. Findings:Per the facility's admission Record , Resident 23 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease. (kidneys can no longer fully clean toxins from the blood) . On 8/25/25 at 9:17 A.M., a joint observation and interview with Resident 23 was conducted. Resident 23 had a midline catheter on her right arm with an unclear dated transparent dressing. Resident 23 stated she stated the midline catheter has not been flushed for a few days and that no one has changed the dressing since it was last done. Resident 23 stated she had been asking the licensed nurses if she still needed the midline catheter since Resident 23 knew she was done with her antibiotic treatment for her urinary tract infection (UTI) but no one has done anything about it. A review of Resident 23's Minimum Data Set ( MDS- a federally mandated assessment tool ) dated 7/1/25 indicated Resident 23 had a brief interview for mental status (BIMS) score of 15 which indicated Resident 23's cognition (thought process) was intact. On 8/27/25 at 10:34 A.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated the licensed nurses were to monitor the midline catheter site for signs and symptoms of infection every shift to prevent the occurrence of infection that could affect Resident 23's health. On 8/27/25 at 10:46 A.M., an interview and record review with Licensed Nurse (LN) 23 was conducted. LN 23 stated he would flush Resident 23's midline catheter before and after her antibiotic treatment. LN 23 does not remember the exact date he changed Resident 23's dressing on her right arm. LN 23 stated it was important for Resident 23's midline catheter to be flushed to avoid coagulation and to prevent it from being clogged. LN 23 stated Resident 23's midline catheter dressing should be changed as ordered by the Physician or per facility policy. A record review of Resident 23's order summary report ,dated 8/3/25 indicated the following: Midline flush orders: flush midline with 10 ml NS before and after IV medications and IV fluids. Maintenance : flush non used ports with 10 ml NS .Use only 10 ml syringes to flush all lumens. Monitor midline for s/s of infection /infiltration every shift. Notify Provider if present every shift. Midline care: Change all midline transparent dressings per sterile technique every 7 days and PRN wet, loose, or soiled. Change injection cap to lumen every 7 days and every PRN dressing change. A record review of Resident 23's Medication Administration Record ( MAR) indicated missed licensed nurse's signatures on the following dates and shifts: 8/19/25 and 8/20/25- flushing was blank 8/14/25 and 8/15/24- monitoring was blank on the AM and NOC shifts 8/17/25- monitoring was blank on the NOC shift 8/19/25 and 8/20/25 - monitoring was blank on the PM shift 8/21/25 and 8/22/25-monitoring was blank on AM shift 8/8/25- PRN or as needed dressing changed was documented. A record review of Resident 23's Medication Administration Record dated 8/25, indicated the dressing on the Midline catheter was changed on 8/8/25 as needed. There was no other record of the midline catheter dressing being changed or the catheter measured. On 8/28/25 at 9:21 A.M., an interview and record review with the Director of Nursing (DON) was conducted. The DON stated the dressing changes of the midline catheter needed to have the measurement of the catheter to prevent migration of the catheter and ensure placement and prevent possible complications for Resident 23's health. The DON stated the orders for measurement of the midline catheter was not in Resident 23's order summary report. The DON stated, the flushing of the midline catheter was not consistent same as the monitoring of the site.The DON stated, if it was not documented, it was not done. A review of the facility's dated 6/25 policy titled, Intravenous /Central/ Venous/ Maintenance did not provide clear guidance on the care of a Midline catheter .

Based on observation, interview and record review , the facility failed to ensure an oxygen tubing was dated on 2 out of 2 residents (Resident 81,Resident 25) reviewed for Oxygen needs.This failure had the potential to affect Resident 81's and Resident 25's respiratory health.Findings:1) Per the facility's undated admission Record ,Resident 81 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory failure with Hypoxia (absence of enough oxygen) . On 8/25/25 at 10:15 A.M., an observation during the initial tour was conducted. Resident 81 had the oxygen nasal cannula (NC-a two-pronged plastic tubing used to deliver oxygen through the nose) regulated at 3 liters per minute via oxygen concentrator. Resident 81's oxygen tubing was not dated. On 8/25/25 at 10:20 A.M., an interview with Resident 81 was conducted. Resident 81 stated she used the oxygen almost twenty-four hours due to Resident 81 could not breathe without the oxygen. A review of the Minimum Data Set (MDS- a federally mandated assessment tool) dated 8/15/25 indicated a brief interview for mental status (BIMS) score of 05 which indicated Resident 81's cognition was severely impaired. A review of Resident 81's Order Summary Report indicated, change O2 tubing q week on Fridays every night shift on a Friday dated 8/5/25. On 8/25/25 at 10:45 A.M., an interview with Licensed Nurse (LN) 21 was conducted. LN 21 stated the oxygen tubing should have been dated to prevent spread of infection to Resident 81 and could cause possible side effects, if not dated to Resident 81's health. On 8/28/25 at 11:00 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was important to date the oxygen tubing to prevent infection and contamination that could affect Resident 81's condition, Resident 81 was dependent on the oxygen for her breathing. 2) Per the facility's undated admission Record, Resident 25 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease(COPD -a chronic lung disease causing difficulty in breathing) . On 8/25/25 at 10:27 A.M., an observation during the initial tour was conducted. Resident 25 had the oxygen nasal cannula that goes into her nostrils ongoing at a flow rate of 3 liters per minute. Resident 25's oxygen tubing was not dated . A review of Resident 25's Order Summary Report indicated Resident 25 was on hospice care for a diagnosis of central nervous system lymphoma(a type of cancer that affects the lymph nodes). A review of resident 25's Minimum Data Set (MDS- a federally mandated assessment tool ) dated 8/10/25 indicated a brief interview for mental status (BIMS) score of 03 which indicated Resident 25's cognition (thought process) was severely impaired. A review of Resident 25's order summary report indicated, change o2 tubing q week on Fridays every night shift on a Friday dated 8/5/25. On 8/25/25 at 10:45 A.M., an interview with LN 21 was conducted. LN 21 stated the oxygen tubing should have been dated to prevent the spread of infection to Resident 25 which could affect Resident 25's health. On 8/28/25 at 11 A.M., an interview with the DON was conducted. The DON stated it was important to date the oxygen tubing to prevent infection and contamination that could affect Resident 25's condition, Resident 25 was dependent on the oxygen for her breathing. A review of the facility's policy on Oxygen Administration dated 5/2025 did not provide a clear guidance related to oxygen use.

