Every finding on record at Golden Modesto Care Center

Based on interview and record review, the facility failed to ensure sufficient nursing staff to meet resident needs when medications were given over 60 minutes late to seven out of seven sampled residents (Residents 1-7).This failure had the potential to result in sub therapeutic serum levels (medication levels dropping below the minimum needed to work), microbial resistance (bacteria becoming resistant to antibiotics), sudden metabolic or physiological instability (vital signs or blood chemistry becoming dangerously unbalanced), and complications with medications that have a narrow therapeutic range (where even small delays can make the dose ineffective or dangerous) leading to longer hospital stays, irreversible organ damage, or death.During a concurrent interview and observation on 6/24/26 at 11:22 am with Licensed Vocational Nurse (LVN) 1, LVN 1 was charting at the nurse's station. LVN 1 stated she had administered medications late because she did not have enough time to give all medications on schedule while also caring for each resident. LVN 1 stated she had worked several shifts where she was assigned more than 30 residents. LVN 1 explained she was responsible for many tasks in addition to giving medications including checking blood sugar levels before breakfast and giving insulin (a hormone that controls sugar in the blood), checking breakfast trays for correct diets, starting gastrostomy tube feedings (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach), admitting and discharging residents, preparing residents for medical appointments, assessing residents, calling doctors for new orders, cleaning and redressing wounds as needed, helping Certified Nursing Assistant's when needed, making care plans (guide to support health), following change of condition documentation and protocol, completing all charting, and responding to resident injuries. LVN 1 stated when residents were injured, she had to assess the injury, call the doctor and family, and arrange transfer to the emergency room. LVN 1 said she told management she had too many residents and could not finish all her work on time, but management told her she should be able to and needed to work faster.During a concurrent interview and observation on 6/24/26 at 12:15 pm with LVN 2, LVN 2 was at her medication cart speaking with a resident in a wheelchair about pain medication. LVN 2 told the resident the pain medication was not due yet and offered to call the doctor for an additional order. The resident agreed and rolled away. LVN 2 said she had just finished her morning medication pass, which started at 6:45 am LVN 2 stated at least four of her residents (Residents 4, 5, 6, and 7) received their medications late that morning. LVN 2 said medications were considered late if they were not given within 60 minutes of the scheduled time. LVN 2 stated it was almost impossible to finish medication passes on time due to the number of residents she was assigned. LVN 2 stated she was also responsible for wound care, care for new amputations, blood sugar checks, insulin before meals, checking meal trays for dietary accuracy, teaching spirometer use (a device to measure lung function), and helping CNAs. LVN 2 said it's a lot to do and explained that nurses also needed to interact with residents and could not just walk away when residents wanted to talk. LVN 2 stated residents had complained about other nurses giving them their medications late. LVN 2 stated she asked management to add another nurse to the shift, but management told her staffing was adequate and she should be able to finish her work on time.During a concurrent interview and record review on 6/24/26 at 12:25 pm with LVN 2, Medication Administration Records (MARs) for Residents 1-7 dated 6/24/26 were reviewed. The MARs reviewed indicated the following: Resident 1's MAR indicated, one late medication (Hydralazine hydrochloride oral tablet 50 milligrams ordered for midnight and given at 1:07 a.m., 7 minutes late).Resident 2's MAR indicated, one late medication (Hydrocodone-Acetaminophen Tablet 5-325 mg ordered for 12:00 p.m. and given at 1:01 p.m., 1 minute late).Resident 3's MAR indicated, six late medications (insulin lispro pen subcutaneous solution then pen injector sliding scale prescribed for 7:00 a.m. given at 9:04 a.m., 1 hour 4 minutes late; levothyroxine sodium oral tablet 75 micrograms ordered for 7:00 a.m. given at 9:04 a.m., 1 hour and 4 minutes late; vitamin D oral tablet ordered for 8:00 a.m. given at 9:06 p.m., 1 hour and 6 minutes late; sertraline hydrochloride oral tablet 25 milligram ordered for 8:00 a.m. given at 9:06 a.m., 1 hour and 6 minutes late; clopidogrel bisulfate tablet 75 milligram ordered for 8:00 a.m. given at 9:06 a.m., 1 hour and 6 minutes late; aspirin Enteric Coated tablet delayed release 81 milligram ordered for 8:00 a.m. given at 9:04 a.m., 1 hour and 4 minutes late.Resident 4's MAR indicated, 10 late medications (liquid protein supplement due at 8:00 a.m. given at 10:21 a.m., 1 hour and 21 minutes late; amiodarone 200 mg ordered for 8:00 a.m. given at 10:21 a.m., 1 hour and 21 minutes late; docusate 100 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; metoprolol tartrate 25 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; ascorbic acid 1000 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; apixaban 5 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; lactulose 10 g ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; tamsulosin 0.4 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; multivitamin ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late; oxybutynin chloride Extended Release 5 mg ordered for 8:00 a.m. given at 10:22 a.m., 1 hour and 22 minutes late).Resident 5's MAR indicated, 10 late medications (propranolol 20 mg ordered for 7:00 a.m. given at 10:00 a.m., 2 hours late; hydralazine 25 mg ordered for 7:00 a.m. given at 10:00 a.m., 2 hours late; psyllium dietary fiber ordered for 8:00 am given at 10:01 a.m., 1 hour and 1 minute late; docusate 100 mg ordered for 8:00 a.m. given at 10:00 a.m., 1 hour late; omeprazole DR 20 mg ordered for 8:00 a.m. given at 10:01 a.m., 1 hour and 1 minute late; dutasteride 0.5 mg ordered for 8:00 a.m. given at 10:00 a.m., 1 hour late; sucralfate 1 g ordered for 8:00 am given at 10:01 am, 1 hour and 1 minute late; sennosides 8.6 mg ordered for 8:00 a.m. given at 10:01 a.m., 1 hour and 1 minute late; buspirone 7.5 mg ordered for 8:00 a.m. given at 10:00 a.m., 1 hour late; lisinopril 20 mg ordered for 8:00 a.m. given at 10:01 a.m., 1 hour and 1 minute late).Resident 6's MAR indicated, 2 late medications (lorazepam//Haloperidol/diphenhydramine cream ordered for 8:00 a.m. applied at 11:09 a.m., 1 hour and 9 minutes late; lorazepam 0.5 mg ordered for 8:00 a.m. given at 11:09 a.m., 1 hour and 9 minutes late).Resident 7's MAR indicated, 7 late medications (amiodarone 200 mg ordered for 8:00 a.m. given at 10:10 a.m., 1 hour and 10 minutes late; midodrine 5 mg ordered for 8:00 a.m. given at 10:11 a.m., 1 hour and 11 minutes late; insulin aspart 25 units ordered for 8:00 a.m. given at 10:12 a.m., 1 hour and 12 minutes late; carvedilol 12.5 mg ordered for 8:00 a.m. given at 10:12 a.m., 1 hour and 12 minutes late; fludrocortisone 0.1 mg ordered for 8:00 a.m. given at 10:12 a.m., 1 hour and 12 minutes late; apixaban 5 mg ordered for 8:00 a.m. given at 10:12 a.m., 1 hour and 12 minutes late).LVN 2 stated she was not aware of any negative effects from these late medications but agreed some late doses, such as insulin, could cause life threatening complications like dangerously high blood sugar.During a concurrent interview and record review on 6/24/26 at 12:44 pm, with the Assistant Director of Nursing (ADON), staffing schedules were reviewed. The ADON stated the facility knew medications were being given late and confirmed that nurses had been complaining about being assigned to too many residents and not having enough time to complete all care. The ADON said the facility did not conduct audits or measurements to ensure adequate staffing. The ADON stated administration would know if there was not enough staffing coverage by late documentation, nurses staying overtime, or medications given late. ADON stated that no staffing adjustments have been made despite nursing complaints and knowledge of late medication administration.During an interview on 6/24/26 at 12:44 p.m. with Administrator (ADM) 2, ADM 2 stated a nurse surveyor had visited the facility on 6/11/26 and was already citing the facility for late medication administration. ADM 2 validated medications had been administered late since the visit on 6/11/26.During a concurrent interview and record review on 7/1/26 at 2:43 p.m. with ADM 1 and the Director of Nursing (DON), the Medication Admin Audit Report from 6/12/26 to 6/24/26 and the facility policy titled Administering Medications (April 2019) were reviewed. The DON stated late medication administration was first reported to the facility on 6/11/26. DON stated medication errors occurred when medications were given outside the 60 minute window before or after the scheduled time. DON stated only one LVN had been identified as administering medications late at that time and received in-service training and monitoring. DON stated she knew nurses were complaining about being assigned too many residents, but she did not adjust staffing because the facility believed it met and exceeded staffing numbers. DON stated some signs indicating more staff were needed are nurses working overtime, unfinished charting, and late medication administration. DON and ADM 1 stated they had not realized the severity of the problem until reviewing the Medication Admin Audit Report from 6/12/26 to 6/24/26, which indicated 83 residents had medication errors during that time frame. ADM 1 said Medical Records was responsible for running audits but had not been doing so. DON stated she was ultimately responsible for ensuring the nurses were administering medications properly. Both the DON and ADM 1 admitted by not auditing late medications, the facility did not realize how many medications were being administered late and so they did not know they needed to review the instances and determine the cause of the late medications. DON and ADM 1 stated administering medications over one hour late and not running audits, the facility had not been following its medication administration policy.During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. 6. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.During a review of the facility's P&P titled Staffing, Sufficient and Competent Nursing, dated August 2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: a. Resident rights; b. Behavioral health; c. Psychosocial care; d. Dementia care; e. Person centered care; f. communication; g. Basic nursing skills; h. Basic restorative services; i. Skin and wound care; j. Medication management; k. Pain management; l. Infection control; m. identification of changes in condition; and n. Cultural competency. 7. Inquiries or concerns relative to our facility's staffing should be directed to the director of nursing services (DNS) or his/her designee.

Based on interview and record review the facility failed to ensure residents were free from significant medication errors according to their policy and procedure titled, Medication Administration for two of three residents (Resident 2, Resident 4) when on 6/11/26 Licensed Vocational Nurse (LVN) 1 did not administer scheduled medication Insulin (used to manage blood sugar by lowering the glucose) for diabetes mellitus (disorder that causes high blood sugar levels and body cannot produce or use insulin) as ordered by the physician. This failure had the potential for delayed medication effects, causing adverse reactions such as high or low blood sugar, dizziness, increased thirst, shakiness and medication ineffectiveness.Findings: During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus. During a review of Resident 2's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/7/26, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment. During a review of Resident 4's admission Record, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnosis for protein calorie malnutrition. During a review of Resident 4's Minimum Data Set, dated [DATE], the MDS indicated Resident 4's BIMS score was 15, which indicated Resident 4 was cognitively intact. During an interview on 6/11/26 at 12:00 p.m. with Resident 4, Resident 4 stated she had a complaint regarding her medications being administered late. Resident 4 stated that she did not receive medications on time and instead had to keep calling the staff into her room to alert the nurse that the medications were due. Resident 4 stated she would press the call light on multiple occasions to ensure she received her scheduled medications daily. Resident 4 stated it was important to receive scheduled medications on time because she needed them to manage her health and because the physician felt it would help her. During a review of Resident 4's document titled, Medication Administration Record (MAR), dated 6/2026, the MAR indicated, . Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale. before meals and at bedtime for high blood sugar -Start Date- 06/03/2026. Scheduled at 7:00 a.m., 11:00 a.m. The MAR indicated Resident 4 was scheduled to receive insulin administration before meals daily. The MAR also indicated that on 6/11/26, Resident 4 was scheduled to receive insulin at 11:00 a.m. but was administered insulin at 2:33 p.m. During an interview on 6/11/26 at 12:41 p.m. with Resident 2, Resident 2 stated he had a complaint regarding his medication administration not completed on time. Resident 2 stated he was concerned about the medication administration for insulin used to manage his high blood sugar. Resident 2 stated the insulin medication was supposed to be administered before meals daily. Resident 2 stated that on 6/11/26, LVN 1 had administered the insulin medication past the administration time for breakfast and for lunch. Resident 4 stated he was scheduled to receive medication this morning before breakfast when his blood sugar was at 298 at 6:53 am, but Resident 2 stated he didn't get his insulin until after 9:00 a.m. Resident 2 stated he was concerned for the management of his diabetes due to not receiving the scheduled insulin at the time it was due. During a review of Resident 2's document titled, Medication Administration Record (MAR), dated 6/2026, the MAR indicated, . Humalog kwikpen Solution pen injector 100 UNIT/ML (Insulin Lispro) Inject 12 unit subcutaneously (under the skin) before meals for diabetes mellitus. start date 6/3/26 . Scheduled at 7:00 a.m., 11:00 a.m. The MAR indicated that on 6/11/26, Resident 2 was scheduled to receive insulin at 7:00 a.m. but was not administered medication until 9:42 a.m. and was also scheduled to receive insulin at 11:00 a.m. but was not administered insulin until 1:44 p.m. During an interview on 6/11/26 at 1:01 p.m. with LVN 2, LVN 2 stated the facility process with medication administration was for the nurses to follow the physician orders for resident medication administration. LVN 2 stated that during medication administration, there was a timeframe that should be followed to ensure medications were administered on time. LVN 2 stated the scheduled medications could have been administered one hour before or one hour after the scheduled time. LVN 2 stated the facility process was to check residents' blood sugar before meals and administer insulin as ordered. LVN 2 stated that any deviation from the physician order would need a physician notification. LVN 2 stated that residents were at risk for unmanaged blood sugars when they were not administered scheduled insulin according to the physician order. During an interview on 6/11/26 at 1:28 p.m. with the director of staff development (DSD), the DSD stated the facility expectation was for all nurses to follow the physician orders and administer medications timely and safely. The DSD stated the facility process was for the nursing staff to ask the administration staff for assistance when they could not complete medication administration timely or when there were other issues preventing the nurses from completing the medication administration. The DSD stated she had not been notified by LVN 1 that medications were administered late or not on time. During an interview on 6/11/26 at 1:37 p.m. with the Registered Nurse Supervisor (RNS), the RNS stated the RNS responsibilities included assessing residents, delegating responsibilities and assisting the nursing staff when needed. The RNS stated she had not been notified by LVN 1 that medications were administered late or not on time. During an interview on 6/11/26 at 1:57 p.m. with LVN 1, LVN 1 stated she was the nurse caring for Resident 2 and Resident 4. LVN 1 stated she began her medication administration for residents at around 7:00 a.m. and recalled being late on administering some of the medications to residents in the morning during breakfast. LVN 2 stated that due to unforeseen circumstances, medications were given late for breakfast, therefore causing the lunch medication to also be late. LVN 1 stated that blood sugar checks appear at 11:00 a.m. with insulin administration as ordered by the physician. LVN 2 stated that she did not administer insulin as ordered to residents before the residents consume their meals. LVN 1 stated this could result in residents to not eat causing blood sugars to become low. LVN 1 stated she waited until after the residents had their meals to administer insulin medication. LVN 1 stated that on 6/11/26, she had started the medication administration at around 12:15 p.m., after the scheduled ordered time for residents to receive insulin medication and blood sugar check. LVN 1 stated when medications were administered late or not on time, the residents were at risk of receiving too much of a dose if it was given too close to the next administration time and could have affected the residents' blood sugar and diabetes management. During an interview on 6/11/26 at 2:17 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the nursing staff to administer medications timely. The ADM stated that nursing staff should have asked the administration staff for assistance when medications were scheduled and there were other unforeseen circumstances occurring. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Medications are administered within one hour of their prescribed time, unless otherwise specified.For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication.

Based on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 6/11/26, the facility staff served Resident 1 a meal tray with a regular consistency (diet with no alterations) and Resident 1 had a physician diet order for soft and bite sized textured meals. This failure resulted in Resident 1 experiencing episode of inability to chew his food and had the potential to cause malnutrition, choking, aspiration and death.Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for protein calorie malnutrition. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 6/11/26 at 12:37 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed attempting to chew his food served on his meal tray. Resident 1 was observed spitting food out his mouth and stated, I can't chew this. Resident 1 stated the food that was served was hard to chew and swallow since he did not have any teeth. Resident 1 was observed opening his mouth to show the surveyor that he did not have any teeth. During a review of Resident 1's, Meal tray Ticket, dated 6/11/26, the meal tray ticket indicated, . [Resident 1] Consistency: Soft bite and bite sized. During a review of Resident 1's, Nutrition Care Plan, dated 12/28/25, the care plan indicated, [Resident 1] is on a therapeutic and mechanically altered texture diet, thin liquids. Interventions. Provide, serve diet as ordered. During a review of Resident 2's admission Record, the AR indicated, Resident 2 was admitted to the facility on [DATE]. During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1's BIMS score was 14 which indicated Resident 1 was cognitively intact. During an interview on 6/11/26 at 12:41 p.m. with Resident 2, Resident 2 stated he had alerted CNA 1 and LVN 1 regarding Resident 1's lunch meal as he believed Resident 1 was served the incorrect meal tray. Resident 2 stated he felt frustrated because both CNA 1 and LVN 1 were checking the electronic medical record (EMR) and meal tray ticket for confirmation that the meal served was correct. Resident 1 stated CNA 1 and LVN 1 should have been looking at the food on the meal tray and assessing Resident 1's inability to chew. During a concurrent observation and interview on 6/11/26 at 12:44 p.m. with licensed vocational nurse (LVN) 1 in Resident 1's room, Resident 1's meal tray was observed. LVN 1 stated that after review of Resident 1's diet order in the EMR, the meal tray ticket and observation of the meal tray served, Resident 1 was served the incorrect diet. Resident 1 stated he could not chew the food on the meal tray because he did not have any teeth. LVN 1 stated she was not comfortable downgrading Resident 1's food and instead would notify the speech therapists for an evaluation of Resident 1's inability to chew his food. During an interview on 6/11/26 at 12:58 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had served Resident 1 his lunch and was caring for Resident 1. CNA 1 stated that Resident 1's roommate (Resident 2) had alerted CNA 1 that Resident 1's food was served incorrectly and needed to be checked. CNA 1 stated she proceeded to check with LVN 2 to ensure the diet was served correctly for Resident 1. CNA 1 stated that LVN 2 compared the meal tray ticket with the physician order in the EMR and ensured CNA 1 that the diet was correct. CNA 1 stated she then proceeded to inform Resident 1 that the diet was served correctly. During a concurrent interview and record review on 6/11/26 at 1:01p.m. with LVN 2, a photo taken at 12:37 p.m. of Resident 1's lunch meal tray served on 6/11/26 and Resident 1's EMR were reviewed. LVN 2 stated that according to the EMR, Resident 1 had a diet order that indicated his diet should have been served soft and bite sized texture with thin liquids. LVN 2 stated that after reviewing the photo of the meal tray served, the food on the tray appeared like a regular texture and was not consistent with Resident 1's diet order for soft and bite sized texture. LVN 2 stated that Resident 1 was at risk for choking when he was served the incorrect textured food and was unable to chew the food served on his meal tray. During a concurrent interview and record review on 6/11/26 at 1:18 p.m. with the certified dietary manager (CDM), a photo taken at 12:37 p.m. of Resident 1's lunch meal tray served on 6/11/26 and Resident 1's meal tray ticket was reviewed. The CDM stated that the meal served on Resident 1's lunch tray appeared to be the incorrect diet and consistency. The CDM stated that Resident 1 should have received soft and bite sized texture which he did not. The CDM stated the expectation was for the dietary staff to follow the physician ordered diets for all residents and to ensure the meals were served with the correct texture and consistency. The CDM stated the expectation once the meals leave the kitchen, was for the nursing staff to then observe and ensure the meals served were served according to the physician's order. The CDM stated Resident 1 was at risk for aspirating or choking when he was served the incorrect meal texture. During a concurrent interview and record review on 6/11/26 at 1:28 p.m. with the director of staff development (DSD), a photo taken at 12:37 p.m. of Resident 1's lunch meal tray served on 6/11/26 and Resident 1's meal tray ticket was reviewed. The DSD stated that Resident 1's meal was not consistent with the diet order for soft and bite sized texture. The DSD stated that based on the photo and the meal tray ticket, Resident 1 was served the incorrect diet. The DSD stated the facility process was for the nurse to assess Resident 1's difficulty in chewing his food, identifying the incorrect diet texture and calling the physician to downgrade Resident 1's diet. The DSD stated this process would ensure Resident 1 was able to consume his meals until the speech therapists could evaluate Resident 1 for diet changes. The DSD stated the expectation was for the nurses and CNA's to ensure the residents were given the correct diet and texture prior to serving the residents their meals. The DSD stated Resident 1 was at risk for inability to chew his food, aspiration or choking. During a concurrent interview and record review on 6/11/26 at 1:54 p.m. with Registered Dietitian (RD), a photo taken at 12:37 p.m. of Resident 1's lunch meal tray served on 6/11/26 and Resident 1's meal tray ticket was reviewed. The RD stated that based on the meal tray observed and meal tray ticket, Resident 1 was not given a diet consistent with soft and bite sized textured food. The RD stated the expectation was for the dietary staff to follow the physician orders for resident diets. During an interview on 6/11/26 at 2:17 p.m. with the administrator (ADM), the ADM stated the facility expectation was for the facility staff who were serving residents meal trays, to observe each meal tray individually, not only the meal tray ticket and the physician order. The ADM stated the process included the dietary cook, dietary aide, nurses and then the CNA were responsible for ensuring Resident 1's meal was served correctly and consistently with physician order. During a review of the facility's policy and procedure (P&P), titled, Therapeutic Diets, dated 2017, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Diet order should match the terminology used by the food and nutrition services department. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. As appropriate, the attending physician may temporarily suspend a therapeutic diet for special occasions. The attending physician may liberalize the diet at the request of the IDT (if the resident is losing weight or not eating well) or the resident.