Based on observation, interview, and record review, the facility failed to provide routine nail care to one of three residents (Resident 48), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 48 was at risk for skin injury and infection.Findings: 1.Resident 48 was admitted to the facility on [DATE], with diagnoses which included stroke, per the facility's admission Record. Resident 48's history and physical (H&P), dated 7/17/25, indicated Resident 48 had altered mental status. On 8/25/25, a review of Resident 48's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/22/25, indicated Resident 48's brief interview for mental status (BIMS, ability to recall) score was 12/15, which meant Resident 48's cognition was moderately impaired. The MDS also indicated Resident 48's functional abilities indicated he had upper extremity impairment and that he required assistance from the staff on his activities of daily living (ADLs). On 8/25/25 at 8:26 A.M., an observation and an interview were conducted of Resident 48 as he laid in bed. Resident 48's right hand was exposed, and fingernails appeared long. Resident 48 stated he wanted to cut his fingernails because they were long. Resident 48 stated he asked the staff about it but, They kept telling me it needs special person to cut it. With his left-hand fingernails, Resident 48 lifted his left arm. Resident 48 stated he could cut his left-hand fingernails but needed help with his right-hand fingernails since his left arm was weak. On 8/27/25 at 8:34 A.M, a joint observation of Resident 48 in his room and an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 48 was alert and oriented. CNA 2 stated Resident 48's right-hand fingernails were long and sharp, and needed to be trimmed. CNA 2 stated Resident 48 could potentially cut and hurt himself with those long fingernails. CNA 2 stated it was important to keep the fingernails cleaned and trimmed for hygiene and infection control practices. On 8/27/25 at 11:18 A.M., a joint observation of Resident 48 in his room and an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 48 was alert and oriented but confusion. LN 2 stated Resident 48 had medium sized long fingernails. LN 2 stated Resident 48's fingernails should have been trimmed short to prevent him from injuring himself and getting an infection since bacteria could get into his skin when he scratched himself. LN 2 stated Resident 48 was not diabetic, and the CNAs could trim Resident 48's fingernails. On 8/28/25 at 8:28 A.M., a joint review of Resident 48's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated Resident 48 had episodes of confusion. DON 1 stated Resident 48 had left arm weakness. DON 1 stated the expectation was for the staff to provide nail care to the residents because it was important for the residents' hygiene and infection control. A review of the facility's policy titled, Quality of Life, revised 6/2025 indicated, .It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/ her abilities.2. Residents who are unable to carry out activities of daily living (ADLs) will receive dignity and necessary services to maintain.Grooming.personal hygiene.

Based on observation, interview, and record review, the facility failed to provide medication therapy in accordance with professional standards of practice for one of five sampled residents (Resident 58) when Licensed Nurse (LN) 11 did not flush (push water through) Resident 58's gastrostomy tube (G-tube, a device used to administer food and medications to individuals with difficulty swallowing) before and in between medication administration.This failure had the potential for Resident 58 not to get the full therapeutic benefit of her medications or to experience complications from her medications clogging in her G-tube.A review of Resident 58's clinical records indicated she was admitted to the facility on [DATE], with diagnoses that included, encounter for attention to gastrostomy.During the medication administration observation on 8/25/25 at 8:45 a.m., LN 11 was observed preparing and administering a total of 10 medications for Resident 58. LN 11 stated Resident 58 received two medications through her G-tube and the rest were administered by mouth.LN 11 prepared the following two medications for G-tube administration: Prevacid (for gastroesophageal reflux disease [GERD], acid reflux) SoluTab (breaks apart) tablet Dispersible (spreads out) 30 milligrams (mg, unit of measure), dated 7/17/25, and Multivitamin with minerals oral tablet for supplement, dated 7/17/25.LN 11 administered each medication separately. Flushing was not observed before medication administration or in between the two medications. After administering the two medications, LN 11 stated, Now I'll do a flush with 60 milliliters (mL, unit of measure) of water.During an interview with LN 11 on 8/26/25 at 8:44 a.m., LN 11 confirmed he did not flush before or in between G-tube medication administration during the medication observation. He stated there should be a flush before every medication, after every medication and in between.During an interview with the Director of Nursing (DON) on 8/27/25 at 8:06 a.m., the DON confirmed that there should have been a flush before medication administration. The DON stated Resident 58 had an active order for a 50 mL flush before and after G-tube medication administration. The DON stated, we would need to flush.because we don't want the tube to clog and we want to make sure the med is administered.A review of Resident 58's clinical record indicated Resident 58 had an active order since 7/20/25 for Flush GT[ube] with 50 mL of H2O [water] before and after med administration.A review of the National Library of Medicine's Medline Plus health information resource (Gastrostomy feeding tube - bolus: MedlinePlus Medical Encyclopedia, accessed 8/29/25), revised 10/20/24, indicated, Always flush the tube with.water between medicines. This will make sure that all the medicine goes in the stomach and is not left in the feeding tube.A review of the facility's policy and procedure (P&P) titled, Medication Administration and Storage revised 3/2025, indicated, .accurately prepare, administer and document medications as per physician's order.Preparing Enteral Medications.4. Flush tube with water before and after.as order.8. Flush tube with water in between each medication as order.

Based on observation, interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were revised and implemented for two of 16 sampled residents (Resident 20 and 40) when: 1. Resident 20 had an altercation with his roommate and the care plan was not revised.2. Resident 40's activities care plan was not implemented. These failures had the potential to affect resident's care needs. Cross Reference F 679.Findings: 1. Resident 20 was admitted to the facility on [DATE], per the facility's admission Record. On 8/27/25, a review of Resident 20's clinical record was conducted. Resident 20's progress notes dated 8/21/25 indicated Resident 20 had physical contact with his roommate. The care plan noted in Resident 20's clinical record related to resident's physical contact with his roommate was not revised. On 8/27/25 at 8:40 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 20 was alert and oriented. CNA 2 stated the report was Resident 20 had physical contact with his roommate. CNA 2 stated Resident 20 was taken to the acute care hospital after the incident. On 8/27/25 at 11:20 A.M., a joint review of Resident 20's clinical record and an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 20 was transferred to acute care hospital. LN 2 stated Resident 20's care plan was not revised related to the altercation with his roommate. LN 2 stated the care plan should have been revised. On 8/27/25 at 11:28 A.M., a joint review of Resident 20's clinical record and an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 20's care plan was not revised. On 8/28/25 at 8:04 A.M., a joint review of Resident 20's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated Resident 20 was alert, confused and would get easily agitated. DON 1 stated Resident 20 became agitated when his needs were not met timely. DON 1 stated Resident 20 had an altercation with another resident prior to the incident with his roommate. DON 1 stated per the LNs report, Resident 20 took the leg of the wheelchair and barricaded himself in his room. DON 1 stated Resident 20's roommate did not know what happened. Per DON 1, Resident 20 was agitated and shut the door until the police officers came to take Resident 20 to the acute care hospital. DON 1 stated the care plan for Resident 20's aggressive behavior was not revised and was not addressed. DON 1 stated the purpose of revising the care plan was to ensure Resident 20's aggressive behavior was addressed. A review of the facility's policy titled, Comprehensive Resident Centered Care Plan, Revised 5/2025, indicated, .4. Care plan will be revised as needed. 2. Resident 40 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like transferring), per the facility's admission Record. On 8/25/25, a review of Resident 40's history and physical (H&P), dated 7/4/25, indicated Resident 40 had the capacity to make decisions. On 8/25/25, a review of Resident 40's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/9/25, indicated Resident 40's brief interview for mental status (BIMS, ability to recall) score was 15/15, which meant Resident 40's cognition was intact. The MDS also indicated Resident 40's functional abilities indicated he had upper and lower extremities impairment and that he required assistance from the staff on his activities of daily living (ADLs, like transferring). On 8/25/25 at 10:56 A.M., an observation and an interview was conducted with Resident 40 in his room. Resident 40 laid in bed watching a television show. Resident 40 stated he had been in the facility for almost two months. Resident 40 stated he was always in his bed and was bored. Resident 40 stated he needed help getting up and out of bed. Resident 40 stated he wanted to attend the activity but, They don't take me out. I wanted to attend. On 8/26/25, a review of Resident 40's care plan related to leisure activity was conducted. Resident 40's care plan indicated, Interventions.Invite to scheduled activities.Needs assistance activity functions. On 8/26/25 at 9:55 A.M., a follow up observation and an interview was conducted with Resident 40 in his room. Resident 40 stated, I just lay here, and they (staff) don't get me up. They don't offer me to attend the activity. Resident 40 stated he received the activity sheet, but staff did not offer him to get up and attend the activity. Resident 40 stated, How can I go there if they don't get me up? On 8/27/25 at 9:19 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 40 was very alert and could make his needs known. CNA 2 stated Resident 40 wanted to get up, but he did not have his own wheelchair. On 8/27/25 at 9:39 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 40 was very alert and oriented. CNA 3 stated Resident 40 required a mechanical lift when transferring from the bed to the wheelchair. CNA 3 stated Resident 40 did not have his own wheelchair. CNA 3 stated she did not remember if she offered Resident 40 to get up and out of bed. CNA 3 stated she should have offered Resident 40 to attend activities to prevent boredom, bedsore and depression. On 8/27/25 at 3:00 P.M., a joint review of Resident 40's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 40 was admitted to the facility on [DATE] for treatment of his lower extremity wound. LN 1 stated she was not aware Resident 40 wanted to attend the facility's activity program. LN 1 stated the staff should have offered Resident 40 the activity program so he was not confined to his room, did not feel boredom and to brighten his moods. LN 1 stated Resident 40's care plan on leisure activity was not implemented. On 8/28/25 at 8:41 A.M., a joint review of Resident 40's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated Resident 40 required assistance from the staff when getting up and out of bed. DON 1 stated Resident 40's care plan was not implemented related to his leisure activity. DON 1 stated the staff should have offered Resident 40 to attend the activities for him to enjoy his stay at the facility. A review of the facility's policy titled, Comprehensive Resident Centered Care Plan, revised 5/2025 indicated, it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The policy did not indicate implementation of the care plan.

Based on observation, interview and record review, the facility failed to develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) within 48 hours for three of 16 residents reviewed for baseline care plan related to:1. Resident 10's urinary catheter use.2. Resident 72's pain management.3. Resident 81's oxygen use. This deficient practice placed newly admitted residents with urinary catheters at risk for developing an infection, residents with pain to have unmanaged pain and residents with oxygen to be at risk for low or high oxygen level. Cross Reference to F 697 and F 695.Findings: 1.Resident 10 was admitted to the facility on [DATE], per the facility's admission Record. On 8/25/25, a review of Resident 10's history and physical (H&P) was conducted. Resident 10's H&P dated 7/5/25, indicated Resident 10 was alert and oriented. On 8/25/25, a review of Resident 10's minimum data set (MDS – a federally mandated resident assessment tool) dated 7/24/25, indicated Resident 10's brief interview for mental status (BIMS, ability to recall) score was 14/15, which meant Resident 10's cognition was intact. Resident 10 s bladder section of the MDS indicated Resident 10 had urinary catheter. On 8/25/25 at 10:43 A.M., an observation of Resident 10 was conducted in his room. Resident 10 laid in bed with a urinary catheter attached to the bed rails. An attempt to interview Resident 10 was conducted. Resident 10 mumbled words which were incomprehensible. On 8/26/25, a review of Resident 10's treatment administration record (TAR) for catheter care was conducted. Resident 10's catheter care had incomplete documentation. On 8/27/25 at 9:14 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 