Based on interview and record review the facility failed to follow and document recommended dietary changes according to professional standards of practice and the facility's policy and procedure titled Diet Change, for one of three sampled residents (Resident 1) when the facility nursing staff did not notify the physician of speech therapy recommendations to change Resident 1's diet order 0n 12/6/25. This failure placed Resident 1 at risk for inadequate food consumption, choking, coughing and inability to swallow food.Findings:During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Dysphagia (difficulty swallowing), Dementia (a condition characterized by impairment of memory).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/26/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment.During a concurrent interview and record review on 3/18/26 at 11:49 a.m. with the assistant director of nursing (ADON), Resident 1's record titled, Order Summary Report, dated 1/1/2024-12/11/2025 and Resident 1's record titled, Speech Therapy Evaluation and Plan of Treatment, dated 12/6/26, were reviewed. The Order Summary Report indicated, . Regular diet Minced and Moist texture, Mildly Thick Liquid consistency. The Speech Therapy evaluation indicated, . Recommendations. Intake, diet recommendations- solids- Puree consistencies, Diet recommendations- Liquids- Nectar thick Liquid. The ADON stated the order summary report, and the speech therapy recommendations were different diet orders, and the order summary did not reflect the changes recommended for Resident 1 in the speech therapy evaluation.During an interview on 3/18/26 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the facility process when there was a swallowing concern for residents, was to complete a nurse assessment, notify the physician and request a speech therapy evaluation. LVN 1 stated that once the speech therapy evaluation was completed, the speech therapists would provide the nursing staff with new recommendations, LVN 1 stated when the new recommendations from the speech therapists were received, the nursing staff would notify the physician of the recommendations. LVN 1 stated that when there was a diet change recommendation the diet would be changed immediately following physician notification, a dietary communication form was completed and provided to the dietary staff to ensure residents new diet recommendation was completed and residents were receiving the correct diet to prevent coughing and choking during meals.During an interview on 3/18/26 at 12:59 p.m. with LVN 2, LVN 2 stated the facility process when there was a swallowing concern for residents, was to complete a nursing assessment, notify the nurse in charge, notify the physician to request a speech therapy evaluation, once order was received from the physician, we completed the order and notified the speech therapists. LVN 2 stated that once the speech therapists completed the speech therapy evaluation, the speech therapists would notify the nursing staff and provide the nursing staff with new recommendations. LVN 2 stated, when the new speech therapy recommendations were received, the nursing staff was responsible for documenting the change on the diet order in the resident's record, notifying the physician and the dietary staff to ensure residents were receiving the appropriate diet and to prevent complications such as choking.During a concurrent telephone interview and record review on 3/26/26 at 2:30 p.m. with the director of nursing (DON), Resident 1's record titled, Speech Therapy Evaluation and Plan of Treatment, dated 12/6/26, was reviewed. The Speech Therapy evaluation indicated, . Recommendations. Intake, diet recommendations- solids- Puree consistencies, Diet recommendations- Liquids- Nectar thick Liquid. The DON stated the facility process for speech therapy evaluations, was for the nursing staff to complete an assessment of the resident's swallowing concerns, notify the MD and request a speech therapy evaluation. The DON stated, when the speech therapy evaluation was completed, the speech therapists would provide new dietary recommendations or order change recommendations to the nursing staff. The DON stated the nursing staff was then responsible for notifying the physician of the recommendations, changing residents' diet order in the medical record and notifying the dietary staff immediately to ensure the residents were receiving the appropriate diet. DON stated, once received the speech therapist recommendation for Resident 1, the licensed nurse should have notified the physician to obtain the new diet orders. DON stated Resident 1 was at risk for chocking, if the diet orders were not updated.During a concurrent telephone interview and record review on 3/25/26 at 3:15 p.m. with the speech therapists (ST), Resident 1's, Speech Therapy Evaluation and Plan of Treatment, dated 12/6/26, was reviewed. The Speech Therapy evaluation indicated, . Recommendations. Intake, diet recommendations- solids- Puree consistencies, Diet recommendations- Liquids- Nectar thick Liquid. The ST stated Resident 1's new diet recommendation was different to the previous diet order. The ST stated the new diet recommendation should have been changed by the facility staff the day of the evaluation completion. The ST stated the facility process was for the nursing staff to follow up with the physician regarding new diet recommendations and then ensuring the diet was changed in the medical record. The ST stated it was important to follow the recommendations to ensure all residents received the appropriate diet and to prevent coughing or choking during meals.During a record review of the facility's policy and procedure (P&P) titled, Diet Changes, dated 7/2008, the P&P indicated, .Policy Statement: Nursing Services notifies the Food & Nutrition Department of changes in a resident's diet, meal service, and eating habits. When a new resident is admitted , discharged , or readmitted , or if there is a diet change, Drug/Food Interaction or nothing by mouth (NPO) order the nurse provides the Food & Nutrition Department with written notice of the diet order.During a review of a professional reference from the American Nurses Association titled, Principles for Nursing Documentation, dates 2010, the reference indicated, . Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. Entries into organization documents or the health record (including but not limited to provider orders) must be Accurate, valid, and complete, Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted, Dated and time-stamped by the persons who created the entry.

Based on interview and record review the facility failed to ensure residents were free from significant med errors according to its policy and procedure titled Medication Administration for nine of 10 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9) when on 12/26/25 Registered Nurse (RN) 1 did not administer scheduled medications as ordered by the physician. This failure had the potential for delayed medication effects, cause adverse reactions, medication ineffectiveness and placed Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9 at increased risk for life and safety.Findings:During an interview on 1/16/26 at 1:12 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process for medication administration included following the physician order and administering all scheduled medications at the right time. LVN 1 stated medications could have been administered an hour before or an hour after the scheduled time. LVN 1 stated there was a potential for harm when residents were not administered medications at the ordered time.During an interview on 1/16/26 at 1:59 p.m. with the director of staff development (DSD), the DSD stated there was a registered nurse (RN) who worked on 12/26/25. DSD stated RN 1 did not administered any scheduled morning medications for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. for unknown reason. The DSD stated it was important to follow the rights (right dose, right time, right route) of medication administration to administer at the right time. The DSD stated medication administration time frames needed to be followed due to the potential of administering double dose of medications to Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. The DSD stated there was a potential for harm to residents with a diagnosis for diabetes when they did not receive needed insulin (a hormone that regulates blood sugar). The DSD stated there was also potential for harm when residents with a diagnosis of hypertension (high blood pressure) were not administered medications that were prescribed to aid in controlling residents' blood pressure. The DSD stated the expectation was that all nurses complete medication administration without medication errors.During an interview on 1/16/26 at 2:43 p.m. with the director of nursing (DON), the DON stated that on 12/26/25 there was an RN from a contracted company that worked during the morning shift. The DON stated he was notified by facility staff that the scheduled morning medications were still in the medication cart and should have been administered. The DON stated he attempted to speak with the RN but was unsuccessful as the RN stated she would not give an explanation. The DON stated it was important to administer all medications on time to ensure there were no adverse effects that could have harmed the residents.During a telephone interview on 1/23/26 at 3:38 p.m. with RN 1, RN 1 stated she was the nurse in charge of administering medications on 12/26/25 for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. RN 1 stated she was not aware of the facility's medication administration schedule times and therefore had not administered medications as ordered. RN 1 stated medications should have been administered on time to residents one hour before or one hour after the scheduled time. RN 1 stated she was aware that there were some residents who were not administered medications. RN 1 stated she should have addressed the missing medications, but she had not. RN 1 stated it was wrong to not administer medications to residents as scheduled and should have notified the resident's physician right away. RN 1 stated there was a potential for adverse side effects for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9 when the medications were not administered as ordered.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for hypertension , Psoriatic arthritis (condition causing joint pain, stiffness, and swelling, with scaly skin rash), Anemia (blood disorder where the blood lacks enough red blood cells to carry oxygen to the body's tissues).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 10/31/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a review of Resident 1's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. no adverse effects or complications noted. Vital signs within baseline. No signs or symptoms medication withdrawal, distress, or change in condition observed. Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 1's, Order Summary Report, dated 12/26/25, the order summary indicated, . Folic acid oral tablet 800 mcg (microgram-unit of measurement), give 800 mcg by mouth one time a day for supplement. Brand name oral tablet 20 mg (milligram-unit of measurement) (furosemide) give one tablet by mouth one time a day for hypertension. Methotrexate sodium tablet 15 mg give one tablet by mouth one time a day every Friday for Psoriatic Arthritis. Metoprolol Succinate extended release tablet 24 hour 25 mg give one tablet by mouth one time a day for hypertension. During a review of Resident 1's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Folic acid oral tablet give 800 mcg, (brand name) Furosemide oral tablet 20 mg, Methotrexate Sodium tablet 15 mg, Metoprolol Succinate extended-release tablet 25 mg.During a review of Resident 2's admission Record, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis for hypertension, Diabetes (condition characterized by high blood sugar resulting from the body's inability to produce or properly use insulin), heart failure (a chronic, manageable condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), Respiratory failure (a condition when there is not enough oxygen passes from lungs to the blood), anemia, Chronic obstructive Pulmonary disease (a progressive group of lung diseases that block airflow, causing severe breathing difficulties, cough, and wheezing).During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 2 was cognitively intact.During a review of Resident 2's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 2's, Order Summary Report, dated 12/26/25, the order summary indicated, . Amlodipine Besylate oral tablet 10 mg give one tablet by mouth one time a day for high blood pressure. Clopidogrel Bisulfate oral tablet 75 mg give one tablet by mouth one time a day for blood thinner. Ferrous sulfate oral tablet 325 mg give one tablet by mouth two times a day for supplement. Furosemide oral tablet give 40 mg by mouth two times a day for high blood pressure. Insulin Glargine Solution 100 unit/ML inject 15 unit subcutaneously (under the skin) one time a day for high blood sugar. Insulin Lispro injection Solution 100 unit/mL inject per sliding scale. before meals and at bedtime for Diabetes. Pantoprazole sodium oral tablet delayed release 40 mg give one tablet by mouth two times a day for ulcer before meals. Potassium Bicarbonate oral tablet give 10 mEq (milliequivalent- a unit of measurement) by mouth two times a day for supplement take with furosemide. Sennosides tablet 8.6 mg give two tablet by mouth two times a day for constipation. Sucralfate suspension 1 GM/10 mL give 1 gram by mouth before meals for gastrointestinal (stomach) bleed. Tolterodine tartrate oral tablet give 2 mg by mouth two times a day for overactive bladder.During a review of Resident 2's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 10 mg, Clopidogrel Bisulfate oral tablet 75 mg, Insulin Glargine solution100 unit/mL (milliliter- measurement of unit), multivitamin oral tablet, Polyethylene Glycol 3350 powder, Budesonide inhalation suspension 1mg/2 mL, Docusate sodium oral capsule 100 mg, Ferrous sulfate oral tablet 325 mg, Furosemide oral tablet 40 mg, Gabapentin Capsule 300 mg, Potassium Bicarbonate oral tablet 10 mEq, Sennosides tablet 8.6 mg, Tolterodine tartrate oral tablet 2 mg, Hydralazine HCL oral tablet 25 mg, Sucralfate suspension 1 gm/10 mL, insulin lispro injection solution 100 unit/ml.During a review of Resident 3's admission Record, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnosis for Benign prostatic hyperplasia (enlargement of the prostate gland), hypernatremia (high concentration of sodium (salt)in the blood) abscess of liver (a pocket of pus (infected fluid) that forms inside the liver).During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status score was 10 out of 15 which indicated Resident 3 had moderate cognitive impairment.During a review of Resident 3's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 3's, Order Summary Report, dated 12/26/25, the order summary indicated, . Cholecalciferol Tablet 1000 unit give 1000 IU by mouth one time a day for supplement. Cozaar oral tablet 100 mg give 100 mg by mouth one time a day for hypertension. Dapagliflozin Propanediol oral tablet 10 mg give 10 mg by mouth one time a day for Diabetes. Donepezil HCL oral tablet 10 mg give 10 mg by mouth one time a day for dementia (a decline in mental abilities-such as memory, reasoning, and thinking-severe enough to interfere with daily life, personality, and behavior). Finasteride oral tablet 5 mg give 5 mg by mouth one time a day for benign prostatic hyperplasia. Memantine HCL oral tablet 10 mg give 10 mg by mouth one time a day for dementia. Metformin HCL oral tablet 500 mg give 500 mg by mouth two times a day for Diabetes with meals. Tamsulosin HCL oral capsule 0.4 mg give 0.4 mg by mouth two times a day for benign prostatic hyperplasia.During a review of Resident 3's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Cholecalciferol Tablet 1000 unit, Cozaar Oral tablet 100 mg, Dapagliflozin Propanediol oral tablet 10 mg, Finasteride oral tablet 5 mg, Memantine HCl oral tablet 10 mg, Vitamin B & C complex oral tablet, Metformin HCl oral tablet 500 mg, Tamsulosin HCl oral capsule 0.4 mg.During a review of Resident 4's admission Record, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnosis for Hypertension, hyperlipidemia (high levels of fats in the blood), muscle spasm (sudden, involuntary, painful tightening of a muscle), Peripheral vascular disease (a circulation disorder where blood vessels outside the heart, in the limbs and organs, narrow, weaken, or block).During a review of Resident 4's Minimum Data Set, dated [DATE], the MDS indicated Resident 4's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 4 was cognitively intact.During a review of Resident 4's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 4's, Order Summary Report, dated 12/26/25, the order summary indicated, . Brimonidine Tartrate Ophthalmic Solution 0.2% instill one drop in both eyes one time a day separate eye drops by 3-5 minutes. Klor-Con 10 oral tablet extended release (Potassium Chloride) give one tablet by mouth one time a day for supplement. Methylcellulose oral powder give 19 gram by mouth one time a day for supplement. Neomycin sulfate oral tablet give 1000 mg by mouth two times a day related to hepatic encephalopathy (a temporary, reversible decline in brain function caused by severe liver disease ). Propranolol HCL oral tablet give 10 mg by mouth two times a day related to hypertension. Timolol Maleate Ophthalmic solution 0.5% instill one drop in both eyes two times a day related to glaucoma ( an eye disease due to increased pressure inside the eye).During a review of Resident 4's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Brimonidine Tartrate Ophthalmic Solution 0.2%, Klor-Con 10 oral tablet extended release, Methylcellulose oral powder, Azelastine HCl Ophthalmic solution 0.05%, Neomycin sulfate oral tablet 1000 mg, Propranolol HCl oral tablet 10 mg, Timolol Maleate Ophthalmic solution 0.5%.During a review of Resident 5's admission Record, the AR indicated, Resident 5 was admitted to the facility on [DATE] with diagnosis for Respiratory failure, Chronic obstructive pulmonary disease, heart failure, hyperlipidemia, muscle weakness, rosacea (a chronic skin condition).During a review of Resident 5's Minimum Data Set, dated [DATE], the MDS indicated Resident 5's Brief Interview for Mental Status score was 14 out of 15 which indicated Resident 5 was cognitively intact.During a review of Resident 5's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. no adverse effects or complications noted. Vital signs within baseline. No signs or symptoms medication withdrawal, distress, or change in condition observed. Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 5's, Order Summary Report, dated 12/26/25, the order summary indicated,. Empagliflozin Oral Tablet 10 MG Give 1 tablet by mouth one time a day for Diabetes, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 25 mg by mouth one time a day for hypertension, Multivitamin-Minerals Oral Tablet Give 1 tablet by mouth one time a day for Promote wound Healing, Spironolactone (medication remove excess fluid, salt and swelling) Oral Tablet 25 MG Give 0.5 tablet by mouth one time a day, Furosemide Tablet 20 MG Give 20 mg by mouth two times a day for edema (swelling), Lisinopril Oral Tablet 5 MG Give 1 tablet by mouth two times a day for hypertension .During a review of Resident 5's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Empagliflozin Oral Tablet 10 MG, Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, Multivitamin-Minerals Oral Tablet, Spironolactone Oral Tablet 25 MG, Furosemide Tablet 20 MG, Lisinopril Oral Tablet 5 MG.During a review of Resident 6's admission Record, the AR indicated, Resident 6 was admitted to the facility on [DATE] with diagnosis for Heart failure, Atrial fibrillation (irregular heart beat), compression fracture (A type of break in a bone caused by pressure and in which the bone collapses), hyponatremia (low concentration of sodium (salt)in the blood.During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS indicated Resident 6's Brief Interview for Mental Status score was 8 out of 15 which indicated Resident 6 had moderate cognitive impairment.During a review of Resident 6's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 6's, Order Summary Report, dated 12/26/25, the order summary indicated,. Amlodipine Besylate oral tablet 10 mg give 10 mg by mouth one time a day for high blood pressure. Atorvastatin Calcium oral tablet 20 mg by mouth one time a day for high cholesterol. Hydralazine HCL oral tablet 25 mg give 25 mg by mouth two times a day for high blood pressure. Isosorbide Mononitrate tablet extended release 30 mg give 30 mg by mouth one time a day for congestive heart failure (Heart muscle is too weak or stiff to pump blood efficiently) .Losartan Potassium oral tablet 100 mg give 100 mg by mouth one time a day for hypertension. Magnesium Oxide oral tablet 400 mg give 400 mg by mouth one time a day for supplement. Omeprazole oral capsule delayed release 20 mg give one capsule by mouth one time a day for indigestion. Sennosides tablet 8.6 mg give two tablet by mouth two times a day for constipation. Tamsulosin HCL oral capsule 0.4 mg give one capsule by mouth one time a day for benign prostatic hyperplasia.During a review of Resident 6's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 10 mg, Atorvastatin Calcium oral tablet 20 mg, Isosorbide Mononitrate extended release 30 mg, Losartan Potassium oral tablet 100 mg, Magnesium Oxide oral tablet 400 mg, Omeprazole oral capsule delayed release 20 mg, Tamsulosin HCl oral capsule 0.4 mg, Apixaban oral tablet 5 mg, Docusate Sodium oral capsule 100 mg, Hydralazine HCl oral tablet 25 mg, Sennosides tablet 8.6 mg, Insulin Lispro solution.During a review of Resident 7's admission Record, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnosis for Chronic obstructive Pulmonary Disease, Schizophrenia (a chronic, severe brain disorder), Personality Disorder (a chronic mental health condition).During a review of Resident 7's Minimum Data Set, dated [DATE], the MDS indicated Resident 7's Brief Interview for Mental Status score was 9 out of 15 which indicated Resident 7 had severe cognitive impairment.During a review of Resident 7's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications .Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 7's, Order Summary Report, dated 12/26/25, the order summary indicated, . Benztropine Mesylate oral tablet 0.5 mg give 1 tablet by mouth one time a day for Schizophrenia. Buspirone HCL oral tablet 10 mg give two tablet by mouth three times a day for schizophrenia. Humalog Injection Solution 100 unit/ML inject as per sliding scale. before meals and at bedtime. Metformin HCL oral tablet 850 mg give one tablet by mouth two times a day for diabetes. Prednisone oral tablet 10 mg give one tablet by mouth one time a day for infection for three days. Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath activated 62.5-25 mcg/act one puff inhale orally one time a day for COPD. Vitamin D3 oral tablet give 2000 unit by mouth one time a day for supplement.During a review of Resident 7's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Benztropine Mesylate oral tablet 0.5 mg, Prednisone oral tablet 10 mg, Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath activated 62.5-25 mcg/act, Vitamin D3 oral tablet, Metformin HCl oral tablet 850 mg, Buspirone HCl oral tablet 10 mg, Humalog injection solution 100 unit/mL.During a review of Resident 8's admission Record, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnosis for Kidney failure (A condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), Sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection), Hydronephrosis ( a condition where one or both kidneys become swollen and stretched due to a build-up of urine).During a review of Resident 8's Minimum Data Set, dated [DATE], the MDS indicated Resident 8's Brief Interview for Mental Status score was 15 out of 15 which indicated Resident 8 was cognitively intact.During a review of Resident 8's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 8's, Order Summary Report, dated 12/26/25, the order summary indicated, . Amlodipine Besylate oral tablet 5 mg give 5 mg by mouth one time a day for hypertension. [name brand] oral capsule 200 mg give 200 mg by mouth one time a day for swelling. Lactobacillus Capsule give two capsule by mouth one time a day for probiotics. Eliquis oral tablet 2.5 mg give 2.5 mg by mouth two times a day for anticoagulation. Nepro 237 mL, Tizanidine HCl oral tablet give 4 mg by mouth two times a day for muscle spasms. Benzonatate oral capsule 100 mg by mouth three times a day for allergies. Cholestyramine oral packet 4 gm give two packets by mouth three times a day for cholesterol .During a review of Resident 8's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Amlodipine Besylate oral tablet 5 mg, [name brand] oral capsule 200 mg, Lactobacillus Capsule, Eliquis oral tablet 2.5 mg, Nepro 237 mL, Tizanidine HCl oral tablet, Benzonatate oral capsule 100 mg, Cholestyramine oral packet 4 gm.During a review of Resident 9's admission Record, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnosis for Hypertension, Necrotizing Vasculopathy (a serious medical condition where blood vessels become severely inflamed), Lupus [a chronic disease where the body's immune system (a complex network of cells, tissues, organs, and the substances that helps the body fight infections and other diseases) mistakenly attacks its own healthy cells, tissues, and organs].During a review of Resident 9's Minimum Data Set, dated [DATE], the MDS indicated Resident 9's Brief Interview for Mental Status score was 12 out of 15 which indicated Resident 2 had moderate cognitive impairment.During a review of Resident 9's document titled, Situation, Background, Appearance and Review (SBAR), dated 12/26/25, the SBAR indicated, .Resident did not receive any morning medications. Resident was unable to receive scheduled morning medications. Morning medications were not administered. Resident assessed afternoon shift with no Adverse effects or complications noted . Recommendations of Primary Clinicians, Resident's with medication orders for one time a day to be given immediately.During a review of Resident 9's, Order Summary Report, dated 12/26/25, the order summary indicated, . Aspirin oral tablet 81 mg by mouth one time a day for deep vein thrombosis (a serious condition where a blood clot (thrombus) forms in a deep vein). Bactrim DS oral tablet 800-160 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday for prophylaxis (action taken to prevent disease ). Docusate Sodium capsule 100 mg give one capsule by mouth one time a day for constipation. Ferrous Sulfate tablet 325 mg give one tablet by mouth one time a day for supplementation. Hydroxychloroquine Sulfate oral tablet 200 mg give two tablet by mouth one time a day for Lupus. Omeprazole oral tablet delayed release 20 mg, Eliquis oral tablet 5mg give 5 mg by mouth two times a day for deep vein thrombosis. Mycophenolate Mofetil oral tablet 500 mg give two tablets by mouth two times a day for Lupus.During a review of Resident 9's, Medication Administration Record (MAR), dated 12/2025, the MAR indicated, the following medications were not administered on 12/26/25, Aspirin oral tablet 81 mg, Bactrim DS oral tablet 800-160 mg, Docusate Sodium capsule 100 mg, Ferrous Sulfate tablet 325 mg, Hydroxychloroquine Sulfate oral tablet 200 mg, Omeprazole oral tablet delayed release 20 mg, Eliquis oral tablet 5mg, Mycophenolate Mofetil oral tablet 500 mg.During a review of the facility's job description titled, Registered Nurse, dated 10/2020, the job description indicated, . The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors .During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 10/2017, the P&P indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personal authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. Medications are administered in accordance with written orders of the attending physician. Medications are administered without unnecessary interruptions. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before and after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility .

Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 1), when Resident 1 had one documented weight on 6/6/25 since being admitted to the facility on [DATE]. Staff did not complete a weight on admission and weekly as ordered by the physician, Resident 1 was not consuming meals to its entirety or refused meals, the facility was aware of Resident 1's refusal to be weighed and the Restorative Nursing Assistant (RNA) did not follow up with the licensed nurses.This failure resulted in a 16% weight loss of 21.2 pounds (lbs.) in two (2) months placing Resident 1 at risk for unmonitored significant weight loss that could have worsened Resident 1's diagnosed heart condition and placed her at risk for inadequate nutritional intake.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis of congestive heart failure (condition in which the heart doesn't pump blood as it should), Dementia (loss of memory, language and other thinking abilities), osteomyelitis (inflammation of a bone caused by infection), Diabetes Mellitus (DM- increased sugar in the blood).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/20/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a telephone interview on 8/12/25 at 12:00 p.m. with family member (FM) 1, FM 1 stated, there were concerns regarding Resident 1 refusing meals and possible weight loss. FM 1 stated, Resident 1 had expressed that the facility food did not taste good and therefore Resident 1 did not consume her meals. FM 1 stated Resident 1 appeared to have lost weight since admission to the facility but was unaware how much weight she had lost.During a concurrent observation and interview on 8/12/25 at 1:01 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed lying in bed appearing thin and frail. Resident 1 stated she had resided in the facility for a few months. Resident 1 stated she disliked the food in the facility and would consume a small portion or none of the food served during mealtimes. Resident 1 stated she was unaware if the facility staff had noticed weight loss or weight gain since admission and stated she was unaware if she had experienced weight loss during her stay.During a review of Resident 1's, Nutrition Evaluation, dated 5/18/25, the evaluation indicated, . At risk for weight fluctuations r/t PO [related to by mouth] intake, DM, and diuretic (medication used to eliminate excess fluid buildup in the body) therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. estimated total daily 1544-1930 calories, protein intake daily 77-93 gram (g). The evaluation indicated the nutritional evaluation was completed by the Registered Dietitian (RD) and documented risks for weight fluctuations after review of Resident 1's evaluation.During a record review of Resident 1's, Order Summary, dated 8/19/2025, the order summary indicated, . Weekly Weights one time a day every Fri (Friday) for Admission.During a review of Resident 1's Electronic Medical Record (EMR) titled, Weights, the EMR indicated, Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document indicated there were no other weights documented on the EMR since admission on [DATE].During a review of the facility's handwritten document titled, Daily weights, dated 5/15/25 for Resident 1, the document indicated, Resident 1 had refused weights from 5/15/25 to 6/3/25, 6/5/25, 6/26/25 to 7/7/25. The document did not indicate any further attempts for weight check after 7/7/25. The document did not indicate if the nurse or physician was made aware of Resident 1's refusals. Concurrent review of the document and Resident 1's EMR indicated there was no documentation or evidence indicating the nurse and the physician were made aware of Resident 1's refusals and multiple attempts to re weigh.During a concurrent interview and record review on 8/12/25 at 1:40 p.m. with licensed vocational nurse (LVN) 1, Resident 1's electronic medical record (EMR) was reviewed, including document titled Weights. The document indicated Resident 1 was only weighed on 6/6/2025 since the admission to the facility and there were no other weights documented in the EMR. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the restorative nursing assistant (RNA). LVN 1 stated Resident 1 should have documented weight checks monthly. LVN 1 stated if Resident 1 had refused to be weighed, the RNA who was assigned to weigh all residents, should have notified the nurse. LVN 1 stated the facility process included documentation of missed weights, physician and resident representative notification.During an interview on 8/12/25 at 2:43 p.m. with RNA 1, RNA 1 stated, part of the RNA duties was to complete weekly and monthly weights for every resident in the facility. RNA 1 stated the RNAs' would receive a list of all residents who needed to be weighed monthly and weekly from the MDS nurse. RNA 1 stated, once the weights were completed and recorded on the list provided by the MDS nurse, the completed list was given back to the MDS nurse who would document the weights obtained in the residents EMR. RNA 1 stated there had been no resident refusals for the month of August 2025 and all residents including Resident 1, should have been weighed. RNA 1 stated, if a resident refused to be weighed, it should have been documented on the list and notified the MDS nurse. RNA 1 stated the facility process was for every resident to be weighed on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise.During a concurrent interview and record review on 8/12/25 at 2:51 p.m. with the director of staff development (DSD), Resident 1's document titled, Weights, dated 6/6/25 and Resident 1's electronic medical record (EMR) were reviewed. The document indicated Resident had a documented weight of 130 pounds on 6/6/2025 and no other documented weights since admission. The EMR indicated there was no documentation indicating Resident 1 had refused to be weighed by the RNA. The DSD stated all residents should have been weighed in the facility on admission, 24 hours after admission, weekly for four weeks after admission, then monthly unless the physician orders otherwise. The DSD stated if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DSD stated, based on the lack of documentation indicating Resident 1 had refused to be weighed by the RNA in Resident 1's EMR, there was no way to definitively say if Resident 1 had weight loss or weight gain since admission.During a concurrent telephone interview and record review on 8/12/25 at 2:58 p.m. with the Registered Dietitian (RD), Resident 1's document titled, Weights, dated 6/6/25, and Resident 1's, Nutrition Evaluation, dated 5/18/25 were reviewed. The document weights indicated Resident 1 had a documented weight of 130 pounds on 6/6/2025. The document Weights indicated there were no other documented weights since admission. The evaluation indicated, . At risk for weight fluctuations r/t PO intake, DM, and diuretic therapy. Resident with obesity which can have a negative effect on their health, including but not limited to altered cardiac output, fluid retention, altered blood sugars, ineffective breathing patterns. The RD stated Resident 1's nutrition evaluation was completed on admission and resident was weighed to reflect the current weight status at the time of assessment. The RD stated nutrition assessments were completed every three months and as needed if there were changes. The RD stated the facility process was for the nursing staff to identify any weight loss, meal preference changes or refusal of meals. The RD stated if there was a concern, the nursing staff would notify the dietary supervisor. The RD stated the facility process was for the staff to offer resident alternatives and communicate with the dietary supervisor of the changes in meal consumption. The RD stated if Resident 1 was refusing meals and weight checks, the nursing staff should have documented the occurrences and attempted to trigger an alert for all staff to be made aware that there was a potential problem. The RD stated there was no documentation reflecting refusals of weight checks and meals from the record review at this time. The RD stated the facility process was to identify residents who were experiencing weight loss and include them in the weekly weight committee where residents would be monitored closely to avoid weight changes if possible.During an interview on 8/12/25 at 3:14 p.m. with the dietary services manager (DSM), the DSM stated the facility process was for the nursing staff to monitor Resident 1's meal intake and weight checks. The DSM stated if there was a change in food preferences or changes in meal consumption, it was the nursing department's responsibility to inform the DSM of the changes. The DSM stated she had not received any complaints or reports indicating Resident 1 was refusing meals and losing weight. The DSM stated she was part of the weight loss committee that met on a weekly basis to discuss residents who were at risk for weight fluctuations. The DSM stated Resident 1 was not part of the group of Residents that were being monitored for weight and nutrition concerns. The DSM stated Resident 1 should have been monitored and staff should have documented the refusal of weight checks and meals to incorporate Resident 1 into the weight loss committee to monitor her weight loss closely.During a review of Resident 1's, Nutrition Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] has a diet order. Controlled Carbohydrate Diet (CCD) Soft and Bite sized texture, Thin Liquid consistency, Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight, no signs and symptoms of malnutrition. Interventions: Provide, serve diet as ordered. Monitor intake and record q meal.During a review of Resident 1's, Noncompliance Care Plan, dated 5/16/25, the care plan indicated, . [Resident 1] is resistive to care noncompliant. being weighed r/t adjustment to nursing home. Goal: [Resident 1] needs will be met by staff daily.During an interview on 8/12/25 at 3:37 p.m. with the director of nursing (DON), the DON stated the facility process was for all residents to have been weighed on admission and then monthly, unless the physician ordered residents to be weighed more often. The DON stated Resident 1 should have been weighed as ordered and if Resident 1 had refused to be weighed by staff, the nurse should have documented the refusal in the EMR. The DON stated the problem was the staff were writing the weights on a list provided by the MDS nurse, but the refusals were not being documented in the EMR to reflect the attempts. The DON stated as a result, staff were not aware if Resident 1 had gained or lost weight. The DON stated there should have been progress notes or a documented refusal to alert the staff to monitor Resident 1 closely. The DON stated, moving forward, the facility will be implementing a new system to assist with documenting all weights and refusals by the residents.During a telephone interview on 8/12/25 at 3:43 p.m. with the MDS nurse, the MDS nurse stated the list of residents to be weighed was provided to the RNAs. The MDS nurse stated once the RNA completed the weights, the list would be given back to the MDS nurse to be reviewed. The MDS nurse stated it was the RNA's responsibility to document and inform the nurse of residents' weights and refusals. The MDS nurse stated, once the list of completed weights was reviewed, the list would be discarded, and there were no other paper records for the weights that were completed. The MDS nurse stated it was the nurse's responsibility to ensure weights were documented in the EMR and all refusals were addressed. The MDS nurse stated it was also the nurse's responsibility to document the refusal and attempts to re-weigh the resident. The MDS nurse stated that the monthly weights were reviewed for the month of August 2025, but there were no refusals to be weighed by any resident. The MDS nurse stated she was not aware of Resident 1's refusal to be weighed every month.During a telephone interview on 8/22/25 at 3:30 p.m. with the DON, the DON stated the facility obtained a current weight for Resident 1 on 8/21/25. The DON stated Resident 1's current weight was 108.8 lbs. The DON stated Resident 1 had a physician order for weekly weight checks that was initiated on admission but was not completed. The DON stated Resident 1 had a significant weight loss of 16% from the previous weight checked on 6/6/25 of 21.2 lbs.During a review of the Resident 1's, Diet Order, dated 5/23/25, the order indicated, . Consistent Carbohydrate (CCD) diet soft and bite sized texture, thin liquid consistency.During a review of the document titled, Diet Average Detail Report- Averages for days 1-28), dated 4/18/25, the document indicated, . CCD diet. Protein 91.175 g (gram- unit of measure), and Energy kCal (calories) 2, 066.76 kCal . The document indicated that Resident 1 should have consumed the amount of nutrition listed on a daily average, when Resident 1 consumed 75-100% of all meals.During a review of Resident 1's document titled, Documentation Survey Report-Nutrition- Meal intake, dated 5/2025, 6/2025, 7/2025 and 8/2025. The report indicated the meal intake percentage (0%- Refused meals completely or consumed one or two bites, 25%-a small amount was consumed, 50% approximately half of food is consumed, 75%- Majority of the food is consumed but one or more items are left, 100%- all meal is consumed) for breakfast, lunch and dinner. The document indicated Resident 1 consumed: May 16th-31st 2025: Resident 1 ate 25% or less, approximately 258 calories and 11 grams of protein for 10 meals out of 45 with four of those meals' resident refused. Resident 1 ate 25 to 50% and approximately 775 calories and 34 grams of protein for 17 meals (38% of the time). Resident 1 ate 51 to 75%, approximately 1300 calories and 56 grams of protein for 18 meals (40% of the time). June 1st- 30th 2025: Resident 1 ate 26 to 50% and approximately 775 calories and 34 grams of protein for 48 meals (53% of the month). Resident ate 0 to 25% and approximately 258 calories and 11 grams protein for 9 meals. Resident 1 refused meals 18 times and ate 0 to 25% for 9 meals. Resident 1 ate between 51 to 75%, approximately 1300 calories and 56 grams of protein for 12 meals out of 90 in the month. July 1st- 31st 2025: Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 28 meals in the month or 30% of the time. Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 31 meals in the month or 33% of the time and refused meals 20 times. Resident 1 ate 51 to 75% for 9 meals (9.7% of the time) in the month. August 1st- 31st 2025: Resident 1 refused meals 43 times (46% of the time). Resident 1 ate 0 to 25%, approximately 258 calories and 11 grams of protein for 20 meals (21.5% of the time). Resident 1 ate 26 to 50%, approximately 775 calories and 34 grams of protein for 20 meals in the month of August. Resident 1 ate 51 to 75 % for 5 meals. The document indicated there was no documented meal intake recorded for breakfast on 5/29/25 & 6/4/25, lunch on 5/25/25, 5/29/25, 6/4/25, & 8/9/25, dinner on 7/9/25 & 7/31/25, therefore there was no indication of the nutritional intake Resident 1 received for the undocumented dates. During a record review of the facility's policy and procedure (P&P) titled, Weights, dated 8/28/2020, the P&P indicated, . The Center uses weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention, or diuresis. Weighing Criteria, New Admits, weigh the day of admission then weekly for one month, if weights and nutritional status are stable after one month, weigh the resident monthly. Weekly Weights, the following are guidelines for residents who may need to be weighed weekly (not all inclusive): Food intake has declined and persisted, Slow trending of weight loss/gain. New or altered diuretic schedule (unless physician orders more frequently). Multiple Stage II and any Stage III or IV pressure ulcers. Significant change of condition. Re-weigh. When the Nutrition Hydration Skin Committee or designee reviews the weights, the Committee determines which residents are evaluated. The team or designee reviews the resident's status and makes recommendations. Obtaining and Recording Weights: Weights are obtained by nursing personnel designated by the Director of Nursing Services. The staff member weighing the resident records the weight on the Weight Worksheet. The nurse reviews the current weight and compares it to prior weight on Weight Worksheet. The nurse requests a re-weigh in accordance with the re-weigh definition outlined above. The nurse records validated weights on the Weight Record in the resident's medical record. Licensed nurses will notify physician, resident/responsible party of significant change in weight and document notification in progress notes. Progress note to include responses.During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892745/pdf/nihms156446.pdf, Patterns of Weight Change Preceding Hospitalization for Heart, dated October 2007, indicated, . Increases in body weight are associated with hospitalization for heart failure and begin at least [one] week before admission. Daily information about patients' body weight identifies a high-risk period during which interventions to avert decompensated heart failure that necessitate hospitalization for Heart Failure . Frequent monitoring of heart failure patients' clinical status, specifically their body weights, can alert clinicians to the early stages of heart failure decompensation. By focusing on weight changes, clinicians would be well positioned to implement interventions that could prevent decompensation of heart failure that necessitates hospitalization .During a review of professional reference titled, Practice Paper of the American Dietetic Association, dated 2010, indicated, . In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). During a review of a professional reference publication titled, Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, . The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight .

Based on interview and record review the facility failed to ensure residents' rights to be treated with respect and dignity were followed for one of seven sampled residents (Resident 7), when Resident 7 did not receive scheduled showers on 7/18/25, 7/25/25, and 7/29/25 while in the facility.This failure placed Resident 7 at risk for an undignified existence that could have resulted in poor hygiene and cleanliness.During a review of Resident 7's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnosis for Diabetes Mellitus (DM- increased sugar in the blood), bacterial infections, kidney failure, obesity, muscle weakness, hypertension (high blood pressure), heart failure, bradycardia (slow heart rate).During a review of Resident 7's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/20/2025, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 7 was cognitively intact.During a telephone interview on 8/21/25 at 10:40 a.m. with family member (FM), the FM stated that while Resident 7 resided in the facility, she had only three showers during her stay. FM stated the facility staff was unaware that Resident 7 had not been receiving her weekly showers. During a review of Resident 7's, Shower Schedule, dated 6/25/25, the shower schedule indicated that Resident 7 should have received scheduled weekly showers on Tuesdays and Fridays.During a review of Resident 7's, Certified Nursing Assistant (CNA) Shower Review Forms, dated 7/15/25 and 7/22/25, were reviewed. The forms indicated Resident 7 received a total of two showers for the month of July. The forms indicated Resident 7 had not received a scheduled shower on 7/18/25, 7/25/25, 7/29/25.During an interview on 8/21/25 at 12:54 p.m. with licensed vocational nurse (LVN) 3, LVN 3 stated it was the facility expectations that all showers and baths be completed for all residents on their scheduled date, any deviation from the schedule should have been communicated to the nurse. LVN 3 stated if a resident refused a shower, the expectation was for the CNA to attempt and offer a shower or bed bath throughout the shift in case the resident changed their mind. LVN 3 stated the expectation was to inform the nurse if the resident continued to refuse and for the CNA to document the refusal to alert staff that the resident had not received their shower. LVN 3 stated that the CNAs would document a shower or refusal on the residents' Electronic Medical Record (EMR) and Shower Review Form should have been written, completed and signed by the CNAs and the nurse. LVN 3 stated if the resident requested a different day or time to have a shower, the expectation was for the CNA to document the refusal and request from the resident. LVN 3 stated all residents have the right to a dignified existence that included dressing, grooming and showering.During a concurrent interview and record review on 8/21/25 at 1:12 p.m. with CNA 3, Resident 7's, Point of Care (POC)-Showers, dated 7/1/25-7/31/25, was reviewed. The POC indicated there were no documented refusals or changes in Resident 7's schedule to move showers to a different date, shift or time. CNA 3 stated the facility process was to give all resident showers on the scheduled date, document the shower, refusal to shower or any changes in the schedule on the residents POC. CNA 3 validated Resident 7 had not received a scheduled shower on 7/18/25, 7/25/25 and 7/29/25. CNA 3 stated all residents have the right to shower and live with dignity and respect.During a concurrent interview and record review on 8/21/25 at 1:40 p.m. with the director of staff development (DSD), Resident 7's, CNA Shower Review Forms, dated 7/15/25 and 7/22/25, were reviewed. The forms indicated Resident 7 received a total of two showers for the month of July. The forms indicated Resident 7 had not received a scheduled shower on 7/18/25, 7/25/25, and 7/29/25. The DSD stated the facility expectation was for the CNAs to follow the shower schedule for each resident and to document the showers, baths or refusals on the POC and notify the nurse. The DSD stated it was not acceptable to have a resident refuse a shower and not document it to alert the nurse and other staff. The DSD stated Resident 7 had not received a shower on 7/18/25, 7/25/25 and 7/29/25 after review of all CNA documentation.During an interview on 8/21/25 at 2:12 p.m. with the director of nursing (DON), the DON stated the facility expectation was for all residents to receive their scheduled showers on the scheduled dates. The DON stated if the resident was refusing the showers, the CNA should have alerted the nurse and completed documentation in the POC and on the shower forms. The DON stated, the facility did not have a policy and procedure (P&P) on showers or Activity of Daily Living (ADL).During a review of the facility's policy and procedure (P&P) titled, Notice of Resident Rights, dated 7/2015, the P&P indicated, . Each resident of a skilled nursing facility has the rights. The Center will seek to ensure that those rights are not violated. The Center will establish and implement written policies and procedures that include these rights and will make a copy of these policies available to the Resident, Resident's Representatives, or the public upon request. General rights. To be encouraged and assisted throughout the period of stay to exercise rights as a resident. To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.

Based on interview and record review the facility failed to develop and implement a baseline care plan (included initial goals based on admission orders, physician orders, summary of residents medication, services and treatments to be administered by the facility, and conditions and risks affecting the residents health and safety) within 48 hours of residents admission according to the facility's policy and procedure (P&P) titled, Baseline Care Plan, for one of seven sampled residents (Resident 7) when Resident 7 did not have a baseline care plan for diagnosis and treatment for Chronic Kidney failure (a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), heart failure (condition where the heart muscle cannot pump blood effectively enough to meet the body's needs) and hypertension (condition characterized by persistently elevated blood pressure readings).This failure placed Resident 7 at risk of delay in care and needs going unmet upon admission and during her stay in the facility.During a review of Resident 7's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnosis for Diabetes Mellitus (DM- increased sugar in the blood), bacterial infections, kidney failure, obesity, muscle weakness, hypertension (high blood pressure), heart failure, bradycardia (slow heart rate).During a review of Resident 7's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 5/20/2025, the MDS indicated, Resident 7's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 7 was cognitively intact.During a concurrent interview and record review on 8/21/25 at 11:05 a.m. with the minimum data set (MDS) nurse, Resident 7's electronic medical record (EMR) for care plans was reviewed. The EMR indicated the baseline care plan was not completed for Resident 7. The MDS stated the process was to initiate the baseline care plans on admission to the facility by the admitting nurse. The MDS stated the importance of the baseline care plans was to establish a plan of care based on Resident 7's needs upon admission. The MDS stated it was important to have a plan of care established to ensure all staff were meeting Resident 7's needs.During an interview on 8/21/25 at 12:58 p.m. with licensed vocational nurse (LVN) 4, LVN 4 stated it was the facility process to ensure all care plans were complete and accurate according to the residents' needs. LVN 4 stated it was important to complete a baseline care plan upon admission to ensure all residents' needs were met and to know how to properly care for each individual resident.During an interview on 8/21/25 at 1:40 p.m. with the director of staff development (DSD), the DSD stated the facility process was for the admitting nurse to initiate the baseline care plan upon resident admission. The DSD stated the baseline care should have been completed within 48 hours from admission for Resident 7. The DSD stated that there should have been a care plan initiated for every diagnosis Resident 7 was being admitted to the facility with. The DSD stated it was important to establish a baseline care plan to ensure residents were being treated with the appropriate interventions. The DSD stated every resident was different and had different needs therefore the care plan was used to ensure all resident needs and preferences were met. The DSD stated if there was no baseline care plan created upon admission, there was a risk that the residents needs would not be met and staff would not be aware of the appropriate interventions to assist them.During an interview on 8/21/25 at 2:12 p.m. with the director of nursing (DON), the DON stated there was no expectation for the facility staff to initiate a baseline care plan. The DON stated the baseline care plan should not have included every diagnosis residents had upon admission if the diagnosis was being treated with medications or other services. The DON stated the baseline care plan should have consisted of new diagnosis or changes in condition while in the facility.During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, dated 7/2025, the P&P indicated, .A baseline plan of care (BPOC) is developed and provided to each resident and/or his/her Representative, following admission. The facility develops the baseline plan of care for each resident, within 48 hours of admission. The baseline plan of care includes information regarding care and services sufficient to promote safe delivery of care. The baseline plan of care consists of the following, Physician Orders, Dietary Orders, Therapy Services, Applicable Social Services Intervention, Applicable PASARR Recommendations, Initial Goals.

Based on interview and record review the facility failed to ensure residents' rights to access and obtain medical records was honored for one of four sampled residents (Resident 1), when Resident 1' s representative requested medical records on 1/8/25 and the facility did not provided records within 30-60 days according to their policy and procedure (P&P). This failure resulted in Resident 1's representative not being provided medical records needed and not respecting Resident 1's right to access and obtain medical records. Findings: Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 4/11/2024. During an interview on 4/9/25 at 12:31 p.m. with the director of nursing (DON), the DON stated the facility did not have a medical records director (MRD) since 1/23/2025. The DON stated the facility did not have a medical records assistant or a designated staff member to assist with medical record requests. The DON stated she was not aware of a request for records for Resident 1 and was not informed by the MRD prior to 1/23/25 that a request had been made. The DON stated the former administrator (FADM) had not made her aware of the request for records prior to the ADM 's exit from the facility and therefore the record request was not completed. During a concurrent interview and record review on 4/9/25 at 12:02 p.m. with the DON, the facility ' s form titled, . Authorization For Release Of Health Information, dated 3/2013 was reviewed. The form indicated, . I understand to the extent I am a current resident, I must provide the center with two working days advance notice to make any copies of the records that I would like to pick up at the center . The DON stated this form was to be completed and signed by the person or resident requesting records. The DON stated the facility process for current residents was to provide the requested records within two business days of submitted request. The DON stated she was not aware what the process or timeframe was for resident record requests when the resident was discharged . During an interview on 4/9/25 at 12:17 p.m. with the Administrator (ADM), the ADM stated the facility did not have a MRD. The ADM stated all requests for records submitted to the facility were fulfilled by the ADM or the DON. The ADM stated he was not aware of the record request submitted for Resident 1's records and therefore was not completed following the MRD and FADM's leave from the facility. The ADM stated the expectation was for the facility to provide medical records to the resident or representative within five business days of the request. The ADM stated the facility followed the policy and regulations in place for medical record requests. During a record review of the facility ' s policy and procedure (P&P) titled, Protected Health Information (PHI), Residents ' Rights Relative to, dated 3/2014, the P&P indicated, . Residents have the right to access and copy their protected health information (PHI) and any other information in their medical records maintained/retained by this facility . our facility will act upon a resident ' s request for access to his/her medical records or other information no later than thirty days after receipt of such request, unless the time period is extended as described . if the information to be accessed is not maintained or accessible on premises, our facility will act upon such request within 60 days of receipt of such request. If the facility is unable to act on the request within applicable 30- or 60-day period, the facility may extend the time for response by 30 days, provided that the resident is given a written notice of the reason(s) for the delay and the date by which a responsive action will be taken . During a record review of the facility's P&P titled, Resident Rights, dated 12/2021, the P&P indicated, . Federal and state laws guarantee certain rights to all residents of this facility. The rights include the resident's right to .q. access personal and medical records pertaining to him or herself .

Based on interview and record review the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and was ordered a full liquid diet with nectar thick consistency. This failure resulted in Resident 1 experiencing episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration and death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was severely cognitively impaired. During a review of Resident 1 ' s, Interdisciplinary Team (IDT) post incident meeting, dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room ] to [rule out] aspiration or other complications . During a review of Resident 1 ' s, Situation, background, appearance, review (SBAR), dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1 ' s, Meal tray Ticket, dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1 ' s, Dietary- Diet order, dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 11:46 a.m. with licensed vocational nurse (LVN)1, LVN 1 stated the facility process was for the nurse on shift to check the meal trays before the meals trays were served to the residents. LVN 1 stated the purpose for checking the trays was to ensure the meal tray ticket indicated the ordered resident diet and to ensure the meal matched the ordered diet. LVN 1 stated it was important for all nurses to check the meal trays to prevent any resident from being served the wrong diet or wrong texture. LVN 1 stated the facility expectation was for the facility ' s certified nursing assistant (CNA)s to wait until the nurses checked the meal trays to serve them to the residents. During an interview on 3/18/25 at 12:24 p.m. with CNA 1, CNA 1 stated the facility process was for the nurse on shift to check the meal trays before they were given to the residents. CNA 1 stated it was important for the nurses to check the meal trays to ensure they were for the right resident and their diet. During a concurrent interview and record review on 3/18/24 at 1:10 p.m. with the director of staff development (DSD), Resident 1's diet slip was reviewed. The DSD stated Resident 1 ' s diet slip had the incorrect diet listed. The DSD stated the dietary staff had served Resident 1, a regular diet when Resident 1 had a physician order for a full liquid diet. The DSD stated the facility expectation was for the nurses on shift to print, review and compare the diet order summary to the meal tray ticket and the food being served. The DSD stated all facility staff had been educated on the meal tray ticket process and how to check for inconsistencies to identify any errors prior to serving meal trays to all residents. The DSD it was important to follow the facility process to avoid giving the residents the wrong meal tray and identify mistakes made in the serving process. During an interview on 3/18/24 at 2:00 pm with the director of nursing (DON), the DON stated the facility process was for all nurses on shift to print the diet order summary daily and compare them to the meal trays when they were served from the kitchen prior to CNAs serving them to the residents. During an interview on 3/26/24 at 4:59 p.m. with LVN 2, LVN 2 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 2 stated the facility process was for all nurses on shift to print the diet order summary for all residents and compare them to the meal tray prior to the CNAs serving the trays to the residents. LVN 2 stated, on 2/20/25, the CNAs served all residents in Resident 1 ' s hallway, their meal trays without waiting for the nurses to check the trays. LVN 2 stated the purpose for checking the meal trays was avoid accidently serving the residents the wrong meal tray and to ensure they were receiving the correct diet ordered. During an interview on 3/26/25 at 5:04 p.m. with LVN 3, LVN 3 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 3 stated the facility process was for the nurse on shift to print the diet order summary, check all the diet slips on the meal tray and check each individual tray for accuracy of the diet ordered. LVN 3 stated on 2/20/25, she had noticed the CNAs on shift had served all meal trays in Resident 1 ' s hallway prior to allowing the nurses on shift to check them for accuracy. LVN 2 stated she had provided all CNAs on shift with education on the importance of allowing the nurse to check all meal trays first prior to serving the residents. LVN 3 stated it was important to check each meal tray to prevent accidently serving residents with the wrong diet or to identify allergies. During a review of the facility ' s, Lesson Plan- Basic Nutrition, dated 2/20/25, the lesson plan indicated, . Objective, upon completion of this program the participant will be able to understand basic nutrition needs for residents . [licensed nurse] to ensure diet order matches tray ticket of food being served, [licensed nurse] to print diet order listing report prior to each meal, prior to meals being distributed [licensed nurse] to ensure diet order matches the ticket on the tray and the food on the plate . During a review of the facility ' s policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician ' s or delegated registered or licensed dietitian ' s order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . Based on interview and record review the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and was ordered a full liquid diet with nectar thick consistency. This failure resulted in Resident 1 experiencing episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration and death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was severely cognitively impaired. During a review of Resident 1's, Interdisciplinary Team (IDT) post incident meeting , dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room ] to [rule out] aspiration or other complications . During a review of Resident 1's, Situation, background, appearance, review (SBAR) , dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1's, Meal tray Ticket , dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1's, Dietary- Diet order , dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 11:46 a.m. with licensed vocational nurse (LVN)1, LVN 1 stated the facility process was for the nurse on shift to check the meal trays before the meals trays were served to the residents. LVN 1 stated the purpose for checking the trays was to ensure the meal tray ticket indicated the ordered resident diet and to ensure the meal matched the ordered diet. LVN 1 stated it was important for all nurses to check the meal trays to prevent any resident from being served the wrong diet or wrong texture. LVN 1 stated the facility expectation was for the facility's certified nursing assistant (CNA)s to wait until the nurses checked the meal trays to serve them to the residents. During an interview on 3/18/25 at 12:24 p.m. with CNA 1, CNA 1 stated the facility process was for the nurse on shift to check the meal trays before they were given to the residents. CNA 1 stated it was important for the nurses to check the meal trays to ensure they were for the right resident and their diet. During a concurrent interview and record review on 3/18/24 at 1:10 p.m. with the director of staff development (DSD), Resident 1's diet slip was reviewed. The DSD stated Resident 1's diet slip had the incorrect diet listed. The DSD stated the dietary staff had served Resident 1, a regular diet when Resident 1 had a physician order for a full liquid diet. The DSD stated the facility expectation was for the nurses on shift to print, review and compare the diet order summary to the meal tray ticket and the food being served. The DSD stated all facility staff had been educated on the meal tray ticket process and how to check for inconsistencies to identify any errors prior to serving meal trays to all residents. The DSD it was important to follow the facility process to avoid giving the residents the wrong meal tray and identify mistakes made in the serving process. During an interview on 3/18/24 at 2:00 pm with the director of nursing (DON), the DON stated the facility process was for all nurses on shift to print the diet order summary daily and compare them to the meal trays when they were served from the kitchen prior to CNAs serving them to the residents. During an interview on 3/26/24 at 4:59 p.m. with LVN 2, LVN 2 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 2 stated the facility process was for all nurses on shift to print the diet order summary for all residents and compare them to the meal tray prior to the CNAs serving the trays to the residents. LVN 2 stated, on 2/20/25, the CNAs served all residents in Resident 1's hallway, their meal trays without waiting for the nurses to check the trays. LVN 2 stated the purpose for checking the meal trays was avoid accidently serving the residents the wrong meal tray and to ensure they were receiving the correct diet ordered. During an interview on 3/26/25 at 5:04 p.m. with LVN 3, LVN 3 stated on 2/20/25 while working her shift, there was an incident regarding Resident 1 receiving the incorrect meal tray. LVN 3 stated the facility process was for the nurse on shift to print the diet order summary, check all the diet slips on the meal tray and check each individual tray for accuracy of the diet ordered. LVN 3 stated on 2/20/25, she had noticed the CNAs on shift had served all meal trays in Resident 1's hallway prior to allowing the nurses on shift to check them for accuracy. LVN 2 stated she had provided all CNAs on shift with education on the importance of allowing the nurse to check all meal trays first prior to serving the residents. LVN 3 stated it was important to check each meal tray to prevent accidently serving residents with the wrong diet or to identify allergies. During a review of the facility's, Lesson Plan- Basic Nutrition , dated 2/20/25, the lesson plan indicated, . Objective, upon completion of this program the participant will be able to understand basic nutrition needs for residents . [licensed nurse] to ensure diet order matches tray ticket of food being served, [licensed nurse] to print diet order listing report prior to each meal, prior to meals being distributed [licensed nurse] to ensure diet order matches the ticket on the tray and the food on the plate . During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets , dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietitian's order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care .

Based on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and had physician orders for a full liquid diet with nectar thick consistency (liquid slightly thicker than water). This failure resulted in Resident 1 experiencing an episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration, and death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 ' s cognition was severely impaired. During a review of Resident 1 ' s, Interdisciplinary Team (IDT) post incident meeting, dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room ] to [rule out] aspiration or other complications . During a review of Resident 1 ' s, Situation, background, appearance, review (SBAR), dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1 ' s, Meal tray Ticket, dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1 ' s, Dietary- Diet order, dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 1:10 p.m. with the director of staff development (DSD), the DSD stated the process for meal trays began in the facility kitchen where the dietary cook would have been the first to see the meal tray ticket, then continued with the dietary aid, the nurse in charge and finally the CNA serving the tray to the resident. The DSD stated the meal tray ticket indicated Resident 1 had an order for a regular diet and the food listed was for regular food. The DSD stated the meal tray ticket had the full liquid diet printed in small letters under the Regular diet, but was missed by all staff due to the printing error. The DSD stated it was important for all staff who were serving meal trays, to check the meal tray tickets and orders to prevent accidents of residents being served the wrong meal tray. During a telephone interview on 3/26/25 at 3:51 p.m. with the certified dietary manager (CDM), the CDM stated there was an incident that had occurred with Resident 1 on 2/20/25 in which Resident 1 was served the incorrect diet tray during dinner. The CDM stated there was an error in the facility ' s meal tracking system used for resident diets. The CDM stated the meal tray ticket was printed with the incorrect diet ordered but once they found out about the mistake, the correct diet order was added to the system. The CDM stated the meal tray ticket indicated a regular diet but Resident 1 ' s physician ordered diet was for a full liquid diet which had also been printed in the same meal tray ticket. The CDM stated the process was for the dietary cooks to recheck the meal tray ticket to ensure the correct texture and amount of food was correct. During a telephone interview on 3/27/25 at 10:07 a.m. with cook 1 (CK 1), CK 1 stated she could not recall the incident that occurred on 2/20/25 involving Resident 1. CK 1 stated she could not recall the meal tray ticket used to serve Resident 1 ' s meal tray. CK 1 stated the process was for the CDM to print the meal tray tickets for the day and to have them ready before meals for the staff in the kitchen. CK 1 stated the process was to look at the diet listed on the top of the meal tray ticket and then look at the bottom of the ticket to begin serving the meal ordered. CK 1 stated the incident should not have happened as the meal tray tickets should have been completed and was accurate prior to serving Resident 1 ' s meal. During a review of the facility ' s policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician ' s or delegated registered or licensed dietitian ' s order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care . Based on interview and record review the facility failed to ensure therapeutic diets were followed according to physician orders for one of five sampled residents (Resident 1) when on 2/20/25, Resident 1 was served a meal tray with a regular consistency (diet with no alterations) and had physician orders for a full liquid diet with nectar thick consistency (liquid slightly thicker than water). This failure resulted in Resident 1 experiencing an episode of coughing and emesis (vomit) and had the potential to cause choking, aspiration, and death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for acute respiratory failure (lungs are unable to get enough oxygen), shortness of breath (difficult or labored breathing), dementia (disorder that causes decline in ability to think, memory and judgment), altered mental status (change in mental function). During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) dated 2/24/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- screening tool used to assess resident cognitive level) score was 0 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1's cognition was severely impaired. During a review of Resident 1's, Interdisciplinary Team (IDT) post incident meeting , dated 2/24/25, the IDT indicated, . Resident is dependent with [activities of daily living] and requires assistance with meals . on 2/20/25 the [charge nurse] noted resident was sitting upright in bed, eating his meal and was noted to have difficulty swallowing with cough. [charge nurse] noted resident was able to spit out food content from mouth with verbal cues preventing chocking incident. [charge nurse] also noted that resident had a small emesis (vomit) of undigested food post coughing episode. No respiratory distress, no decline in [oxygen] saturation, no loss of consciousness during or after episode. Resident recovered rapidly and spontaneously without medical intervention needed. as a precautionary measure resident was sent to [emergency room ] to [rule out] aspiration or other complications . During a review of Resident 1's, Situation, background, appearance, review (SBAR) , dated 2/20/25, the SBAR indicated, . Resident received dinner tray that was incorrect from his diet order. No signs and symptoms (s/sx) of respiratory or abdominal distress. Vital signs(VS) within normal limits. [physician] notified . During a review of Resident 1's, Meal tray Ticket , dated 2/19/24, the meal tray ticket indicated, . [Resident 1] Regular, mildly thick, full liquids . Italian sausage sub w/pepper and onion- 1 sandwich, French fries . capri vegetable blend . tropical fruit salad . milk mildly thick . During a review of Resident 1's, Dietary- Diet order , dated 2/19/25, the order indicated, . Full liquid diet full liquid texture, nectar thick consistency, for as tolerated . During an interview on 3/18/25 at 1:10 p.m. with the director of staff development (DSD), the DSD stated the process for meal trays began in the facility kitchen where the dietary cook would have been the first to see the meal tray ticket, then continued with the dietary aid, the nurse in charge and finally the CNA serving the tray to the resident. The DSD stated the meal tray ticket indicated Resident 1 had an order for a regular diet and the food listed was for regular food. The DSD stated the meal tray ticket had the full liquid diet printed in small letters under the Regular diet, but was missed by all staff due to the printing error. The DSD stated it was important for all staff who were serving meal trays, to check the meal tray tickets and orders to prevent accidents of residents being served the wrong meal tray. During a telephone interview on 3/26/25 at 3:51 p.m. with the certified dietary manager (CDM), the CDM stated there was an incident that had occurred with Resident 1 on 2/20/25 in which Resident 1 was served the incorrect diet tray during dinner. The CDM stated there was an error in the facility's meal tracking system used for resident diets. The CDM stated the meal tray ticket was printed with the incorrect diet ordered but once they found out about the mistake, the correct diet order was added to the system. The CDM stated the meal tray ticket indicated a regular diet but Resident 1's physician ordered diet was for a full liquid diet which had also been printed in the same meal tray ticket. The CDM stated the process was for the dietary cooks to recheck the meal tray ticket to ensure the correct texture and amount of food was correct. During a telephone interview on 3/27/25 at 10:07 a.m. with cook 1 (CK 1), CK 1 stated she could not recall the incident that occurred on 2/20/25 involving Resident 1. CK 1 stated she could not recall the meal tray ticket used to serve Resident 1's meal tray. CK 1 stated the process was for the CDM to print the meal tray tickets for the day and to have them ready before meals for the staff in the kitchen. CK 1 stated the process was to look at the diet listed on the top of the meal tray ticket and then look at the bottom of the ticket to begin serving the meal ordered. CK 1 stated the incident should not have happened as the meal tray tickets should have been completed and was accurate prior to serving Resident 1's meal. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets , dated 10/2022, the P&P indicated, . All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines . therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet . to provide food that a resident is able to eat . mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietitian's order . diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care .