10 had a urinary catheter. CNA 2 stated catheter care was done by the CNAs. On 8/27/25 at 9:47 A.M., an interview was conducted with CNA 3. CNA 3 stated catheter care was done by the CNAs and documented in the facility's computer system. On 8/27/25 at 3:53 P.M., a joint review of Resident 10's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 10 had a urinary catheter upon admission. LN 1 stated the treatment nurse was responsible for catheter care for residents with urinary catheter. LN 1 stated there was no initial care plan developed for Resident 10 related to his urinary catheter. LN 1 stated it was important to develop a care plan because it provided guidelines on how to take care of the residents. On 8/28/25 at 9:06 A.M., a joint review of Resident 10's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated she did not see a baseline care plan for Resident 10's urinary catheter. DON 1 stated it was important to develop a baseline care plan for the residents to address the residents' care needs and to manage their care. A review of the facility's policy titled, Comprehensive Resident Centered Care Plan, revised 5/2025 indicated, .it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.A comprehensive care plan is developed within 14 days of resident admission. 2. Resident 72 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer of right buttock (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), per the facility 's admission Record. Resident 72's H&P, dated 6/26/25, indicated Resident 72 had the capacity to make decisions. On 8/25/25, a review of Resident 72's minimum data set (MDS – a federally mandated resident assessment tool) dated 7/2/25, indicated Resident 72's brief interview for mental status (BIMS, ability to recall) score was 15/15, which meant Resident 72's cognition was intact. On 8/25/25 at 10:04 A.M., an observation and an interview of Resident 72 was conducted in her room. Resident 72 sat up in a wheelchair watching a television show. Resident 72 stated she had problem getting her pain medications over the weekend. Resident 72 stated she experienced pain all over her body and was not able to perform her favorite activity which was crocheting. Resident 72 stated she informed the assigned Licensed Nurse (LN) but did not get the pain medication. Resident 72 stated she was also informed she could not get an over-the-counter pain medication because there was no physician's order. Resident 72 stated her sister brought her over the counter pain meds on Sunday (8/24/25) to help with her pain. On 8/27/25 at 9:34 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 72 was alert and oriented. CNA 3 stated Resident 72 would ask for pain medication on her due time. On 8/27/25 at 3:19 P.M., a joint review of Resident 72's clinical record and an interview was conducted with LN 1. LN 1 stated Resident 72 could make her needs known. LN 1 stated Resident 72 was admitted to the facility due to pressure ulcer on her right foot. LN 1 stated Resident 72 usually received her pain medication every day. LN 1 stated Resident 72 missed her pain medication dose over the weekend. LN 1 stated the last time Resident 72 received her pain medication was last Friday (8/22/25). LN 1 stated, When we run out of meds and the pharmacy takes a while to deliver them, we use the emergency meds from the emergency kit. LN 1 stated she did not see a care plan was developed for Resident 72's pain management. LN 1 stated it was important to manage Resident 72's pain and check her response to the medications and required another intervention. On 8/28/25 at 9:06 A.M., a joint review of Resident 72's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated she did not see a baseline care plan for Resident 72's pain management. DON 1 stated it was important to develop a baseline care plan for the residents to address the residents' care needs and to manage their care. A review of the facility's policy titled, Comprehensive Resident Centered Care Plan, revised 5/2025 indicated, .it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.A comprehensive care plan is developed within 14 days of resident admission. 3. Per the facility's undated admission Record ,Resident 81 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory failure with Hypoxia (absence of enough oxygen) . On 8/25/25 at 10:15 A.M., an observation during the initial tour was conducted. Resident 81 had the oxygen nasal cannula (a device that gives extra oxygen) into her nostrils flowing at 3 liters per minute. On 8/25/25 at 10:20 A.M., an interview with Resident 81 was conducted. Resident 81 stated she used the oxygen almost twenty-four hours due to Resident 81 could not breathe without the oxygen. A review of the Minimum Data Set (MDS- a federally mandated assessment tool) dated 8/15/25 indicated a brief interview for mental status (BIMS) score of 05 which indicated Resident 81's cognition was severely impaired. A review of Resident 81's baseline care plan on Oxygen use was not found in Resident 81's medical record. On 8/25/25 at 11:00 A.M., an interview and record review with Licensed Nurse (LN) 1 was conducted. LN 1 stated there was no care plan regarding the use of oxygen on Resident 81's medical record. On 8/28/25 at 11:20 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the care plan is important as it outlines the specific healthcare and support needs of Resident 81's care. The DON stated it also acts as a communication to the healthcare staff regarding Resident 81's specific care needs. A review of the facility's policy titled , Comprehensive Resident Centered Care Plan dated 5/2025 indicated, it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.

Based on observation, interview and record review, the facility failed to ensure dignity and respect was provided for one of three sampled residents (73) during lunchtime, when a staff was standing over, while assisting and feeding the resident. This failure had the potential to affect the resident's self-esteem and resident's safety.Findings: Resident 73 was readmitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), and blindness per the facility's admission Record. On 8/25/25 at 12:27 P.M., a lunch observation was conducted in Resident 73's room. Resident 73 was in bed with the lunch tray at the bedside table. A Certified Nursing Assistant (CNA) 1 was assisting and feeding Resident 73 while standing. There was a folded metal chair by the wall. CNA 1 was noted not to be in level with Resident 73. On 8/25/25 at 12:33 P.M., an interview was conducted with CNA 1. CNA 1 stated Resident 73 was confused and blind. CNA 1 stated Resident 73 was dependent on staff for all activities of daily living (ADLs, like eating). CNA 1 stated Resident 73 was not all the way up to CNA 1 while assisting and feeding Resident 73. CNA 1 stated he should have sat down to be at Resident 73's level for dignity and safety of Resident 73. ON 8/27/25 at 9:50 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 73 was blind and dependent on the staff on all ADLs. CNA 3 stated staff needed to sit down close to Resident 73 and explained to Resident 73 on what he wanted to eat first since the resident could not see. CNA 3 stated in that way, it was easy for the staff to see Resident 73 while eating for Resident 73's safety. On 8/28/25 at 8:53 A.M., an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated Resident 73 was alert with occasional confusion. DON 1 stated the expectation was for the staff to sit with the residents, take their time while assisting and feeding the residents for dignity and safety of the resident. A review of the facility's policy titled, Dining Services and Meal Serving, revised 3/2025, indicated, .Procedures.8. Allow the resident plenty of time to eat. Sit next to any residents requiring physical assistance with feeding.