Based on interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three residents, (Resident 1), when Resident 1 was admitted on [DATE] with history of abnormalities of gait and mobility, assessed with severe cognitive impairment and the need for assistance with mobility, and experienced falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24 and did not provide supervision and effective interventions to prevent falls in accordance with policies and procedures and professional standards of practice. These failures failure resulted in Resident 1 obtaining an acute, mildly displaced left intertrochanteric and subtrochanteric fractures (type of break in the bones near the hip) following the 11/15/24 fall and causing Resident 1 to undergo open reduction and external fixation (ORIF- surgical procedure that treats broken bones by inserting implants), avoidable pain and suffering, hospitalization from [DATE]-[DATE] and ongoing physical therapy (PT) to regain strength and balance. Findings : During a review of Resident 1's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for syncope (fainting), repeated falls, orthostatic hypotension (low blood pressure that occurs when standing or sitting), Parkinson ' s disease (disorder that causes nerve cells in the brain to weaken or die), abnormalities of gait (walking) & mobility , bradycardia (slow heart beat), dizziness, muscle weakness, gout (causes joint pain and swelling due to uric acid build up), mood disorder, shortness of breath, hyperuricemia (condition of too much uric acid in the blood), hypertension (high blood pressure), cerebral aneurysm (a bulge in a blood vessel in the brain), arthritis (painful inflammation and stiffness of the joints). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/11/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 4 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s document titled, Incident by Incident Type- Falls, dated 12/4/24, the document indicated, Resident 1 had documented falls on 11/7/24, 11/8/24, 11/11/24, 11/14/24 and 11/15/24. During a record review of Resident 1 ' s, Fall Care Plan, dated 11/7/24, the CP indicated, .At risk for fall or injury due to impaired balance, weakness, orthostatic hypotension . During a record review of Resident 1 ' s, Fall Risk Evaluation, dated 11/8/24, the record indicated, Resident 1 had a documented fall risk score of 31 (a score 10 or higher indicates high risk for falls). During a record review of Resident 1 ' s Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident ' s care) Post Fall Meeting, dated 11/8/24, the record indicated, . Resident had two unwitnessed falls that occurred on 11/8/2024 at approximately 2134 (9:34 p.m.) and 0440 (4:40 a.m.) . IDT recommendations fall mat to right side of bed- room change closer to nursing station for visibility- placed of fall program 11/8 . During a record review of Resident 1 ' s, Behavior Care Plan (CP), dated 11/8/24, the CP indicated, . behavior symptoms, non-compliance continuously removing brief, impulsive behavior continuously attempting to self-transfer, crawling out of bed and preferring to lay on floor . During a record review of Resident 1 ' s, Functional abilities section-GG, dated 11/11/24, the record indicated, Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting, dressing, lying/sitting on side of bed, sit to stand and transfers wheelchair/bed. During a record review of Resident 1 ' s, IDT Post Fall Meeting, dated 11/14/24, the record indicated, . Resident had a witnessed fall that occurred 11/14/24 . continue with 30-minute checks, staff to assist resident with toileting after meals and at bedtime. Continue on fall program . During a review of Resident 1 ' s, Fall Care Plan, dated 11/14/24, the record indicated, . witnessed fall on 11/14/24 . interventions, 1 on 1 (staff member assigned to care for resident at all times) staff observation . During a record review of Resident 1 ' s, Post Fall Risk Evaluation, dated 11/14/24, the record indicated Resident 1 ' s fall risk score was 26 (Score 10 or higher indicated the resident is at high risk of fall). During a record review of Resident 1 ' s Clinical Alert, dated 11/15/24, the record indicated, CNA come at 7:30 a.m. went to the nurse got report what patient was on 1 on 1 CNA went to the doorway and saw the patient getting up and witness the patient fall . During a record review of Resident 1 ' s, Nurses Note, dated 11/15/24, the note indicated, . Resident was attempting to sit on her wheelchair when she slipped and fall hitting her head on the wall as per the CNA that witnessed the fall. Resident helped off the floor to the bed. An assessment was done with no visible cut to the head . Resident later transferred to the hospital . During a record review of Resident 1 ' s, Post Fall Risk Evaluation, dated 11/15/24, the record indicated Resident 1 ' s fall risk score was 17 (Score 10 or higher indicated the resident is at high risk of fall). During a record review of Resident 1 ' s, Emergency department Results, dated 11/15/24, the record indicated, . there is an acute, mildly displaced left intertrochanteric and subtrochanteric fractures . During a review of Resident 1 ' s, Emergency Department Note, dated 11/15/24, the note indicated, . brought in by ambulance (BIBA) from [facility name] for fall. Patient got up to use the restroom using her walker and tripped fell to left side striking left side of head. Patient main complaint is left leg pain . During a review of Resident 1 ' s, Operative Report, dated 11/16/24, the report indicated, . procedure performed open treatment of left intertrochanteric femur fracture with cephalomedullary nailing (form of fixation that restores length, alignment and rotation of the femur) . During a review of Resident 1 ' s, Orthopedic Trauma Progress Note, dated 11/17/24, the note indicated, . post operation day 1 status post left hip ORIF. Plan weight bearing as tolerated to left lower extremity, physical therapy and occupational therapy evaluation and treatment . During an interview on 12/4/24 at 1:04 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated the facility process was for residents who had two or more falls within a 24-hour period, would have been placed on one -to-one care until further notice. CNA 1 stated the purpose of the one-to-one care was to prevent falls and to keep the residents safe. CNA 1 stated when a resident was assigned a one-on-one care, it indicated a staff member was expected to be with the resident at all times. During an interview on 12/4/24 at 1:15 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated it was the facility process to assign one to one care for residents who had two or more falls in a 24-hour period. LVN 1 stated the one-on-one care was implemented to prevent further falls and for resident safety. During a concurrent interview and record review on 12/4/24 at 2:03 p.m. with the director of nursing (DON), Resident 1 ' s, Fall Care Plan, dated 11/14/24 was reviewed. The Fall Care Plan indicated, . Witnessed fall on 11/14/24 . interventions, 1 on 1 staff observation . The DON stated on 11/14/24, Resident 1 was assigned a one-to-one care that began on the afternoon shift from 2 p.m. to 10:30 p.m. The DON stated on the night shift of 11/14/24-11-15/24 from 10:30 p.m. to 7:30 p.m., there was no staff assigned for one-on-one care for Resident 1 until 7:30 a.m. on 11/15/24. The DON stated Resident 1 had a fall on 11/15/24 during shift change at 7:30 a.m. when the night shift staff left and the morning staff began their shift. The DON stated Resident 1 was confused, non-compliant with care and had behaviors that included attempting to get out of bed without assistance. The DON stated Resident 1 had a total of five falls in the facility since admission. The DON stated the facility process was for residents to be put on one-to-one care when the resident had two or more falls in 24-hour period. The DON stated, a staff sould have been assigned 1:1 care to monitor Resident 1 and prevent an avoidable fall on 11/15/2024. During a telephone interview on 12/5/24 at 12:40 p.m. with LVN 4, LVN 4 stated on 11/14/24, Resident 1 was supposed to have a staff member assigned to a one on one care. LVN 4 stated, Resident 1 did not have a staff member assigned prior to Resident 1 ' s fall on 11/15/24. LVN 4 stated the facility process was for a resident who had two or more falls in a 24-hour period, be assigned a staff member for one-to-one care. LVN 2 stated according to the facility policy, Resident 1 should have had a staff member assigned for one on one due to multiple falls and had behaviors that included attempting to self transfer and noncompliance with asking for assistance. LVN 4 stated Resident 1, should have had a staff member present during an avoidable fall that occurred on 11/15/24. During a telephone interview on 12/10/24 at 10:45 a.m. with family member (FM 1), FM 1 stated Resident 1 was able to complete all task while at home including walking and transferring prior to admitting to the facility. FM 1 stated it was not normal for Resident 1 to have had five falls in the facility as Resident 1 was only in the facility for short term rehabilitation. During an interview on 12/11/24 at 10:55 a.m. with registered nurse (RN) 1, RN 1 stated the facility process was for residents with or more falls in 24 hours to have been placed on one-to-one care. RN 1 stated that the process was to inform the DON of all falls and the DON determined when a resident was placed on one-to-one care, 30-minute monitoring or 15-minute monitoring. RN 1 stated apart from the DON, the charge nurse and nurse assigned to resident could have assigned a one-on-one care as needed for the Resident 1's safety. During an interview on 12/11/24 at 11:11 a.m. with LVN 3, LVN 3 stated the facility process for falls was for residents who experience two or more falls in 24 hours be placed on one-on-one care. LVN 3 stated the process was to inform the DON of all falls and the DON would decide who and when would be placed on one-to-one care. LVN 3 stated the one-to-one care could have benefited residents by preventing falls and ensuring safety. During an interview on 12/11/24 at 11:34 a.m. with the administrator (ADM), the ADM stated there was a new fall program implemented for the facility that included revision of the policy. The ADM stated it was the facility expectation for all staff to follow the new implementations related to falls. During a telephone interview on 12/18/24 at 9:01 a.m. with CNA 2, CNA 2 stated that on the morning of 11/15/24, she was called to the facility for a 1 on 1 care for Resident 1. CNA 2 stated she had arrived to the facility between 7:30 a.m. and 8:00 a.m., when CNA 2 arrived she reported to LVN 4 for report and update on Resident 1. CNA 2 stated the morning shift had begun at 6:00 a.m. that morning and when she arrived there was no one assigned to Resident 1. CNA 2 stated after receiving report from LVN 4, she entered Resident 1 ' s room and observed Resident 1 standing and then falling to the floor. CNA 2 stated Resident 1 had behaviors of transferring without assistance, noncompliance and attempting to walk without supervision. CNA 2 stated, Resident 1 ' s fall would have been avoidable if there was a staff member present for 1 on 1 care as assigned. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 11/2024, the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The facility recognizes frequent falling to be 2 falls in 30 days. If a resident falls 2 or more times within 24 hours they will be placed one on one supervision for 72 hours and will be reevaluated by IDT for further interventions, if needed .

Based on interview and record review the facility failed to ensure residents were free of significant medication error for one of four sampled residents (Resident 1), when Resident 1 was administered the Insulin (a hormone that helps regulate blood sugar level) without a physician order and diagnosis. This failure had the potential to result in Resident 1 experiencing a hypoglycemic event (occurs when the body ' s sugar levels drop too low) causing trembling or shaking, weakness, sweating or chills, dizziness or lightheadedness, confusion or trouble concentrating, irritability, tingling or numbness of the lips, tongue or cheeks and had the potential to result in death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for syncope (fainting), repeated falls, orthostatic hypotension (low blood pressure that occurs when standing or sitting), Parkinson ' s disease (disorder that causes nerve cells in the brain to weaken or die), abnormalities of gait (walking) & mobility, bradycardia (slow heart beat), dizziness, muscle weakness, gout (causes joint pain and swelling due to uric acid build up), mood disorder, shortness of breath, hyperuricemia (condition of too much uric acid in the blood), hypertension (high blood pressure), cerebral aneurysm (a bulge filled with blood in the brain), arthritis (painful inflammation and stiffness of the joints). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 11/11/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 4 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During an interview on 12/4/24 at 1:44 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated it was important to accurately document physician orders to avoid administration of the wrong medication to the wrong resident. LVN 1 stated Resident 1 had a potential for harm when the medication for insulin was administered. During a concurrent interview and record review on 12/4/24 at 2:03 p.m. with the director of nursing (DON), Resident 1 ' s, Physician Order (PO), dated 11/10/24, and Medication Administration Record (MAR), dated 11/2024 were reviewed. The PO indicated, . Insulin Lispro injection solution . inject 5 unit (unit of measure) subcutaneously (beneath the skin) before meals for hyperglycemia (high blood sugar) . The MAR indicated, Resident was administered insulin lispro (type of insulin) on 11/10/24. The DON stated Resident was administered insulin medication on 11/10/24 as a result of a medication error. The DON stated on 11/11/24, LVN 3 received a PO for another resident in the facility for insulin. The DON stated LVN 3 incorrectly documented the PO on Resident 1 ' s electronic medical record (EMR). The DON stated LVN 3 identified the medication error the next morning on 11/11/24 and contacted the physician. The DON stated Resident 1 was placed on 72 hour monitoring for signs and symptoms of low blood sugar and any side effects resulting from the medication error. The DON stated Resident 1 ' s blood sugar was monitored every four hours for one day. During a record review of Resident 1 ' s, PO, dated 11/10/24, the PO indicated, . Insulin Lispro injection solution . inject 5 unit (unit of measure) subcutaneously (beneath the skin) before meals for hyperglycemia (high blood sugar) . During a record review of Resident 1 ' s, Medication Administration Record (MAR), dated 11/2024, the record indicated, Resident was administered medication (insulin lispro) on 11/10/24. During a review of Resident 1 ' s, MAR-fasting blood sugar, dated 11/24, the MAR indicated, . fasting blood sugar (FSBS) every four hours for one day . The MAR indicated Resident 1 ' s blood sugar was checked from 11/11/24-11/12/24. During concurrent telephone interview and record review on 12/5/24 at 12:40 p.m. with LVN 3, LVN 3 stated she had documented the incorrect PO on Resident 1 ' s EMR. LVN 3 stated she had identified the medication error when she arrived the next morning on 11/11/24. LVN 3 stated she contacted the physician to report the medication error and physician gave new order for blood sugar check every four hours for one day. LVN 3 stated Resident 1 did not have a history of diabetes and was not receiving blood sugar checks prior to medication error. LVN 3 stated when Resident 1 was administered the medication (insulin lispro) in error, there was a possibility of hypoglycemia (low blood sugar) and death. During an interview on 12/11/24 at 10:55 a.m. with registered nurse (RN) 1, RN 1 stated it was important to ensure the right medication was administered to the right resident. RN 1 stated when Resident 1 was administered the incorrect medication (insulin lispro) there was a risk for hypoglycemia. During an interview on 12/11/24 at 11:11 a.m. with LVN 4, LVN 4 stated the expectation was to ensure the right medication was administered to the right resident. LVN 4 stated, when Resident 1 received incorrect medication (insulin lispro), there was potential for hypoglycemia or death. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services . During a review of the facility ' s P&P titled, Adverse Consequences and Medication Errors, dated 4/2014, the P&P indicated, . The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate . Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported . An adverse drug reaction (ADR), a form of adverse consequences, is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of the drug . A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services . Examples of medications errors include . unauthorized drug - a drug is administered without a physician's order .

Based on observation interview and record review, the facility failed to ensure residents were free from abuse and neglect for one of three sampled residents (Resident 2) when Resident 2 did not receive assistance to go to the restroom and was told by CNA 1 to soil herself while in bed. This failure resulted in Resident 2 feeling humiliated and neglected by CNA 1 when Resident 2 held her urine until her stomach was in pain and urinated on herself. Findings: During a concurrent observation and interview on 10/25/24 at 11:00 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was observed communicating using a notepad. Resident 1 stated that on the night of 10/14/24, Resident 2 asked certified nursing assistant (CNA) 1 for assistance to the restroom. Resident 1 stated CNA 1 told Resident 2, to wet her brief in bed because CNA 1 did not have time to take her to the restroom. Resident 1 stated Resident 2 was a nice person and heard Resident 2 tell CNA 1 that she was sorry, she would try harder and be a better resident. Resident 1 stated she felt angry and helpless because of the incident. During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/5/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia (mental disorder with loss of reasoning, thinking and remembering), muscle weakness, abnormalities of gait (walking) and mobility, urinary calculi (hard masses that form in the urinary tract), falls . During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 8 out of 15 which indicated Resident 2 had moderate cognitive impairment. During an observation on 10/25/24 at 11:02 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 was observed assisted to the restroom by CNA 2. During an interview on 10/25/24 at 11:17 a.m. with Resident 2, Resident 2 stated she recalled that during the night she had requested to go to the restroom. Resident 2 stated she was told by the staff member to wet her bed because the staff member was not going to assist her to the restroom. Resident 2 stated she held the urge to urinate because she could not soil herself and laid in bed until her stomach hurt and was forced to urinate on her bed. Resident 2 stated she felt demeaned, humiliated and felt like she was wrong for wanting assistance to the restroom. Resident 2 stated she told the staff member that she was sorry, I know I could do better. During an interview on 10/25/24 at 11:22 a.m. with CNA 2, CNA 2 stated Resident 2 was continent of bowel and bladder and would use the restroom as needed. CNA 2 stated Resident 2 would stand, pivot and transfer to the restroom and to bed without any issues and requiring one-person moderate assistance. CNA 2 stated it was the facility expectation that assigned staff would assist residents when they requested to go to the restroom. CNA 2 stated it was not acceptable for a staff member to refuse to assist Resident 2 to the restroom. During a review of Resident 2 ' s, Activities of Daily Living (ADL) care plan (CP), dated 10/8/24, the CP indicated, . requires assistance with ADLs . call light within reach and answered promptly . transfers partial to moderate assist . During an interview on 10/25/24 at 11:39 a.m. with CNA 3, CNA 3 stated it was the facility ' s expectation for CNAs to assist residents with care, especially residents such as Resident 2 who used the restroom. CNA 3 stated it was important to maintain the resident ' s ability to transfer and use the restroom to keep residents from declining in physical function. CNA 3 stated, when CNA 1 refused to assist Resident 2 to the restroom, it was a form of neglect. During an interview on 10/25/24 at 11:47 a.m. with CNA 4, CNA 4 stated it was the facility expectation that staff assist all residents in the facility. CNA 4 stated staff could not refuse to assist a continent resident, such as Resident 2, to the restroom because it was the residents right. CNA 4 stated it was considered neglect, when CNA 1 refused to assist Resident 2 to the restroom. CNA 4 stated Resident 2 was put at risk for falls, and episodes of incontinence when she was not assisted. During an interview on 10/25/24 at 12:05 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was the facility expectation for staff to assist residents to the restroom if they are continent. LVN 1 stated it was not acceptable for any staff members to refuse to assist residents to the restroom and ask them to soil themselves. LVN 1 stated it as considered neglect when CNA 1 refused to assist Resident 2 to the restroom. LVN 1 stated Resident 2 was at risk for urinary tract infection, pain and falls when not assisted to the restroom. During an interview on 10/25/24 at 12:27 p.m. with the Director of Staff Development (DSD), the DSD stated it was the facility ' s expectation for staff to assist all residents with their needs. The DSD stated it was considered neglect and abuse when CNA 1 did not assist Resident 2 to the restroom. During an interview on 10/25/24 at 1:06 p.m. with the administrator (ADM), the ADM stated it was the facility ' s expectation that all staff will ensure residents were safe. The ADM stated CNA 1 had been removed from the facility and no longer working pending investigation. The ADM stated the facility was ensuring all residents were safe and free from abuse. During a telephone interview on 10/30/24 at 9:57 a.m. with CNA 1, CNA 1 stated she was no longer employed by the facility following incident on 10/14/24. CNA 1 stated she could not recall any incident involving residents the night of 10/14/24 and did not recall refusing to take any resident to the restroom. CNA 1 stated during her employment in the facility she was in serviced and trained on abuse and neglect. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, neglect, exploitation and misappropriation prevention program dated 2/2021, the P&P indicated, . Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but.is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to, facility staff, other residents . During a review of the facility ' s P&P titled, Resident Rights, dated 2/2021, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . free from abuse, neglect, misappropriation of property, and exploitation .