Based on observation, interview and record review, the facility failed to ensure a tube feeding formula was labeled for one of one resident (58) reviewed for Parenteral Nutrition. This failure had the potential to affect Resident 58's health conditions and decline.Findings: A review of Resident 58's admission Record indicated that Resident 58 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous tumors) of the tongue. Resident 58's history and physical (H&P), dated 7/17/25, indicated Resident 58 was alert and oriented to person, place and time. On 8/25/25, a review of Resident 58's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/21/25, indicated Resident 58's brief interview for mental status (BIMS, ability to recall) score was 8/15, which meant Resident 58's cognition was moderately impaired. The MDS also indicated Resident 58's nutritional status indicated she was on feeding tube (a tube inserted through the stomach) upon admission. On 8/26/25 at 8:23 A.M., an observation and an interview of Resident 58 was conducted in her room. Resident 58 had a gastrostomy feeding tube with a formula in the pump machine. Resident 58's feeding tube formula was not labeled. Resident 58 stated she had cancer of the tongue and was placed on tube feeding. Resident 58 stated she did not know when the tube feeding was administered. On 8/26/25 at 8:40 A.M., a joint observation of Resident 58's tube feeding and an interview was conducted with the MDS Nurse (MDSN). The MDSN stated the tube feeding was not labeled and dated. The MDSN stated the Licensed Nurse (LN) who administered the tube feeding should have labeled and dated the tube feeding so the next nurse knew when it was administered. The MDSN stated the LN should also label/ date the water flush. On 8/27/25 at 3:48 P.M., a joint review of Resident 58's clinical record and an interview was conducted with LN 1. LN 1 stated the process when administering tube feeding to the resident was to label the tube feeding and water flush to ensure it wat the right resident, the right amount and when the tube feeding was administered. On 8/28/25 at 8:38 A.M., a joint review of Resident 58's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated expectation was for the LNs to label the tube feeding and water flush with the resident's name, the flow rate, the time and the date the tube feeding was administered to ensure the resident was receiving the appropriate amount of hydration and nutrition and prevent further weight loss. A review of the facility's policy titled, Medication Administration, revised 3/2025, indicated, It is the policy of this facility to accurately prepare, administer and document medications as per physician's order.Preparing Enteral Medications.4.b. Ensure all feeding tubes and water flushes are labeled/date.

Based on interview and record review, the facility failed to ensure one out of five residents (Resident 72) was free from unnecessary medications when blood pressure (BP) and heart rate (HR) hold parameters were not followed with the administration of medications.This failure had the potential for Resident 72 to experience low BP and low HR.A review of Resident 72's clinical record indicated she had an active order for atenolol 50 milligram (mg, unit of measure) tablet, give one and half tablet by mouth two times a day (at 9 a.m. and 5 p.m.) for hypertension (HTN, high blood pressure). Hold if HR less than 60, originally dated 6/28/25. Resident 72 received doses, as documented on her July 2025 and August 2025 Medication Administration Record (MAR), despite a HR less than 60 on the following dates:7/6/25 HR 53 the 9 a.m. dose was administered7/13/25 HR 57 the 9 a.m. dose was administered7/18/25 HR 57 the 9 a.m. dose was administered8/2/25 HR 57 the 5 p.m. dose was administered8/12/25 HR 55 the 5 p.m. dose was administered8/13/25 HR 56 the 5 p.m. dose was administeredA review of Resident 72's clinical record indicated she had an active order for lisinopril 5 mg tablet, give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure (SBP, the top number on the BP reading) less than 110 and HR 60, dated 6/26/25. Resident 72 received doses, as documented on her July 2025 and August 2025 MARs, despite having SBP less than 110 or HR less than 60 on the following dates:7/6/25 BP 106/54 and HR 537/13/25 BP 144/91 and HR 577/18/25 BP 135/75 and HR 578/2/25 BP 116/69 and HR 57During an interview with the Consultant Pharmacist (CP) on 8/28/25 at 11:14 a.m., the CP was asked about the lisinopril dose on 8/2/25. The CP stated that if either the SBP or HR fell below the threshold, the dose should be held.During an interview with the Director of Nursing (DON) on 8/28/25 at 1:15 p.m., the DON verified the instances when BP meds were given despite the hold parameters. When asked if lisinopril should be held only when both the SBP and HR are below the threshold, the DON stated No, either one. The DON stated that it is not appropriate to give BP meds despite the hold parameters because the dose is made to maintain their BP and HR at a certain level. HR might drop lower.A drug review of the medication, lisinopril, on Daily Med (DailyMed - LISINOPRIL- lisinopril tablet, accessed 8/29/25), a drug resource site, updated 11/3/21, listed hypotension (low BP) as the most likely manifestation of overdosage and as one of the side effects, in addition to dizziness and syncope (fainting).A drug review of the medication, atenolol, on Daily Med (DailyMed - ATENOLOL tablet, accessed 8/29/25), updated 2/21/24, indicated side effects such as low HR, postural hypotension (a drop in BP upon changing to an upright position), dizziness, tiredness and drowsiness.A review of the facility's policy and procedure (P&P) titled, Medication Administration and Storage, revised 3/2025, indicated, .accurately.administer.medications as per physician's order.

Based on observation, interview and record review, the facility failed to provide individualized therapeutic and/or social activities according to their plan of care for one of one reviewed resident (Resident 40) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 40 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement. Cross Reference F 656.Findings: Resident 40 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like transferring), per the facility's admission Record. On 8/25/25, a review of Resident 40's history and physical (H&P), dated 7/4/25, indicated Resident 40 had the capacity to make decisions. On 8/25/25, a review of Resident 40's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/9/25, indicated Resident 40's brief interview for mental status (BIMS, ability to recall) score was 15/15, which meant Resident 40's cognition was intact. The MDS also indicated Resident 40's functional abilities indicated he had upper and lower extremities impairment and that he required assistance from the staff on his activities of daily living (ADLs, like transferring). On 8/25/25 at 10:56 A.M., an observation and an interview was conducted with Resident 40 in his room. Resident 40 laid in bed watching a television show. Resident 40 stated he had been in the facility for more almost two months. Resident 40 stated he was always in his bed and was bored. Resident 40 stated he needed help getting up and out of bed. Resident 40 stated he wanted to attend the activity but, They don't take me out. I wanted to attend. On 8/26/25 at 9:55 A.M., a follow up observation and an interview was conducted with Resident 40 in his room. Resident 40 stated, I just lay here, and they (staff) don't get me up. They don't offer me to attend the activity. Resident 40 stated he received the activity sheet, but staff did not offer him to get up and attend the activity. Resident 40 stated, How can I go there if they don't get me up? On 8/27/25 at 9:19 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 40 was very alert and could make his needs known. CNA 2 stated Resident 40 wanted to get up, but he did not have his own wheelchair. On 8/27/25 at 9:39 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 40 was very alert and oriented. CNA 3 stated Resident 40 required a mechanical lift when transferring from the bed to the wheelchair. CNA 3 stated Resident 40 did not have his own wheelchair. CNA 3 stated she did not remember if she offered Resident 40 to get up and out of bed. CNA 3 stated she should have offered Resident 40 to attend activities to prevent boredom, bedsore and depression. On 8/27/25 at 3:00 P.M., a joint review of Resident 40's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 3 was admitted to the facility on [DATE] for treatment of his lower extremity wound. LN 1 stated she was not aware Resident 40 wanted to attend the facility's activity program. LN 1 stated the staff should have offered Resident 40 the activity program, so he was not confined to his room, did not feel boredom and to brighten his moods. On 8/28/25 at 8:41 A.M., a joint review of Resident 40's clinical record and an interview was conducted with the Director of Nursing (DON) 1 with the presence of DON 2. DON 1 stated Resident 40 required assistance from the staff when getting up and out of bed. DON 1 stated the expectation was for the staff to offer Resident 40 to attend leisure activities for him to enjoy his stay at the facility and to promote emotional well-being. A review of the facility's policy titled, Quality of Life, revised 6/2025 indicated, .It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/ her abilities.

Based on observation, interview, and record review, the facility failed to ensure that the facility was free of accident hazards and that a safe environment was provided for one of three sampled residents (Resident 2). An uneven level of two adjoining (touching) surfaces, a concrete pavement and a sand pit, in the patio was a hazard to residents. This failure resulted in Resident 2 sustaining serious injuries to include a fractured femur (thigh bone), a fractured cervical vertebra (neck bone), and a head laceration (deep cut). Findings: On 10/13/16 at 8 A.M., an entity reported incident was investigated regarding Resident 2, who had a fall on 10/4/16. Resident 2 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set assessment (MDS), Section C, Cognitive Patterns, dated 10/14/16, was reviewed. It indicated Resident 2 had a BIMS (Brief Interview for Mental Status) coded (score) of 15. According to the Resident Assessment Instrument (RAI) 3.0 manual for MDS, a score of 13-15 indicated that the resident was cognitively intact. An interview with the director of nursing (DON) was conducted on 10/13/16 at 8:30 A.M. The DON stated Resident 2 fell while smoking on the patio on 10/4/16 at 3:35 P.M. She stated the housekeeper supervisor (HS) witnessed Resident 2 trip, fall forward, and hit her head on the pole. The DON stated Resident 2 was sent out of the facility on 10/4/16 by calling 911. The DON stated Resident 2 returned to the facility on [DATE] after she had surgery and now wore a neck collar. The DON further stated, We put a fence now to prevent the problem. The DON acknowledged that the uneven level of the two adjoining surfaces, a concrete pavement and a sand pit in the patio was an accident hazard. An observation of Resident 2 was conducted on 10/13/16 at 9:10 A.M. Resident 2 sat in a wheelchair and propelled herself out onto the smoking patio. She wore a neck collar. A concurrent interview and observation of the smoking patio was made with the DON on 10/13/16 at 9:12 A.M. The smoking patio had a cement porch, a fence, and just beyond the fence a lower level of sand, not even surface level. The lower level of sand area was accessible, by walking around the fence, which was done with the DON while touring the area. The porch also had four poles which supported an awning (covering that provided shade). The DON acknowledged that the facility's environmental hazard of an uneven level of the two adjoining surfaces, a concrete pavement and a sand pit, was not fenced off to prevent an unnecessary/avoidable accident, on 10/4/16. An interview with the HS was conducted on 10/13/16 at 9:20 A.M. The HS stated that on 10/4/16 around 3:20 P.M., Resident 2 asked for another cigarette. She was standing in the sand area trying to step up to the cement porch area, tripped, and fell . The HS stated Resident 2 hit her head on the left front steel pole of the porch awning. The HS stated that Resident 2 complained of hip pain and her head was bleeding. The HS stated two licensed nurses arrived to the patio and tended to Resident 2. An interview with licensed nurse (LN) 1 was conducted on 10/13/16 at 9:40 A.M. LN 1 stated that on 10/4/16, during change of shift report, HS 1 called the nurse's station and said someone fell . LN 1 stated, I and another nurse, (LN 2's name), went to smoking patio. (Resident 2's name) was on the floor. There's an overhang/pole and she was holding her upper body up using the pole. Her whole body was around the pole. Her lower body was completely on the floor, but upper body up 'cause she was holding on to the pole. There's a dirt pit. She said she was trying to walk around the pole . She said she slipped off of the pavement. She was bleeding on her forehead . She didn't initially complain of pain but started holding her neck. She didn't have facial grimacing. She later complained of hip pain. She was brought to her room. Charge nurse notified and received order from doctor to send her out. An interview with LN 2 was conducted on 10/13/16 at 10 A.M. LN 2 stated, It was during change of shift, 3 o'clock or so (on 10/4/16). I was giving a report. Charge nurse let, I believe (LN 1's name) was charge, me know an incident happened downstairs and needed help. (LN 1's name), I, and an oncoming nurse (name), went to smoking patio. I saw (Resident 2's name) sitting to her right side on edge of cement/dirt area. I saw bleeding on forehead An observation and interview with Resident 2 on 10/13/16 at 12:50 P.M. was conducted. Resident 2 was lying in bed in her room. She was observed with a sutured cut on the top center part of her forehead. Resident 2 stated she was getting a cigarette and stepped off of the (patio) platform into the sand area when she fell . Resident 2 stated when she came back to step on the (patio) platform, she misjudged the depth and fell . Resident 2 stated she broke her neck, femur, and had a head laceration (deep cut) with seven to nine stitches. Resident 2 stated she was sent to the hospital and went to surgery. The clinical record review for Resident 2 was conducted. A care plan for Resident 2, dated 4/25/16, indicated This resident is (Moderate) risk for falls. Per the care plan a goal for the resident was to be free of minor injury. The Progress Notes for resident 2, dated 10/4/16 at 3:59 P.M., indicated Resident stated she fell on pavement/edge next to sand pit located next to smoking area while she was trying to walk around the pole. Resident stated if that ledge wasn't there, I wouldn't of tripped, Resident expressed frustration on depth of sand pit next to pavement . The Assessment Summary Notes for Resident 2, dated 10/4/16 at 4:16 P.M., indicated IDT (interdisciplinary team) Fall Investigation notes . Resident did not see the step off at the end of concrete sidewalk, leading to sandy patch. Conclusion (Including new interventions) . Smoking participants will be reminded of smoking break safety and need to stay within smoking area (not beyond awning pole). Sandy patch area next to concrete sidewalk will be filled so that sand is leveled with pavement so that there is no step off . The hospital discharge summary for Resident 2, dated 10/7/16, indicated diagnosis- fall, fracture of femur, and cervical spine fracture . head laceration (deep cut) sutured on 10/4/16. The facility's policy and procedure titled Fall Management, dated 7/08 was conducted. This policy indicated, Policy: It is the policy of SNF (skilled nursing facility) that our physical environment remains as free of accident hazards as possible.