Based on interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents according to the facility' s policy and procedure (P&P) for one of three sampled residents (Resident 1), when the facility had knowledge of Resident 1' s history of falls and Parkinson's disease (brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) on admission and did not provide interventions and supervision to prevent an unwitnessed fall with injury on [DATE] and an unwitnessed fall with injury on [DATE]. These failures resulted in Resident 1 sustaining injuries including dislocation (move from its proper place or position) of the fifth finger of the left hand , Right posterior (back) parafalcine subdural hematoma (collection of blood or bleeding that forms between the brain ' s surface and the covering that occurs after a head injury) a collection of blood), laceration (tearing) to the posterior head and intracranial bleed (bleeding within the skull) with hospitalization in the intensive care unit due to a traumatic brain injury (injury caused by force) and could have contributed to Resident 1's death on [DATE]. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis for . abnormalities of gait (walking) and mobility (movement), muscle weakness, encephalopathy (damage or disease that affects the brain), history of falling, Parkinson ' s disease , sleep apnea (disorder that causes your breathing to stop or get very shallow), hypertension (condition in which the blood vessels have persistently raised pressure) . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] ,d+[DATE] moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment. During a record review of Resident 1 ' s Fall Risk Evaluation dated [DATE], the assessment indicated, . If the total score is 10 or greater, the resident should be considered at High risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . The evaluation indicated Resident 1 ' s fall risk score was 21. During a review of Resident 1 ' s At risk for Falls Care plan (CP) dated [DATE], the CP indicated, . At risk for fall or injury due to impaired balance, impaired mobility, impaired safety awareness, weakness . assist with activities of daily living (ADL) and mobility needs, ongoing as needed . Fall assessment to be completed on admission, quarterly and as needed, low bed . During a review of Resident 1 ' s Nursing Note dated [DATE], the nursing note indicated, . Patient continues to climb out of bed, refusing to listen to being redirected. Patient appears to be agitated and saying he wants to go home and will go home . During a record review of Resident 1's Nursing Note dated [DATE], the nursing note indicated, .At 0235 (2:35 a.m.) the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . During a concurrent interview and record review on [DATE] at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Nursing Note dated [DATE], was reviewed. The nursing note indicated, .At 0235 the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . LVN 1 stated Resident 1 had an unwitnessed fall on [DATE] causing a dislocation of the left-hand pinky. LVN 1 stated there was no other documentation regarding the fall on [DATE]. LVN 1 stated it was the facility process to document a change of condition, complete a skin assessment and initiate neuro checks for an unwitnessed fall. During a review of Resident 1 ' s Fall Care Plan dated [DATE], the CP indicated, . Fall on [DATE] with injury due to poor safety awareness, non-compliance as evidenced by continuously self-ambulating (walking) without calling for assistance . interventions, neuro-checks every shift for 72 hours from initial occurrence . placed in fall program . The care plan indicated the facility staff did not implement the intervention for neuro checks following Resident 1 ' s fall on [DATE] as documented in the care plan. During a review of Resident 1 ' s Fall Program Care Plan dated [DATE], the CP indicated, . Fall program . blue bracelet, blue fall intervention sign above the head of bed, blue name sign by the door, Non-skid footwear, low bed . During a review of Resident 1 ' s Interdisciplinary Team Note (IDT- team that consists of various staff that are involved with resident ' s care), dated [DATE], the note indicated, . Resident has had episodes of confusion after wife has gone home including non-compliance with care, impulsivity as evidenced by self-transferring and ambulation (walking) without assistance and making false accusations towards staff since admission . During a review of Resident 1 ' s Order Summary Report, dated [DATE], the order summary indicated, . Fall interventions in place: nonskid footwear, low bed every shift . The order summary indicated the facility staff did not implement intervention for nonskid footwear and low bed until three days after the creation of the fall care plan. During a review of Resident 1 ' s Nursing Note dated [DATE], the note indicated, . resident had unwitnessed fall . resident has left side head injury. Pressure applied to the injury. Medical doctor (MD) notified and received order to send to hospital . During an interview on [DATE] at 12:08 p.m. with LVN 2, LVN 2 stated the facility process was to identify residents were a fall risk upon admission and initiate fall precautions, which included bed in low position, non-slip socks and frequent monitoring. Resident 1 ' s fall program was not initiated until 11 days after admission to the facility. LVN 2 stated the facility process for falls was for the charge nurse (CN) to assess the resident for injury, initiate neurological checks, complete a post fall assessment, change of condition assessment, and monitor resident for delayed injury for 72 hours. LVN 2 stated when Resident 1 was exhibiting behaviors that included attempting to self-transfer or ambulating without assistance, it was expected that a 15-minute monitoring would have been initiated or a staff member assigned to monitor Resident 1, but there was no order for these interventions. LVN 2 stated there were interventions that could have been initiated that included floor mats next to bed, redirecting Resident 1 by providing activities or talking, taking Resident 1 to the nurse ' s station for supervision and a one on one for safety. During an interview on [DATE] at 12: 21 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was confused, attempted to self-transfer, unable to use his call light and difficult to re-direct. CNA 1 stated that Resident 1 ' s spouse would visit with Resident 1 approximately ,d+[DATE] hours a day and during this time, Resident 1 ' s spouse alerted staff if Resident needed assistance. CNA 1 stated when Resident 1 ' s spouse was in the facility, Resident 1 was calm with no behaviors. CNA 1 stated that when Resident 1 ' s spouse would leave the facility, Resident 1 would exhibit behaviors. CNA 1 stated it would have been beneficial for Resident 1 to have been assigned a one-on-one staff member for his safety. CNA 1 stated it was important to monitor all residents who are a high risk for falls and who exhibit behaviors such as Resident 1, to ensure they are not falling or injuring themselves. During an interview on [DATE] at 12:28 p.m. with CNA 2, CNA 2 stated Resident 1 was confused, unsteady when attempting to stand or walk and at risk for falls. CNA 2 stated that when she was assigned Resident 1, she was afraid he was going to fall due to behaviors of self-transferring and unsteadiness. CNA 2 stated, Resident 1 was wheeled to sit with CNA 2 during most of the morning shift to monitor Resident 1. CNA 2 stated it would have been beneficial for Resident 1 to have had a one-on-one staff member after Resident 1 ' s spouse left the facility, to monitor Resident 1 for his safety. CNA 2 stated it was important to monitor Resident 1 because he had a history of falls. During a concurrent interview and record review on [DATE] at 12:31 p.m. with the Director of Nursing (DON), Resident 1 ' s Fall Risk Evaluation dated [DATE], Nursing Note dated [DATE], Fall Program Care Plan dated [DATE], and Nursing Note dated [DATE] were reviewed. The fall risk evaluation indicated, . if the total score is 10 or greater, the resident should be considered at High risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan . The evaluation indicated Resident 1 ' s fall risk score was 21. The nursing note dated [DATE] indicated, . patient continues to climb out of bed, refusing to listen to being redirected. Patient appears to be agitated and saying he wants to go home and will go home . The nursing note dated [DATE], .at 2:35 a.m. the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . The Fall program CP indicated, . Fall program . blue bracelet, blue fall intervention sign above the head of bed, blue name sign by the door, Non-skid footwear, low bed . The care plan was created until five days after Resident 1 ' s fall on [DATE]. The intervention for nonskid footwear and low bed was initiated 8 days after Resident 1 ' s fall on [DATE], when the physician order was documented. The DON stated Resident 1 ' s fall risk score was at 21 on admission, indicating Resident 1 was a high risk for falls. The DON stated Resident 1 had an unwitnessed fall [DATE], was sent to the acute care hospital and diagnosed with a dislocated left-hand pinky. The DON stated there was no change of condition assessment completed, no post fall assessment or skin assessment and there were no neurological checks initiated by the nurse on shift the day of the fall on [DATE]. The DON stated it was the facility process for all documentation to be completed and to properly assess Resident 1 for possible injury. The DON stated, as a result, she was not made aware of Resident 1 ' s fall with injury until [DATE], 4 days later. The DON stated that the fall program which included, a blue bracelet, blue sign above Resident 1 ' s bed, blue name band at the door and low bed, was initiated on [DATE] for Resident 1. The DON stated the fall program should have been initiated upon admission but, was not initiated until after the fall on [DATE] due to DON not being aware Resident 1 had a history of falls. The DON stated Resident 1 would exhibit behaviors manifested by attempting to self-transfer, non-compliant with personal care and non-compliant with using the call light for assistance when his spouse would leave the facility. During a concurrent interview and record review on [DATE] at 12:47 p.m., with the DON, Resident 1 ' s Change of Condition (COC) assessment dated [DATE] and Nursing Note dated [DATE], were reviewed. The COC indicated Resident 1 had an unwitnessed fall on [DATE] with injury. The nursing note indicated, . Resident had unwitnessed fall . resident has left side head injury. Pressure applied to the injury. Medical doctor (MD) notified and received order to send to hospital . The DON stated Resident 1 was found lying on the floor in his room with a left side abrasion to the head. The DON stated she was not aware of the details of the fall as they were not documented and did not know if bed was in a low position at the time of Resident 1 ' s fall on [DATE]. The DON stated there were no floor mats and there was no monitoring protocol put in place for Resident 1. The DON stated Resident 1 ' s intervention was to initiate the fall program to help staff identify Resident 1 as a fall risk. The DON stated she was aware Resident 1 was attempting to walk without assistance but did not identify a pattern of behaviors until after Resident 1 ' s fall on [DATE]. During a phone interview on [DATE] at 2:15 p.m. with LVN 3, LVN 3 stated Resident 1 had an unwitnessed fall on [DATE] and was transferred to the acute care hospital. LVN 3 stated Resident 1 was exhibiting behaviors that included attempts to self-transfer. LVN 3 stated Resident 1 was a high risk for falls and was taken to the nurse ' s station for a one-on-one monitoring. LVN 3 stated the one-on-one monitoring was an intervention that was implemented for that night shift while behaviors were present. LVN 3 stated Resident 1 requested to go back to bed and was taken by CNA 3 to his room. LVN 3 stated Resident 1 was assisted back to bed and was left in his room without monitoring. LVN 3 stated that approximately 30 minutes later, CNA 3 reported Resident 1 had an unwitnessed fall and was found lying on the floor. LVN 3 stated when Resident 1 was experiencing behaviors manifested by attempts to self-transfer, confusion, or restlessness, it was important to monitor Resident 1 for safety and not left alone while the behaviors were present. LVN 3 stated when a resident was admitted to the facility with a history of falls, the fall program should have been initiated immediately for prevention of falls. Resident 1 ' s fall program was initiated on [DATE], eight days after admission to the facility. During a telephone interview on [DATE] at 2:26 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 had an unwitnessed fall on [DATE]. RN 1 stated Resident 1 had behaviors manifested by attempting to self-transfer from the bed to wheelchair. RN 1 stated Resident 1 required frequent re-orientation after Resident 1 ' s spouse would leave the facility. RN 1 stated Resident 1 was at a high risk for falls and was concerned that Resident 1 ' s room was too far from the nurse ' s station. RN 1 stated Resident 1 had episodes of being confused, was oriented to self and situation at times. RN 1 stated that when a resident is admitted to the facility with a history of falls, the fall program should be initiated immediately for resident safety. Resident 1 ' s fall program was initiated on [DATE], eight days after admission to the facility. During a review of Resident 1 ' s Emergency Department Note dated [DATE], the note indicated, . unwitnessed, patient found on ground (in facility), positive for head strike with laceration to left head, patient reports loss of consciousness . Glasgow Coma Scale (GCS- 13 a clinical scale used to measure a person ' s level of consciousness after a brain injury. Score levels ,d+[DATE] are sever traumatic brain injury [TBI], ,d+[DATE] moderate TBI, and ,d+[DATE] mild TBI) 14 per emergency medical systems patient is at baseline . 3 centimeter (unit of measure) laceration to posterior (back) scalp . Computed tomography scan (CT- diagnostic imaging procedure produces images of the inside of the body) impression: Right posterior parafalcine subdural hematoma measures up to 5 millimeters (unit of measure) . will be admitted to the trauma service for ground level fall causing intracranial bleed . During a record review of Resident 1 ' s critical Care Note, dated [DATE], the note indicated, . Patient is seen and examined at bedside. Alert and following commands. Appear slightly confused with garbled speech. Close to baseline per family at bedside. Does not recall falling . considering patient has had multiple falls over the past few weeks as well as his underlying Parkinson ' s and other comorbidities (the condition of having two or more diseases at the same time), I have recommended a palliative care evaluation . During a review of Resident 1 ' s Palliative Care Consultation Note, dated [DATE], the note indicated, . met with [Family] . at baseline they feel he (Resident 1) experiences hallucinations at times. [Family member] expressed concerns about patient having dementia . he has had several falls .that other issues such as his impulsiveness and falling might be his undoing . During a review of Resident 1 ' s hospital Trauma Surgery Discharge Summary, dated [DATE], the summary indicated, . Closed head injury, Palliative care patient, Syncope (fainting), Scalp laceration, Subdural hematoma, Ground-level fall, traumatic brain injury (TBI) . Injuries were found to be non-operative. He remained neurologically intact to baseline until [DATE] when he became unresponsive . On [DATE], patient reported dyspnea (difficulty breathing) to the CNA at bedside after mobilizing with physical therapy (PT). CNA called staff and rapid response. Patient was unresponsive, pale, cyanotic(blue) with agonal (not getting enough oxygen and gasping for air) breathing in pulseless electrical activity (PEA- condition when there is no pulse, no heartbeat, and no breathing). During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated ,d+[DATE], the P&P indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . once a review is completed resident may be placed on the fall program. The individuals that have two or more falls in 90 days or fall with injury will be automatically placed on the fall program . the facility can use the following interventions but not limited to these interventions for the resident. falling matt, 1:1, bed in lowest position, moving resident closer to the nurse ' s station, call lights within reach . or any other interventions that are resident centered . During a review of the facility ' s P&P titled, Safety and Supervision of Residents, dated ,d+[DATE], the P&P indicated, . Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and identified hazards in environment. The type of frequency of resident supervision may vary among residents and over time for the same resident .

Based on interview and record review the facility failed to follow facility's policies and procedures and meet professional standards of quality for one of three sampled Residents (Resident 1), when staff did not document Resident 1's change of condition and post fall assessment for unwitnessed fall with injury on 9/26/24. This failure had the potential to result in the inaccurate assessment of Resident 1 and had the potential for falls and delay in care. Findings: During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses for acute gastroenteropathy (Inflammation of the lining of the stomach and the intestines), abnormalities of gait (walking) and mobility (movement), muscle weakness, encephalopathy (damage or disease that affects the brain), diarrhea, history of falling, depression (condition that causes a persistent feeling of sadness and loss of interest in activities), nausea, hyperlipidemia (high levels of fats in the blood), Parkinson's disease (brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), sleep apnea (disorder that causes your breathing to stop or get very shallow), hypertension (condition in which the blood vessels have persistently raised pressure), atherosclerotic heart disease (thickening or hardening of the arteries), gastro-esophageal reflux disease (GERD- digestive disorder that occurs when stomach contents flow back into the esophagus), Barrett's esophagus (condition where the lining of the lower esophagus is damaged by stomach acid) and benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to enlarge). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 10/2/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 12 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had moderate cognitive impairment. During a record review of Resident 1's Nursing Note dated 9/26/24, the nursing note indicated, .at 0235 the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . During a concurrent interview and record review on 10/10/24 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing Note dated 9/26/24, was reviewed. The nursing note indicated, .at 0235 the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . LVN 1 stated Resident 1 had an unwitnessed fall on 9/26/24 with injury causing dislocation of the left-hand pinky. LVN 1 stated there was no other documentation regarding the fall on 9/26/24. LVN 1 stated it was the facility process to document a change of condition, complete a skin assessment and initiate neuro checks for an unwitnessed fall. During an interview on 10/10/24 at 12:08 p.m. with LVN 2, LVN 2 stated the facility process for falls was for the charge nurse (CN) to document and assess the resident for injury, initiate neurological checks, complete a post fall assessment, change of condition assessment, and monitor resident for delayed injury for 72 hours. LVN 2 stated complete and accurate documentation was important to know what happened and what interventions were initiated. LVN 2 stated complete documentation was used to provide a safe environment and initiate the proper plan of care for Resident 1. During a concurrent interview and record review on 10/10/24 at 12:31 p.m. with Director of Nursing (DON), Resident 1's Nursing Note dated 9/26/24 was reviewed. The nursing note dated 9/26/24, .at 0235 the writer was walking the hall to clock in after lunch the resident kneeling to floor near the door for asking for phone the writer made him to sit on floor called for help by the time he hold the door to stand by himself and slipped out but did not hit the head or anywhere but patient complains of pain on left little finger and stating that it is broken so informed supervisor . send him to the hospital . The DON stated Resident 1 had an unwitnessed fall 9/26/24, was sent to the acute care hospital and diagnosed with a dislocated left-hand pinky. The DON stated there was no change of condition assessment completed, no post fall assessment or skin assessment and there were no neurological checks initiated by the nurse on shift the day of the fall on 9/26/24. The DON stated it was the facility process for all documentation to be completed and to properly assess Resident 1 for possible injury. The DON stated complete and accurate documentation was important, to paint a picture of what happened, what was initiated and how to treat Resident 1. The DON stated when the documentation was not completed, there was a risk for inaccurate assessment of Resident 1 to accurately initiate a plan of care. During an interview on 10/10/24 at 2:14 p.m. with the Administrator (ADM), the ADM stated it was important to have thorough documentation to complete an accurate assessment and treat residents appropriately. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, . all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . the following information is to be documented in the resident medical record . treatments or services performed, changes in the resident's condition, events incidents or accidents involving the resident . documentation in the medical record will be objective, not opinionated, or speculative, complete, and accurate . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly .

Based on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) during high-contact resident care activities for 2 (Residents #81 and Resident #22) of 2 residents observed during wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 08/2024, indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant [sic] organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. The policy revealed, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included: h. wound care (any skin opening requiring a dressing). The policy further indicated, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 1. An Admission Record revealed that the facility admitted Resident #81 on 09/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, cellulitis, unspecified open wound on the right foot, and acquired absence of other right toe(s). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/07/2024, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also indicated Resident #81 had an infection of the foot, diabetic foot ulcer(s), and surgical wound(s). Resident #81's care plan included a focus area initiated 09/04/2024 that indicated the resident had an actual infection caused by methicillin-susceptible staphylococcus aureus. Interventions directed staff to administer antibiotics per order, monitor intravenous site for signs and symptoms of infection, and provide treatment(s) as ordered. Further review revealed the resident had a peripherally inserted central catheter to their right upper extremity. The care plan also included a focus area initiated 09/04/2024 that indicated the resident had an alteration in skin integrity due to an open wound to their right lower extremity. Interventions directed staff to provide treatment as ordered. Resident #81's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 09/18/2024, to cleanse distal diabetic foot ulcer to the right plantar foot with normal saline, pat dry, apply a wet to dry betadine dressing, wrap with kerlix, and secure with ace bandage every day and evening shift. The Order Summary Report also contained an order, dated 09/18/2024 to cleanse incision site to right plantar foot with normal saline, pat dry, apply a wet to dry betadine dressing, wrap with kerlix, and secure with ace bandage every day and evening shift. During an observation of wound care for Resident #81 on 09/18/2024 at 1:58 PM, Licensed Practical Nurse (LPN) #5 was observed using standard precautions, not enhanced barrier precautions. LPN #5 did not have on a gown during wound care. During an interview on 09/18/2024 at 2:11 PM, LPN #5 stated that she did not know about enhanced barrier precautions. During an interview on 09/19/2024 at 10:16 PM, the Director of Nursing (DON) stated that EBP was meant to decrease the spread of MDROs in nursing homes. The DON stated direct hands-on care with residents increased the risk of transmission, so full personal protective equipment (PPE), was meant to reduce that risk. The DON stated she expected going forward that staff use a gown and gloves when providing high-contact care. During an interview on 09/19/2024 at 10:34 PM, the [NAME] President of Clinical Operations stated that EBP was meant to protect residents from MDROs. The VP of Clinical Operations stated it was important to protect residents and staff, so nobody transmitted those infections to someone else. The VP of Clinical Operations stated it was her expectation that staff use EBP. 40141 2. An Admission Record indicated the facility admitted Resident #22 on 04/28/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #22 had severe impairment in cognitive skills for daily decision making and had short-term and long-term memory problems per a staff assessment of mental status (SAMS). Resident #22's care plan included a focus area revised on 08/01/2024 that indicated the resident had the potential for impairment in skin integrity. Resident #22's Order Summary Report, with active orders as of 09/18/2024, contained an order dated 08/24/2024 for betadine-soaked gauze and dry gauze over the left big toe daily until resolved. During an observation on 09/18/2024 at 9:58 AM, Licensed Practical Nurse (LPN) #1 provided wound care for Resident #22. A small open area was noted to the resident's left hallux. LPN #1 did not implement enhanced barrier precautions and wore only gloves during the provision of wound care. During an interview on 09/18/2024 at 10:10 AM, LPN #1 stated she was not familiar with enhanced barrier precautions and did not know to wear a gown and gloves when providing wound care. During an interview on 09/18/2024 at 2:11 PM, the Infection Preventionist (IP) stated she did know the specifics about enhanced barrier precautions. The IP stated the facility had not implemented enhanced barrier precautions.

Based on interview, record review, and facility policy review, the facility failed to follow pharmacy recommendations for 1 (Resident #19) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to respond to May and June 2024 pharmacy recommendations for an AIMS (abnormal involuntary movement scale) assessment for Resident #19. Findings included: A facility policy titled, Antipsychotic Medication Use, revised 12/2016, indicated, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia, or tardive dyskinesia, stroke or TIA [transient ischemic attack]. A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, 9. An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. The policy revealed, 11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. An Admission Record revealed the facility admitted Resident #19 on 03/29/2017. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified dementia, restlessness and agitation, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/06/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #19's care plan included a focus area initiated 10/03/2022, that indicated the resident used antipsychotic medication for agitation manifested by picking at their brief and smearing stool. Interventions directed staff to administer antipsychotic medications as ordered by the physician, monitor for side effects and effectiveness every shift, monitor for adverse reactions of psychotropic medications, and to consult with the pharmacy. Resident #19's Order Summary Report, with active orders as of 09/19/2024, revealed an order dated 09/13/2024 for quetiapine fumarate oral tablet 75 milligrams (mg) by mouth at bedtime. The Order Summary Report revealed an order dated 09/13/2024 for quetiapine fumarate oral tablet 75 mg by mouth one time a day. Resident #19's Consultant Pharmacist's Medication Regimen Review, dated 05/31/2024, revealed a recommendation that included Resident is due for an AIMS assessment due to antipsychotic medication use. It should be done every 3 months. Resident #19's Consultant Pharmacist's Medication Regimen Review, dated 06/28/2024, revealed a recommendation that included Resident is due for an AIMS assessment due to antipsychotic medication use. It should be done every 3 months. Resident #19's Abnormal Involuntary Movement Scale (AIMS), dated 12/05/2023, revealed a score of 1, which indicated the resident had a low risk of movement disorder. Further review revealed the AIMS dated 12/05/2023 was the most recent AIMS score in the resident's record. During an interview on 09/18/2024 at 10:48 AM, Licensed Practical Nurse (LPN) #6 stated she did not know how often AIMS assessments were done for residents. LPN #6 stated if the pharmacist recommended an AIMS assessment for a resident, it was the responsibility of the registered nurse (RN) supervisor or the Director of Nursing (DON) to complete the assessment. During an interview on 09/18/2024 at 12:14 PM, LPN #1 stated the RN on the floor did the AIMS assessment if the pharmacist recommended it. During an interview on 09/18/2024 at 12:51 PM, RN #7 stated the AIMS assessment was done for residents on psychotropic medications every six months. RN #7 stated if the pharmacy made the recommendation for an AIMS assessment, then the specific instructions came down to the floor where they could be implemented. He stated he was not sure why Resident #19 had not received an AIMS assessment in response to the pharmacy recommendation, nor had he seen the recommendation. During an interview on 09/19/2024 at 10:16 AM, the DON stated that staff should follow the medication regimen review recommendations and do the psychotropic monitoring as recommended. The DON stated the facility did not do the AIMS assessment, and she expected staff to do the monitoring recommended by the pharmacist. During an interview on 09/19/2024 at 10:34 AM, the [NAME] President (VP) of Clinical Operations stated that she expected staff to go over the pharmacy recommendations and implement that recommendation. She stated the nursing recommendations are put in with an order that would notify nurses to implement the recommendation. The VP of Clinical Operations stated when the facility transitioned from their old electronic medical record system to a new one, the AIMS assessment changed, and this was likely why Resident #19's AIMS assessment was not done.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Pre-Admission Screening and Resident Review (PASARR) was complete and accurate for 2 (Resident #62 and Resident #12) of 3 residents reviewed for PASARR. Specifically, Resident #62 and Resident #12 had a Level I PASARR completed that did not capture all their mental health diagnoses. Findings included: A facility policy titled, Admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. 1. An Admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar type schizoaffective disorder (onset date 04/14/2024), bipolar disorder (onset date 06/12/2020), major depressive disorder (onset date 06/12/2020), and anxiety disorder (onset date 06/12/2020). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antipsychotic medication of aripiprazole related to a bipolar disorder diagnosis manifested by mood swings. Interventions directed staff to administer psychotropic medications as ordered and to monitor and document episodes of bipolar depression daily. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antidepressant medication of sertraline related to depression. Interventions directed staff to administer antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift. Resident #62's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 08/23/2024, for aripiprazole (antipsychotic) 5 milligrams (mg) by mouth every other day for rapid, alternating changes in mood related to bipolar schizoaffective disorder. Resident #62's Order Summary Report, contained an order, dated 08/23/2024, for sertraline hydrochloric acid (HCl) (antidepressant) 12.5 mg by mouth one time a day for sad facial expressions and flat affect related to major depressive disorder. Resident #62's Order Summary Report, contained an order, dated 08/22/2024, for valproic acid 250 mg by mouth every 12 hours for audio/visual hallucinations related to bipolar disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/16/2022, revealed the screening was positive for suspected MI. Further review revealed a mental disorder diagnosis of major depressive disorder; the diagnoses of anxiety and bipolar disorders were not listed. During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated Level I PASARR screenings were completed at the hospital and he reviewed them for any discrepancies upon admission. The MDS Director further stated Resident #62's Level I PASARR was inaccurate because it did not include the resident's diagnoses of bipolar and anxiety disorder. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Level I PASARR screenings were completed at the hospital prior to admission and that Resident #62's PASARR was inaccurate because it did not capture all the resident's mental health diagnoses. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the Level I PASARR process screened residents with mental illness to determine if they would benefit from additional services. The DON further stated Resident #62's Level I PASARR should have captured the resident's bipolar and anxiety disorder diagnoses. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the Level I PASARR screenings were completed prior to admission. The VP of Clinical Operations further stated bipolar and anxiety disorder diagnoses should have been captured on Resident #62's Level I PASARR. 40141 2. An Admission Record specified the facility originally admitted Resident #12 on 12/20/2017 with a readmission on 11/10/2021. According to the Admission Record, the resident had a medical history that included diagnoses of delusional disorder (onset date 12/20/2017), psychosis (onset date 12/20/2017), single episode major depressive disorder (onset date 12/20/2017), recurrent depressive disorders (onset date 12/20/2017), and hallucinations (onset date 12/20/2017). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had diagnoses of depression and psychotic disorder. Resident #12's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 11/10/2021 indicated the resident had no diagnosed mental disorder. Resident #12's Level I PASRR letter dated 11/10/2021 specified the Level I PASRR submitted on 11/10/2021 was negative due to no mental illness. During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated a new admission PASRR was completed at the hospital and was reviewed for discrepancies. The MDS Director stated any changes to psychotropics medications, significant change, a cognitive decline, or a new psychiatric diagnosis indicated for another PASRR screen to be completed. The MDS Director stated Resident #12's PASRR screen was inaccurate without the diagnoses addressed. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Resident #12's PASRR was inaccurate when it was not marked with all the diagnoses the resident had. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the PASRR process screened residents for mental illness to determine if additional psychiatric care would be needed. The DON stated Resident #12 had mental health diagnoses, so the screening form was not accurate. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the PASRR needed to be reviewed when a resident was admitted to make sure it was accurate with diagnoses, medications, and resident history, and they should complete a new one if it was inaccurate. The VP of Clinical Operations stated Resident #12's PASRR was inaccurate without the diagnoses identified.