Based on observation, interview and record review, the facility failed to assure that a [MEDICAL TREATMENT] care plan was updated to reflect the fluid restrictions and precautions relating to the [MEDICAL TREATMENT] (a surgically created blood vessel used for [MEDICAL TREATMENT]), for 1 of 11 sampled residents (31). 1. Resident 31 was readmitted to the facility on [DATE] from a general acute care hospital, after replacement of a [MEDICAL TREATMENT], and with [DIAGNOSES REDACTED]. On 8/10/12 at 2:00 P.M., Resident 31 was observed in a wheel chair in the hallway near the nurse's station. The Resident's [MEDICAL TREATMENT] was visible and noted as a lime-sized bulge under the skin on the inner part of the left upper arm. On 8/14/12 at 12:30 P.M., during a medical record review the care plan entitled, '[MEDICAL TREATMENT] Care Plan' dated 5/25/12 was noted to be incomplete because it indicated a blank line. The plan of care indicated, "No blood pressure, blood draws or injections on _____ arm". The care plan did not identify which arm not to use. On 8/14/12 at 3:20 P.M., an interview was conducted with a licensed nurse LN (2) assigned to care for Resident 31. When asked how the nursing assistants and other relevant staff would know which arm to avoid when taking a blood pressure, LN (2) stated that the staff could find that information by asking the LN. The LN further stated that staff could also read the posted and covered "Note to Staff," located on the inside of the resident's closet door and added, "But the care plan should not be blank like that." 2. Resident 31 was readmitted to the facility on [DATE] from a general acute care hospital, after replacement of a [MEDICAL TREATMENT], and with [DIAGNOSES REDACTED]. On 8/14/12 at 12:32 P.M., during a medical record review Resident 31's care plan entitled, "[MEDICAL TREATMENT] Care Plan" dated 5/25/12 was noted to be incomplete indicating a blank line. The plan indicated, "Fluid restrictions per order, not to exceed ______cc (cubic centimeters) /24 hours." The blank had not been filled in with the parameters ordered by the physician. A review of the physician's orders [REDACTED]. A subsequent physician's orders [REDACTED]. Neither the 6/21/12 nor the 7/31/12 orders regarding Resident 31's fluid restrictions were reflected on Resident 31's [MEDICAL TREATMENT] Care Plan. Resident 31's [MEDICAL TREATMENT] Care Plan did not indicate it had been updated since her admission to the facility on [DATE]. On 8/14/12 at 3:20 P.M., a joint interview and record review was conducted with a licensed nurse LN (2) assigned to care for Resident 31. When asked why the amount of fluid restriction was blank on the [MEDICAL TREATMENT] Care Plan for Resident 31, the LN stated, "The staff know to go ask the nurses, but the care plan should not be blank like that."

Based on observation, interview, and record review the facility failed to utilize an assessment to develop, review and revise the comprehensive plan of care for 1 of 24 sampled residents (83) after a fall with injury. Resident 83 sustained another fall and the facility failed to implement identified interventions to prevent falls. In addition, two Resident's were not assessed for smoking safety (39, 58). Findings: 1. Resident 83 was admitted to the facility on [DATE] per the facility Admission Information Sheet (AIS). The AIS indicated the resident had [DIAGNOSES REDACTED]. On 6/19/12 at 9:20 A.M. the initial tour of the facility was conducted with licensed nurse (LN) 23. LN 23 stated that Resident 83 had told the staff that the entrance to his bathroom door was too small for his wheelchair. LN 23 also stated that Resident 83 was continent of bowel and bladder. LN 23 stated a concern that Resident 83 was more "confused" than he had been. On 6/21/12 at 9:10 A.M. a review of the forms entitled Physician's/Telephone Orders Audit (PTOA) and and the Resident Plan of Care (RPC) Actual Fall was conducted. The PTOA dated 6/10/12 indicated "tab Alarm in Bed and W/C fall prevention". The RPC related to falls indicated, "tab alarm in bed and wheelchair", "discourage transferring self" and "toilet Q 2 (hours) prn (as needed)". On 6/19/12 at 6:40 P.M., an observation and interview related to the current fall safety interventions for Resident 83 was conducted with licensed nurse (LN) 22. LN 22 stated that to prevent falls a tab alarm was to be in place when Resident 83 was in the wheelchair and also when he was in bed. The tab alarm was in place to alert staff of attempts by Resident 83 to transfer independently. LN 22 acknowledged that the tab alarm was not in place as ordered, that it was found located in the drawer in Resident 83's bedside table. LN 22 stated that Resident 83 refused to wear the tab alarm. On 6/21/12 at 9:10 A.M. a review of a form entitled Fall Risk Assessment, dated 2/28/12 indicated that Resident 83's Total Score was 18, and the form indicated that a Total score of 10 or above represented high risk. The fall assessment indicated that Resident 83 was chair bound, had poor vision, and a gait and balance problem in multiple areas. On 6/21/12 at 9:10 A.M. a review of the assessment entitled minimum data set (MDS), dated [DATE] indicated that Resident 83 had deficits in his cognitive patterns. The assessment indicated that Resident 83 could repeat words but he was unable to state the same words when asked to recall them after another task. Resident 83's summary score for his "brief interview for Mental Status" was a score of 5 out of 15. On 6/21/12 at 9:10 A.M. a review of the assessment entitled MDS dated [DATE] indicated that Resident 83 had deficits in his functional status. The resident assessment indicated that Resident 83 required extensive assist and the support of 1 staff member for transfers, dressing and hygiene. Also the assessment indicated that Resident 83's balance was "unsteady, only able to stabilize self with staff assistance". On 6/21/12 at 9:10 A.M. a review of the Resident Plans of Care (RPC) related to Actual Fall dated 6/5/12 and B&B Toileting 9/18/08 for Resident 83 was conducted. The RPC related to Actual Fall did not indicate analysis of the fall which occurred on 6/5/12 in the bathroom or any new approaches to prevent another fall in Resident 83's bathroom. The RPC B&B Toileting indicated no updated approaches to assist Resident 83 in the bathroom since 9/18/08. In addition a review of an additional RPC Actual Fall indicated that Resident 83 had another fall on 6/10/12 when transferring self unassisted. On 6/21/12 at 9:10 A.M. a review of the forms entitled Nurses Notes (NN) was conducted. The NN on 6/5/12 at 1:00 P.M. indicated that Resident 83 was "found on the restroom floor.... "He slipped from the wheelchair to the restroom."..."Asked for pain pill for back pain". The NN did not indicate any assessment of Resident 83's current bowel and bladder program or the last time that he was assisted to the bathroom. The NN dated 6/6/12 at 6:30 A.M. indicated that Resident 83 complained of "pain" on the right side of his "back" and a "bruised area" was noted. On 6/6/12 the NN indicated that a "hematoma" was observed, tylenol was given for right lower back pain". There was no assessment of the size of the bruise indicated in the NN. On 6/10/12 at 3:15 P.M. a NN indicated that Resident 83 was "found on ...bathroom floor laying down...trying to go back to w/c from toilet...". On 6/10/12 at 3:40 P.M. the NN indicated that resident complained of pain in the area of the old bruise. On 6/10/12 at 7:00 P.M. the NN indicated that an order for [REDACTED].M. the NN indicated that Resident 83 was medicated every 6 hours for pain. There was no assessment of the size of the bruise indicated in the NN. The monitoring in the NN did not indicate that interventions were attempted to prevent a future fall for Resident 83 or the resident's response to interventions. On 6/21/12 at 9:55 A.M. an interview and joint record review regarding Resident 83's falls on 6/5/12 and 6/10/12 and the facility follow-up related to the falls, was conducted with licensed nurse (LN) 24. LN 24 stated that Resident 83 fell in the bathroom on 6/5/12 and 6/10/12. LN 24 stated that Resident 83's RPC post fall on 6/5/12, indicated that the plan of care related to Actual Fall and B&B Toileting were not accelerated to prevent future falls. LN 24 acknowledged that the NN did not indicate that the plan of care and monitoring post fall was accelerated to prevent falls or to assist with Resident 83's safety needs related to toileting self in the bathroom. LN 24 acknowledged that Resident 83 had back pain and bruising after the fall on 6/5/12 and the pain required pain medication. In addition LN 24 acknowledged that Resident 83 required ongoing pain medication and an x-ray after the second fall in the bathroom on 6/10/12. On 6/21/12 at 9:10 A.M. a review of the PTOA for Resident 83, dated 6/10/12 at 3:40 P.M. indicated that the primary MD requested an x-ray of right flank secondary to pain. Further the next day an additional order for a lumbar sacral spine x-ray was obtained on 6/12/12 at 10:25 AM..per contracted Hospice. On 6/21/12 at 9:10 A.M. a review of the form entitled (Hospice name Visit Description Log) (HDL). The HDL indicated on 6/11/12 that Resident 83 had an "accumulating bruise R flank, x-ray in AM". The HDL notes on 6/11/12, indicated "pt c/o pain on his right side of his body". The HDL on 6/12/12 indicated "[MEDICATION NAME] effective". On 6/22/12 at 12:00 PM a review of the facility policy and procedure entitled Falls Management was conducted. The "Policy" indicated that "Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls. Residents will be assessed for injury, nursing or medical interventions will be provided to maintain the well-being of the resident.... The "Procedure for risk identification/prevention:...8. Licensed nurses will monitor the resident's status and revise care plans as needed during their weekly progress notes." 2. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/20/12 at 10:00 A.M. Resident 39 was observed in a common resident area holding a cigarette lighter. On 6/21/12 at 10:35 A.M. an interview and joint observation was conducted with Resident 39 stated that he was a smoker and that he smoked outside the facility as he was directed by the facility staff. Resident 39 stated that he often stored his cigarettes and lighters in an unlocked drawer in the bedside table. The cigarettes and lighters were observed stored in Resident 39's drawer. On 6/21/12 an interview was conducted with the social services assistant (SSA) related to the smoking procedures. The SSA stated that the facility is a non smoking facility, but smokers had a right to smoke cigarettes. The SSA stated that the facility did not have a process where smokers signed any acknowledgement related to smoking upon admission. The SSA stated that there are currently smokers in the facility. The SSA stated that Resident 39 is a smoker and the SSA acknowledged that there was currently no smoking assessment or care care plan for Resident 39. 3. On 6/19/12 at 11:00 A.M., an initial tour of the Resident 58's room was conducted with a licensed nurse LN 10. A pack of cigarettes and a lighter were observed on Resident 58's bedside table. During the tour, LN 10 acknowledged that the facility was a "non smoking facility" and that the cigarettes and lighter should not have been at the Resident's bedside. On 6/26/12 at 9:30 A.M., an interview was conducted with the social services director (SSD). During the interview, the SSD acknowledged that the facilty is a non smoking facility and that residents cigarettes and lighters were not kept in the resident's rooms. In addition, the SSD stated that the facilty policy and procedure included "assessment of residents safety if a smoker." Furthermore, the SSD acknowledged that Resident 58 had not been assessed for smoking. The policy and procedure entitled " Smoking Guidelines" was reviewed on 6/22/12 at 12:00 P.M.. the "Policy" indicated " It is the standard policy to monitor and evaluate residents for safety related to smoking. ...the IDT is responsible for ensuring that safety risks are evaluated, and that smoking is conducted in a safe manner. The "Procedure"...4. Staff will control all lighting materials. 5. Resident's must agree and adhere to individual facility smoking rules. 6. Residents who smoke will be evaluated and have appropriate interventions implemented to ensure safe smoking.