Based on interview, record review, and facility policy review, the facility failed to submit a status change to a Level I Pre-Admission Screening and Resident Review (PASARR) following a new mental health diagnosis for 1 (Resident #62) of 3 residents reviewed for PASARR. Specifically, Resident #62 had a positive Level I PASARR and was later diagnosed with a new mental health disorder and the facility failed to submit a status change to the resident's Level 1 PASARR evaluation. Findings included: A facility policy titled, Admission Criteria, revised in March 2019, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. An Admission Record revealed the facility admitted Resident #62 on 06/12/2020. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar type schizoaffective disorder (onset date 04/14/2024), bipolar disorder (onset date 06/12/2020), major depressive disorder (onset date 06/12/2020), and anxiety disorder (onset date 06/12/2020). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received antipsychotic and antidepressant medications during the assessment period. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antipsychotic medication of aripiprazole related to a bipolar disorder diagnosis manifested by mood swings. Interventions directed staff to administer psychotropic medications as ordered and to monitor and document episodes of bipolar depression daily. Resident #62's care plan included a focus area revised on 10/12/2023 that indicated the resident received an antidepressant medication of sertraline related to depression. Interventions directed staff to administer antidepressant medications as ordered by the physician and to monitor and document side effects and effectiveness every shift. Resident #62's Order Summary Report, with active orders as of 09/19/2024, contained an order, dated 08/23/2024, for aripiprazole (antipsychotic) 5 milligrams (mg) by mouth every other day for rapid, alternating changes in mood related to bipolar schizoaffective disorder. Resident #62's Order Summary Report, contained an order, dated 08/23/2024, for sertraline hydrochloric acid (HCl) (antidepressant) 12.5 mg by mouth one time a day for sad facial expressions and flat affect related to major depressive disorder. Resident #62's Order Summary Report, contained an order, dated 08/22/2024, for valproic acid 250 mg by mouth every 12 hours for audio/visual hallucinations related to bipolar disorder. Resident #62's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/16/2022, revealed the screening was positive for suspected MI. Further review revealed a mental disorder diagnosis of major depressive disorder. Review of Resident #62's medical record during the recertification survey from 09/16/2024 to 09/19/2024 revealed another Level I PASARR had not been completed since 11/16/2022. During an interview on 09/19/2024 at 8:33 AM, the MDS Director stated Level I PASARR screenings were completed at the hospital and he reviewed them for any discrepancies upon admission. The MDS Director further stated when a resident obtained a new mental health diagnosis after admission, a new Level I PASARR should be completed to capture that diagnosis and when Resident #62 obtained their schizoaffective disorder diagnosis, a new Level I PASARR should have been completed. During an interview on 09/19/2024 at 8:40 AM, Medical Records (MR) stated Level I PASARR screenings were completed at the hospital prior to admission and an updated Level I PASARR should be completed with a new mental health diagnosis. MR further stated Resident #62's new diagnosis of schizoaffective disorder was probably missed and that was why a new Level I PASARR had not been completed. During an interview on 09/19/2024 at 10:07 AM, the Director of Nursing (DON) stated the Level I PASARR process screened residents with mental illness to determine if they would benefit from additional services. The DON further stated when a resident received a new mental health diagnosis, staff should complete an updated Level I PASARR to see if the resident qualified for those additional services. During an interview on 09/19/2024 at 10:26 AM, the [NAME] President (VP) of Clinical Operations stated the Level I PASARR screenings were completed prior to admission. The VP of Clinical Operations further stated a new Level I PASARR should be completed with a new mental health disorder to ensure that resident received the care they need for their new diagnosis.

Based on interview and record review, the facility failed to provide supervision and services for the prevention of accidents for two of five sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 were both admitted with diagnoses that included dysphagia (difficulty swallowing or chewing) and were not evaluated or treated in accordance with professional standards of practice and the comprehensive care plan. Speech Therapy was not consulted, swallow evaluations (to determine the presence and severity of dysphagia as well as to determine the need for further testing) not conducted, meals were not supervised, modified meals to prevent the risk of choking and risk of aspiration (sucking food into the airway) were not served. These failures resulted in the risk of choking and aspiration for both Residents 1 and 2; and for Resident 1 could have contributed to the event on [DATE] where Resident 2 was found pulseless while eating and coroner's preliminary report indicated cause of death as asphyxia (condition caused by an injury or obstruction of the airway passages like choking) due to aspiration from food. Findings: 1. During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, Dysphagia. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 2 out of 15 (0 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 15) cognitively intact) which indicated Resident 1 was cognitively impaired. During a review of Resident 1's Nursing Situation, Background, Assessment and Recommendation (SBAR) dated [DATE], the SBAR indicated, . Resident found unresponsive in his wheelchair (w/c) . Resident had food in his mouth and airway had to be cleared out . During a review of Resident 1's Meal Tray Ticket (MTT), dated [DATE], the MTT indicated, . Lunch . consistent carbohydrate diet (CCD) Dysphagia advanced . Italian sausage . brown gravy . parmesan noodles . sauteed spinach with garlic . dinner roll/bread . sliced pears . 8 oz skim milk . During a review of Resident 1's nutritional Care plan (CP) dated [DATE], the CP indicated, . monitor/document/report when needed (PRN) any s/sx (sign/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . During an interview on [DATE] at 11:51 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she responded to Resident 1's room on [DATE] due to a call for help from CNA 1. LVN 1 stated that upon entering Resident 1's room, Resident 1 was observed sitting up in his wheelchair, head tilted backward, arms resting on arm rest, facing his bed with back turned to roommate and bedside table was positioned to the front of Resident 1. LVN 1 stated Resident 1's meal tray was on top of the bedside table, there was no food on the plate, and it appeared Resident 1 had consumed the entire lunch meal. LVN 1 stated Resident 1's head was straightened up and carotid pulse (pulse felt on the front of the neck below the angle of the jaw) was checked and LVN 1 determined Resident 1 did not have a pulse. LVN 1 stated CPR was initiated. During an interview on [DATE] at 12:18 p.m. with the Assistant Director of Nursing (ADON), the ADON stated on [DATE] there was a code (life threatening emergency) called for Resident 1. The ADON stated upon entering Resident 1's room LVN 2 was observed performing chest compressions (also called cardiopulmonary resuscitation [CPR] action used to push down hard and fast in a specific way on the person's chest) on Resident 1 who was lying on his back on the floor. The ADON stated the artificial manual breathing unit bag (ambu bag a device used to provide respiratory support) was placed over Resident 1's nose and mouth. The ADON stated when the ambu bag was compressed to assist with respirations it was noted, the ambu bag was not delivering oxygen appropriately as Resident 1's chest, because Resident 1's chest did not rise. The ADON stated Resident 1's head was repositioned and Resident 1's tongue was observed hanging to the side of his mouth. The ADON stated she inserted two fingers into Resident 1's mouth to feel for any residual food and felt tongue was swollen. The ADON stated there was no food felt in Resident 1's mouth but observed the DON scooping Resident 1's bilateral cheeks. The ADON stated she observed the Director of Nursing (DON) scoop out pocketed food from Resident 1's cheek which was size of a quarter, the food appeared to be spinach and pasta. The ADON stated the suction machine was used to remove remaining food particles from Resident 1's mouth. The ADON stated once the food was removed from Resident 1's mouth, the ambu bag was repositioned and Resident 1's chest began to rise when oxygen was delivered. The ADON stated Resident 1 required set up help for meals and did not have previous concerns with meal consumption. During an interview on [DATE] at 12:50 p.m. with the Registered Nurse Supervisor (RNS), the RNS stated he was called to Resident 1's room for a Code. The RNS stated that upon entering the room he observed the DON using the ambu bag and LVN 2 delivering compressions to Resident 1. The RNS stated when the ambu bag was used it was noted not delivering oxygen appropriately as Resident 1's chest was not rising. The RNS stated the DON scooped Resident 1's bilateral cheek and removed approximately 30 mL's (unit of measure) of food from Resident 1's mouth. The RNS stated the suction machine was used to remove remaining food particles from Resident 1's mouth. The RNS stated the food appeared chewed and looked like spinach mixed with an unknown white substance. The RNS stated there were no known food or drug allergies for Resident 1. The RNS stated, when the food was removed from Resident 1's mouth, the ambu bag was repositioned and oxygen was delivered effectively. During an interview on [DATE] at 1:11 p.m. with the DON, the DON stated she was called to Resident 1's room for a code. The DON stated when she entered Resident 1's room, LVN 2 was observed administering chest compressions to Resident 1 who was observed lying on the floor on his back. The DON stated Resident 1's skin appeared pale, he was fully dressed, eyes were open, and body was flaccid. The DON stated she assessed Resident 1's carotid pulse and concluded there was no pulse. The DON stated she was in charge of the ambu bag during cardiopulmonary resuscitation and noted there was a leak in the ambu bag seal when Resident 1's chest did not rise. The DON stated she removed the ambu bag and proceeded to scoop Resident 1's bilateral cheek for food. The DON stated there was food removed from the left cheek that appeared to have been spinach and there was food removed from the right cheek that appeared as ground meat. The DON stated she was unsure how much food was removed from Resident 1's mouth but that it was a small amount. The DON stated Resident 1 had an unusually heavy tongue that required for it to be pulled out of Resident 1's mouth to suction the back of the throat for remaining food particles. The DON stated once Resident 1's mouth was cleared of food, the ambu bag was repositioned and effectively delivered oxygen when Resident 1's chest was observed to rise. The DON stated Resident 1 required set up help only for meals and had a diagnosis of dysphagia without prior complications. During an interview on [DATE] at 1:39 p.m. with the Regional Director of Rehab (RDR), the RDR stated Resident 1 was not evaluated or treated in the facility since admission by the Speech Therapy department. The RDR stated there were no speech therapy notes in Resident 1's electronic medical record (EMR). During a concurrent interview and record review on [DATE] at 1:43 pm with the DON, Resident 1's EMR and nutritional care plan dated [DATE], were reviewed. The EMR indicated Resident 1 was not evaluated or treated by a speech therapist (ST) since admission to the facility on [DATE]. The CP indicated, . monitor/document/report when needed (PRN) any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . The DON stated the facility staff was not monitoring Resident 1 specifically for pocketed food or choking. The DON stated the expectation was for a monitoring order to have been put in place to monitor Resident 1 during and after meals as there was a potential for pocketing food to become a choking hazard. During an interview on [DATE] at 1:52 pm with CNA 1, CNA 1 stated she was assigned to care for Resident 1 on [DATE]. CNA 1 stated Resident 1 was served his lunch tray in his room while he sat in his wheelchair with bedside table positioned in front of him and then she exited the room. CNA 1 stated when she entered Resident 1's room to retrieve the lunch tray, Resident 1 was observed sitting in wheelchair with head tilted back, eyes open but wasn't responding to verbal stimuli. CNA 1 stated she was not aware that Resident 1 had a history of pocketing or choking on food. CNA 1 stated it was important to monitor Resident 1 as there was a potential for choking during meals. During a review of Resident 1's dietary profile dated [DATE], the dietary profile indicated, . Resident does not speak English, so his Family Member (FM) was called for preferencing interview. She said her father has a hard time chewing some meals due to dental issues. Will tell speech therapist about it . During a concurrent interview and record review on [DATE] at 9:29 a.m. with the speech therapist (ST), Resident 1's EMR and nutritional care plan dated [DATE], were reviewed. The EMR indicated Resident 1 was not evaluated or treated by a ST since admission to the facility on [DATE]. The CP indicated, . monitor/document/report when needed (PRN) any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . The ST stated that based on Resident 1's history, the facility should have downgraded Resident 1's diet to a puree texture and should have referred to ST services to ensure resident was given the appropriate diet. The ST stated that based on Resident 1's history, diagnosis and care plan it was her professional opinion that Resident 1 should have been referred, evaluated and treated as indicated by a ST. During a concurrent interview and record review on [DATE] at 10:18 a.m. with the facility's registered dietitian (RD), Resident 1's diet order dated, [DATE], and dietary profile dated [DATE], were reviewed. The diet order indicated, Consistent Carb Diet dysphagia advanced texture thin liquids. The dietary profile indicated, . Resident does not speak English, so his daughter was called for preferencing interview. She said her father has a hard time chewing some meals due to dental issues. Will tell speech therapist about it . The RD stated Resident 1 was admitted to the facility with a diet order for Dysphagia advanced texture and continued without a diet change until Resident's death on [DATE]. The RD stated that a dysphagia advanced texture consisted of finely chopped foods, dinner rolls and pasta and should have been soft and did not require chopping. The RD stated the dietary manager (DM) in the facility at the time of the documented dietary profile was no longer an employee of the facility. The RD stated the process was for the dietary manager to attend all resident's interdisciplinary team (IDT team of healthcare professionals who work together toward the goals of their clients) meetings and report any findings. The RD stated the DM should have notified the ST and the IDT team of the family's concern at the time of the dietary profile to evaluate Resident 1's diet. During a telephone interview on [DATE] at 3:10 p.m. with the coroner's office sheriff (COS), the COS stated, Resident 1's preliminary report indicated cause of death was asphyxia due to Aspiration of food. During a telephone interview on [DATE] at 2:50 pm with the family member (FM) 1, the FM 1 stated Resident 1 had a history of dysphagia that presented by difficulty swallowing foods. FM 1 stated Resident 1 had episodes of pocketing food during meals and required supervision and redirection during meals. FM 1 stated the facility staff was informed that Resident 1 was pocketing food and FM1 requested staff follow up with Resident 1 during meals. During a telephone interview on [DATE] at 3:38 p.m. with LVN 3, LVN 3 stated Resident 1 had a diagnosis of dysphagia since admission. LVN 3stated dysphagia was interpreted as trouble swallowing food. LVN 3 stated the facility process was for the admitting nurse to look at Resident's history and determine which diet order was in place and notify the physician. LVN 3 stated Resident 1 was administered crushed medications in applesauce during medication administration because Resident 1 had a hard time swallowing. LVN 3 stated Resident 1 did not have a physician order in place to crush medications. LVN 3 stated the facility process was for the facility nurses to notify MD and speech therapy if Resident 1 was having trouble swallowing and this was not done for Resident 1 . During a review of Resident 1's Emergency Medical Services (EMS) Patient Care Report, dated [DATE]. The EMS report indicated, . Oropharyngeal Airway (OPA device used to maintain an open airway by assisting in moving the tongue or other possible obstructions and improving the airway, placed, but rejected by patient due to intact gag reflex. Initial video laryngoscopy (procedure in which a fiberoptic camera is used to visualize the upper airway for intubation) utilized for use in clearing airway, where bits of noodle and greens were removed. 2. During a review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Dysphagia. During a review of Resident 2's Minimum Data Set (MDS a resident assessment tool used to identify cognitive and physical functional level assessment) dated [DATE], the MDS indicated Resident 2's BIMS score was 13 out of 15 which indicated Resident 2 was cognitively intact. During a review of Resident 2's Dietary Order, dated [DATE], the Diet order indicated, . Regular diet, regular texture, thin consistency . During a review of Resident 2's Dental Consult, dated [DATE], the dental consult indicated, . Resident strongly refusing extractions today, stated why pull them if they don't hurt me, patient does not want extractions . During a concurrent interview and record review on [DATE] at 1:20 p.m. with the DON, Residents 2's EMR was reviewed. The EMR indicated Resident 2 was not evaluated or treated by ST since admission to the facility. The DON stated that upon review of the EMR, Resident 2 had no documented history of speech therapy services. During a concurrent observation and interview on [DATE] at 12:05 p.m. with Resident 2 in Resident 2's room, Resident 2 was observed lying in bed. Resident 2 stated the facility speech therapist, as far as she was aware, had not evaluated her. 2 stated she was not having issues chewing or swallowing food at the time of the interview but was experiencing facial nerve pain. Resident 2 stated the facial nerve pain was located on her left side of the face. Resident 2 stated that there were times when she had to put her head up to swallow food due to the nerve pain. Resident 2 was observed lifting head backward to show position for swallowing. During an interview on [DATE] at 12:33 p.m. with the physical therapy assistant (PTA), the PTA stated after review of Resident 2's physical therapy documentation, Resident 2 had not been evaluated or treated by speech therapy since admission. During a concurrent interview and record review on [DATE] at 12:55 p.m. with the social services assistant (SSA), Resident 2's dental consult, dated [DATE] was reviewed. The dental consult indicated, . Resident strongly refusing extractions today, stated why pull them if they don't hurt me, patient does not want extractions . The SSA stated Resident 2 was last seen by the dentist on [DATE] and had refused any further treatment. The SSA stated Resident 2 had a lot of dental issues that needed to be addressed including multiple tooth extractions. During a concurrent telephone interview and record review on [DATE] at 9:22 a.m. with the facility ST, Resident 2's EMR, diet order dated [DATE] and dental consult dated [DATE] were reviewed. The EMR indicated Resident 2 had not been referred, evaluated, or treated by a ST since admission to the facility. The Diet order indicated, . Regular diet, regular texture, thin consistency . The ST stated, it was her professional opinion that based on Resident 2's diagnosis of dysphagia, resident reports of left sided facial pain, inability to swallow and documented dental issues, Resident 2 should have been referred to ST for an evaluation, MD notified of concern and diet changed. During a telephone interview on [DATE] at 4:24 p.m. with Registered Nurse Manager (RNM), the RNM stated the facility process for residents with dysphagia was for the admitting nurse to notify the physician and refer to speech therapy for evaluation. The RNM stated all residents with dysphagia should have been monitored and referred to speech therapy services for an evaluation. The RNM stated if Resident 2 had a history of difficulty swallowing, it was expected that Resident 2 be referred to speech therapy. During a telephone interview on [DATE] at 4:26 p.m. with the DON, the DON stated it was the facility process when a resident is admitted with a diagnosis of dysphagia, to request a speech therapy evaluation. The DON stated it was the expectation for the admitting nurse to clarify with physician and follow the diet orders sent from the hospital upon admission. The DON stated it was the expectation that nursing staff monitor the resident for any changes in eating habits. The DON stated it was not an acceptable practice to not monitor a resident with a diagnosis of dysphagia including Resident 1 and Resident 2. During a telephone interview on [DATE] at 4:28 p.m. with the facility administrator (ADM), the ADM stated it was the expectation that the admitting nurse notify MD and obtain an order for speech therapy services for residents with dysphagia upon admission. The ADM stated if the facility staff identified difficulty with eating or swallowing it was the expectation that the charge nurse evaluate and asses the resident and refer to speech therapy for evaluation. During a review of the facility's policy and procedure (P&P) titled, Speech Therapy, dated ,d+[DATE]. The P&P indicated, . The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders . Speech therapists treat . Dysphagia difficulty in chewing or swallowing . the speech therapists work to provide a comprehensive evaluation and treatment plan for residents . the speech therapists complete an evaluation of the following speech and language skills . ability to swallow . During a review of the facility's policy and procedure (P&P) titled, Dysphagia, dated ,d+[DATE], the P&P indicated, . the staff and the physician will identify individuals with a history of swallowing difficulties or related diagnosis such as dysphagia . based on the information collected and correlated by various disciplines, the staff and practitioner, in conjunction with the SLP (speech language pathologist), will define the situation carefully . and whether the situation needs additional evaluation and clarification . if a swallowing problem is identified or suspected, a healthcare practitioner, in conjunction with nursing and SLP, will identify and document pertinent information, including the resident's level of consciousness, ability to swallow 3 ounces of water without drooling, coughing, or choking . previous and recent history of swallowing capability and difficulty . it is important to clarify the symptoms and the history in detail in order to help identify causes, since symptoms related to chewing or swallowing may have modifiable causes .

Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the resident environment was accident-free for four of ten sampled residents (Residents 2, 3, 7, and 8) when Licensed Nurses failed to follow facility policy and procedures and professional standards in developing and implementing resident-specific and comprehensive care plan interventions meant to prevent falls for Residents 2, 3, 7 and 8. These failures resulted in avoidable falls for Residents 2, 3, 7 and 8. Each resident suffered an injury requiring transport, assessment, and healthcare services at a General Acute Care Hospital (GACH). Resident 2 experienced an avoidable fall on 2/25/2023 and suffered a worsening to an already existing left proximal femur fracture (broken thigh bone), decreased ability to function, decreased mobility, disruption of healing, and increased pain. Resident 3 experienced two avoidable falls on 3/20/2023 and was diagnosed with a Traumatic Brain Injury (TBI- a sudden injury that causes damage to the brain), decreased ability to function, decreased mobility and pain. Resident 4 experienced an avoidable fall on 4/28/2023 and was diagnosed with a ground level fall .traumatic hematoma [a collection of blood outside of blood vessel commonly caused by an injury] to the left head, decreased ability to function, decreased mobility. Resident 7 experienced an avoidable fall on 3/17/2023 and was diagnosed with a right closed femur fracture, decreased ability to function, decreased mobility pain. Resident 8 experienced an avoidable fall on 2/4/2023 and was diagnosed with a right occipital bone fracture, (broken skull bone) and laceration (cut). Findings: 1. During a review of Resident 2's Nursing SBAR [Situation-Background-Assessment-Recommendation- a standardized way for members of the health care team to report about a patient's condition.] dated 2/25/2023 indicated Resident 2 was transferred to the GACH for a complaint of left knee pain after an unwitnessed fall from bed, in his room, at 10:00 p.m. During a review of Resident 2's Face Sheet (FS- a document containing resident profile information) dated 4/13/2023, the FS indicated, Resident 2 is a [AGE] year old initially admitted to the facility on [DATE] for rehabilitation with diagnoses which included .Major Depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) . Type 2 Diabetes Mellitus (Diabetes) with hyperglycemia (high blood sugar), .hypertension (high blood pressure) . Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) .with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety .Fall .need for assistance with personal care . Fracture of left femur (broken thigh bone) .Muscle weakness .difficulty walking . During a review of Resident 2's Avalon Fall Risk Evaluation (AFRE), dated 2/17/2023 (before the fall with injury on 2/25/2023), the AFRE indicated, .Score: 16 (which indicated Resident 2 was a medium risk for falls) . the AFRE .dated 3/3/2023 (after the fall with injury on 2/25/2023) indicated, .Score: 14 (which indicated Resident 2 was a medium risk for falls) . During a concurrent interview and record review, on 4/14/2023, at 9:00 a.m., with MDSC 1, Resident 2's Care Plan was reviewed. Resident 2's Care Plan indicated Focus [Resident 2] has had an actual fall .Date Initiated: 3/9/2023 .Goal [Resident 2} will resume usual activities without further incident through the review date .Interventions .frequent room check for pt safety .keep bed locked and in low position .fall mat in place . The MDSC 1 stated Resident 2's care plan did not include interventions specific enough to minimize the potential for accidents specific to Resident 2's admission diagnoses. The MDSC 1 stated that examples of interventions that could have been implemented instead of frequent room check for pt safety, licensed nurses could have planned scheduled rounding by CNA every 30 minutes and nurse every 60 minutes, keeping personal items within reach, and answering call light within a specific timeframe (under 5 minutes) and to remove clutter, keep belongings at bedside within resident reach. Ensure that call lights are answered right away and to stay alert to any unexpected noises. The MDSC 1 stated these interventions would help keep the resident safe because the resident forgets has Dementia and Resident 2 does not always call for help with ADL's. The MDSC 1 stated Resident 2 does not always remember not to raise the bed height when he has access to the remote control, staff should anticipate that the bed height could be a problem and during rounding should inspect the current height of the bed, lower the bed as needed and keep the remote control out of sight to prevent the resident from accidentally raising the bed height. The MDSC 1 stated that planning for fall mat should include the location where (right or left) the mat is to be placed. The MSDC 1 stated that Resident 2's Care Plan did not include a pain management focus. The MDSC 1 began to modify the Care Plan as the interview was underway to include the specifics he mentioned. MDSC 1 stated that as the facility MDSC and RN, he has the responsibility to update and modify resident Care Plans as appropriate. The MDSC 1 stated the purpose of a care plan is to meet the specific needs of each resident if there isn't a good plan the result could be harm, like in this case Resident 2 suffered a re-injury and had to have a second operation on his left leg. The MDSC 1 stated as a Registered Nurse (RN) it is his expectation that licensed nurses update the care plan anytime the resident has a new or change in condition. During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., of Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive and physical functional status assessment) Section C dated 2/23/2023, with the MDS Coordinator (MDSC) 1, the MDSC 1 stated Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive [pertaining to reason, memory and judgement] status) was 10 of 15 points (indicating moderate cognitive impairment in decision making during Activities of Daily Living [ADL's- bathing, toileting, transferring] and required cues and supervision). Resident 2's MDS Section G, dated 2/23/2023 indicated Resident 2 required .extensive assistance of two, plus staff members to transfer from one surface to another . During a concurrent observation and interview on 4/14/2023, at 10:46 a.m., with Resident 2, in Resident 2's room, Resident 2's environment was observed to have a privacy curtain was drawn around his bed in the semi-private room. Resident 2 was lying in bed, eyes open, alert, relaxed, television was on and bedside table approximately two feet away from resident's reach. Resident 2 stated that sometimes staff leave his bedside table too far away where he is unable to reach his glasses and something to drink. Resident 2 was observed to not have soft floor mats on the floor at his bedside. Resident 2 was not wearing a fall risk armband and there was no fall risk sign present to alert staff to Resident 2's fall risk. Resident 2 stated that he did not recall what he was doing at the time of the fall, or exactly when the fall happened. Resident 2 says he remembered being told he had a broken foot. Resident 2 stated that he went to the hospital and had to have his foot operated again after he slipped and fell . Resident 2's call bell was located at the head of the bed, near Resident 2's right shoulder. Resident 2 stated the call bell wasn't working, it was missing the red button. Resident 2 stated when the call bell is at his right side, he can't press it because his right arm doesn't work. Resident 2 pointed, with his left hand, to his right arm which was lying on top of Resident 2's lap to demonstrate the flaccid (a body part hanging loosely or limp) condition of his right arm. During a concurrent observation and interview on 4/14/2023, at 10:53 a.m., with Resident 2 and Certified Nursing Assistant (CNA) 1, in Resident 2's room, CNA 1 responded to a request for assistance. It was brought to CNA's attention that the call light was on Resident 2's right side. CNA 1 placed the call button in Resident 2's left hand. Resident 2 pressed the call button; the call light did not alarm. Resident 2 stated that when the call light does work, staff do not respond right away. Resident 2 stated he has waited over 30-minutes for help. CNA 1 stated she was not aware that the call light wasn't working. CNA 1 stated that she would try to fix the call bell by either taking a working call bell from another room or by entering a report for maintenance to fix it if she could not fix the problem. CNA 1 stated she did not understand why the privacy curtain was closed. CNA 1 stated that Resident 2 sometimes called out or waved to staff if he needed help. CNA 1 stated that with the privacy curtain is drawn, when care wasn't actively being provided, Resident 2 did not have a way to alert staff he needed help and staff could not see resident from the hallway. During a concurrent interview and record review on 4/17/2023 at 4:20 p.m., with MDSC 1 in the facility conference room, Resident 2's Inter-Disciplinary Team Meeting (IDT- [interdisciplinary team-approach to healthcare that integrates multiple disciplines through collaboration]) note, dated 4/17/2023 was reviewed. The MDSC 1 stated Resident 2 was hospitalized from 2/25/2023 to 3/3/2023 (six days) with no new falls reported since his return from the GACH. The MDSC 1 stated that the IDT Note was not entered into the system directly after the IDT met to review the fall event. The MDSC 1 stated it was entered as a late entry on 4/17/2023.; The meeting was held on 3/6/2023 at 11:00 a.m. The IDT Note indicated .IDT met to discuss recent unwitnessed fall on 2/25/23 which caused an injury to a pre-existing left femur fx [fracture]. According to charge nurse assessment, LLE [left lower extremity] was swollen and pt [patient] complained of 10 out 10 pain and requested to be sent to acute [GACH]. Pt returned to facility on 3/3/23 after hardware revision on the L [left] femur fx, with current weight bearing order of touch toe (no weight bearing, only toe touches floor). Care plan (direction on the type of nursing care the individual may need) updated regarding fall precautions. IDT Present: Administrator (ADM), Social Services Director (SSD), Physical Therapist (PT) Occupational Therapist (OT), Restorative Nursing Assistant (RNA) Director of Staff Development (DSD), Infection Prevention/Unit Manager (IP/UM), MDSC 1 . The MDSC 1 stated Resident 2 experienced a decline in mobility and increased pain and suffering due to the fall and re-injury of the left lower extremity (limb). During a review of Resident 2's Order Summary Report, (OSR) dated 4/13/2023, the OSR indicated, . [Generic Name] opioid (a class of drug used to reduce moderate to severe pain) pain medication 5 mg .give 1 tablet by mouth every 4 hours as needed for pain . During a review of the Medication Administration Record (MAR) dated 3/1/2023 indicated, on 3/22/2023 Resident 2's pain level was a 10 (physician's order dated 2/17/2023 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Ibuprofen (pain reliever) 400 milligrams (mg- a unit of measurement) was administered, 3/24/2023. Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/28/2023 Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/29/2023 Resident 2 reported a pain level of 6 and Ibuprofen 400 milligrams was administered. During an observation and interview on 5/25/2023 at 1:20 p.m., on the unit, with Resident 2, in Resident 2's room, Resident 2 stated feels so-so, pain medication given but doesn't seem to help (Ibuprofen). Resident 2 was wearing gray nonslip socks, no fall mat on either side of bed present. Resident 2 stated that call light doesn't work will call for assistance and the light will ring and ring and no one answers. Resident pressed call light and a Call Light Attendant (CLA) 1 responded within three minutes. During a review of Resident 2's Emergency Department (ED) Note/History and Physical (H&P) dated 2/25/2023, the ED Note/H&P indicated, .Left thigh pain with associated shortness of breath .reports that he was transferring from his bed to his bathroom when he fell . No head strike or loss of consciousness reported .Final Diagnosis .closed fracture of proximal end of left femur (broken thigh bone) .ED MD consulted Orthopedic Surgeon. The ED Note/H&P indicated .spoke to [Orthopedic Surgeon] who says that [Resident 2] would need to be admitted for a revision . Consult to Orthopedic Surgery .Left femur peri implant fracture .HPI . [Resident 2] is a [AGE] year-old male with left femur peri implant fracture. He was seen and evaluated at [local GACH] sometime in January when [Resident 2] was treated with a short intramedullary nail to the left femur. Apparently, [Resident 2] sustained recurrent injury while in rehabilitation that resulted in a peri implant femur fracture [break(s) around joint replacement prostheses (artificial body part, such as a leg, a heart or a breast implant) are commonly called periprosthetic fractures whereas fractures around plates, rods, or prostheses]. [Resident 2's] fracture began at the distal aspect of the intramedullary nail and has resulted in shortening and mechanical failure of the current implant. During a review of Resident 2's hospital records of Resident 2's [X-Ray] (picture through the body to see bones) Femur Left Final Result (XR [X-ray] femur 2 or more views), dated 2/25/2023, the XR femur indicated, .Reason for exam .Left femur pain status post (after) femur fracture .Finding/Impression .ORIF [Open reduction and internal fixation- a surgical procedure for repairing fractured bone using either plates, screws or a rod to stabilize the bone changes] of the left femur. 2.During a review of Resident 3's Progress Note dated 3/20/2023 at 12:35 a.m., (fall event number one). The Progress Note indicated the Registered Nurse (RN) was called to resident's room approximately 12:30 a.m. on entering room, resident was found lying on the floor on the right side of his bed on his back. Upon assessment [Resident 3] was noted to be bleeding from the back of his head and his left eyebrow where he sustained a laceration no loss of consciousness noted alert with confusion, pressure applied to bleeding laceration, 911 was called and pt [patient] was taken to the Emergency Department (ED) at a [local GACH] . During a review of Resident 3's Progress Note dated 3/20/2023 2:45 a.m. (fall event number two) the Progress Note indicated Pt had an unwitnessed fall at [1:00 a.m.]. Pt was yelling help from his room, call light had just turned on per assigned CNA. [Two] CNAs responded to room, at this time, pt was found lying face down with blood on floor. Pt was lying on floor right hand side of bed, with chair between window and bed staff immediately called out for RN charge nurse to respond to room for further assessment. [Two] X2 nurses responded and found patient on his back, with large amounts of blood on floor and surrounding patient. Pt had a laceration to left elbow, under L (left) eye L eyebrow and back of head. UTD [Unable to Determine] size of lacerations, bed was in lowest position, pt was unable to state how he fell or what caused him to fall. [Ambulance] was called immediately, arrived within just a couple of minutes, pt was refusing to allow staff to apply pressure drsg [dressing] to wound laceration, continuously rips drsg off. Pt repeating I'm ok pt awake, responsive verbally with forgetfulness. Pt was lifted by four CNA's and the paramedics onto gurney pt to be assessed at [GACH] During a review on 4/13/2023 of Resident 3's Face Sheet (FS) dated 4/13/2023, the FS indicated, Resident 3 is a [AGE] year-old and was initially admitted to the facility on [DATE], with a history of falls .Polycythemia Vera (a disease in which there are too many red blood cells in the bone marrow and blood, causing the blood to thicken) .muscle weakness .Wernicke's Encephalopathy (a neurological disorder caused by thiamine (a nutrient in the vitamin B complex that the body needs in small amounts to function and stay healthy) deficiency, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements, and unsteady gait) .cognitive communication deficit (difficulty with thinking and how someone uses language) .Type 2 Diabetes Mellitus (diabetes- a disease of too much sugar in the blood) .difficulty walking . Resident 3 was readmitted to the facility on [DATE], (after a hospital stay from 3/20/2023 to 3/27/2023 or seven days), with diagnoses which included .Intracranial Injury (injury to the skull following a head strike) with Loss of Consciousness (fainting) .Traumatic Subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness .fall .Fracture .cervical vertebra [bone] .base of skull .orbit, . Laceration (cut) of head . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1 of Resident 3's Risk History report (history of reported events (such as falls, injury or behavioral)) dated 4/14/2023, the MDSC 1 stated Resident 3 had a long history of both witnessed and unwitnessed falls. MDSC 1 stated the last reported fall (unwitnessed) was on 12/2/2022. The Risk History report indicated Resident 3 had an unwitnessed fall on 12/2/2022, 1/15/2022, 12/6/2021, 6/15/2021, 6/7/2021, 1/30/2021, 1/29/2021, 1/28/2021, 1/27/2021, 9/2/2017, 4/21/2017. The report indicated Resident 3 had a witnessed fall on 10/30/2021- with head injury, 1/27/2021, 11/23/2019- with head injury, 9/25/2017- with head injury. During a concurrent interview and record review on 4/14/2023 at 09:15 a.m., with the MDSC 1, of Resident 3's MDS dated [DATE], the MDSC 1 stated Resident 3's MDS Section C- BIMS was 6 of 15 points (indicating severe cognitive impairment in decision making .). The MDS Section G indicated Resident 3 needed one-person physical assist for all ADL's . During an observation on 4/14/2023, at 10:20 a.m., in Resident 3's room, Resident 3 was lying in bed, on his back; the bed was in low position (close to the floor). Resident 3 had eyes open, responded to name, nodded, and smiled, but did not speak. Resident 3 held a brown ball, about the size of a golf ball, in his right hand. This ball was presumed to be feces as there was a strong mal odor in the room and brown substance smeared on Resident 3's hands, clothing, and sheets. Facility staff was immediately alerted to this observation. During a review of Resident 3's AFRE, dated 12/2/2022 (before the fall with injury on 3/20/2023), the AFRE indicated, .Score: 8 (which indicated Resident 2 was a low risk for falls) .resident had an unwitnessed fall while attempting to transfer self to the restroom without assistance. Resident was in wheelchair and did not lock the breaks when transferring resulting in a head injury to the right side of head, x-ray has been ordered. Resident also has skin tear on the right elbow. Resident also has complained of pain to the left knee no skin tear noted . During a review of Resident 3's AFRE .dated 3/27/2023 (after the fall with injury on 3/20/2023), indicated, a .Score: 15 (which indicated Resident 2 was a moderate to high risk for falls) . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with the MDSC 1 of Resident 3's Care Plan (CP), dated 3/27/2023, the CP indicated, .Resident had an unwitnessed fall with injury 3/20/2023 .Date initiated: 3/20/2023 .Goal [Resident 3] will have no further complications r/t [related to] fall until next review date . Date Initiated: 3/20/2023 .Target Date: 4/11/2023 .Interventions .frequent room check for safety . prompt response to call light for assistance . The MDSC 1 stated the problem with these interventions was they were not specific enough. The MDSC 1 stated that as written, the current care plan interventions indicating frequent, and prompt left the timing open to individual interpretation versus clear instruction for how often the staff should be checking for safety. The MDSC 1 stated that what frequent or prompt means to one person may not be the same to another. The MDSC 1 stated that Resident 3's history and risk of falls in the facility both witnessed and unwitnessed, was known to licensed nurses. The MDSC 1 stated that Resident 3's CP did not address this history and risk for falls before the 3/20/2023 fall with injury . The MDSC 1 provided an electronic version of Resident 3's CP for Focus .Long Term/Custodial Placement, initiated 1/13/2022, which indicated history of falls with fracture to right hip but did not address fall prevention/safety interventions. The facility was not able to provide any documentation of care planned fall prevention interventions prior to 3/20/2023. During a record review of Resident 3's Progress Notes dated 4/27/2023, the Progress Note indicated the . resident had an unwitnessed fall .4/27/2023 2:00 a.m.attempting to self-transfer to wheelchair .orders . send to ER (emergency room ) . sustained an unwitnessed fall sustaining multiple skin tears to right arm . per staff there is a change in baseline mentation . 4/27/2023 7:55 a.m.he stated he was trying to get to his wheelchair. During an interview on 5/25/2023 at 11:37 a.m. with CNA 1, CNA 1 stated Resident 3 had two falls on 4/27/23 and was taken to GACH for evaluation. CNA 1 stated Resident 3 was readmitted later that day with a neck brace. CNA 1 stated Resident 3 has been at the facility for approximately six years and has recently declined. CNA 1 stated he was able to walk but now he keeps falling. During a concurrent observation and interview on 5/25/2023 at 11:58 a.m., with Resident 3 in Resident 3's room, Resident 3 was lying on his back in his bed with a brace on his neck. The privacy curtain was pulled around Resident 3 blocking him from view to staff at Nurse's Station and in the hall. Resident 3 appeared to be confused and when asked if he remembered falling, he pointed to the floor. Resident 3 did not speak or communicate by nodding his head. During an interview and record review on 5/25/2023 at 12:53 p.m., with the MDSC 1 The Fall Check List was reviewed. The Fall Check List indicated; the steps required after each resident falls. Risk Management Entry . Fall Evaluation .: Care Plan with Immediate Fall Intervention . The MDSC 1 stated the facility was not following the facility's Fall P&P or the Care Plan P&P. The MDSC 1 stated there were no new planned interventions put into place for Resident 3 following the falls on 4/27/2023. 3. During a review of Resident 7's Nursing Situation-Background-Assessment-Recommedation (document which provides a framework for communication between members of the health care team about a patient's condition) dated 3/17/2023, indicated, Resident 7 .was seen falling in the bathroom. Patient was toileting and was trying to close the door to the bathroom. Patient c/o [complained of] pain in the hip . this started on: 3/17/2023 [12:10 a.m.] .Patient was sent out to hospital due to the hip pain possible fracture . During a review of Resident 7's General Acute Care Hospital (GACH) Medical Records, the Emergency Department History and Physical (H&P) indicated resident 7's Chief Complaint was due to a fall with resultant hip pain. Resident 7 was admitted to the GACH for right hip fracture and taken to surgery on 3/18/2023 for an .Open Reduction Internal Fixation (ORIF) right proximal (situated near the point of attachment) femur (large bone in the lower extremity). Resident 7's hospital stay was from 3/17/2023 to 3/20/2023 for three days and was readmitted to the facility on [DATE]. During a review of Resident 7's Admission Record (AR- a document containing resident profile information), dated 4/13/2023, indicated, Resident 7 a [AGE] year-old was initially admitted to the facility on [DATE] .dementia (memory loss, poor decision making-skills) .difficulty in walking .muscle weakness .cognitive communication deficit .fall .hypertension (high blood pressure) .macular degeneration (a distortion or loss of central vision) . Resident 7's AR indicated she was readmitted to the facility on [DATE] with a diagnosis of right femur fracture (broken thigh bone). During a review of Resident 7's Minimum Data Set (MDS) assessment, dated 4/13/2023, Section C, indicated, Resident 7's Brief Interview of Mental Status (BIMS) was 3 of 15 points (indicating severe cognitive impairment) .Section G (functional status), and ADL (Activities of Daily Living) Assistance indicated Resident 7 needed .one-person physical assist . for all ADL's. During a review of Resident 7's {name of facility coorporation] Fall Risk Evaluation (AFRE) dated 10/16/2022, (before the fall with injury on 3/17/2023) indicated, .Score: 11 (which indicated Resident 7 was at a medium risk for falls) . During a review of Resident 7's AFRE dated 3/20/2023 (after the fall with injury on 3/17/2023), indicated a .Score: 18 (which indicated Resident 7 was a high risk for falls) . During a review of Resident 7's IDT [interdisciplinary team] Note dated 3/21/2023 indicated .Created Date [Late Entry] 4/17/2023 by SSD [Social Service Department] .IDT met to discuss Resident's fall in bathroom on 3/17/2023 . ambulated with front wheel walker to bathroom. After [Resident 7] used the toilet, nurse witnessed her pull pants up without difficulty.Nurse observed as [Resident 7] attempted to close bathroom door with only one hand on her walker in front of her. [Resident 7] lost her balance and fell on to her right side and slightly backwards landing on right hip . IDT recommends that staff assist all toileting activities . During a concurrent interview and record review on 4/14/2023 at 9:15 a.m., with MDSC 1 of Resident 7's Care Plan (CP), dated 4/14/2023, the CP indicated .Focus [Resident 7] has a right hip fracture r/t fall .Date initiated: 3/20/2023 .Goal [Resident 7] will remain free from complications r/t fracture until next review date . Date Initiated: 3/20/2023 .Revision on 3/22/23 .Target Date: 4/9/2023 .Interventions .Give medications as ordered. Monitor/document for side effects and effectiveness .Monitor/document/report PRN [as needed] s/sx [signs/symptoms] or complications related to fracture .Reposition as necessary to prevent skin breakdown. Prevent 90-degree flexion to prevent circulation problems . Focus [Resident 7] has an ADL self-care performance deficit r/t [related to] muscle weakness, advanced Dementia . Date initiated: 5/11/2022 .Revision on 5/28/2022 .Target Date: 4/9/2023 .Interventions .Toilet use: The resident requires limited to extensive assist of (1) staff for toilet use .Focus [Resident 7] is at risk for falls r/t Deconditioning, Gait/balance problems, impaired balance, highly impaired vision, Dementia, ambulatory, wandering behavior .Date initiated: 5/13/2022 .Goal [Resident 7] will be free of minor injury through the review date . Date Initiated: 5/13/2022 .Revision on 5/28/2023 .Target Date: 4/9/2023 .Interventions .Anticipate and meet the resident's needs .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility .Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room .Monitor the resident to ensure use of walker when ambulating to aid in fall prevention .Non slid strips to left side of bed [date initiated 10/17/2022] . PT evaluate and treat as ordered or PRN . The MDSC 1 stated that there was no documentation in the EMR of an IDT meeting or notes. MDSC 1 stated a weekly nurse assessment was done on 3/5/2023 but not after injury. The MDSC 1 stated another weekly nurse assessment should have been done by the licensed nurse on 3/12/2023 but was not done possibly due to hospitalization . The MDSC 1 stated that he was unable to find documentation of any nursing weekly notes after the fall. The MDSC 1 stated it is his expectation that licensed nurses perform weekly assessments for all residents and that any event such as an accident or fall would trigger a head-to-toe assessment be completed. The MDSC1 stated that a fall risk assessment should be completed on admission, and as needed if there is a change in condition and after any falls with a report made to the ADM or DON. The MDSC 1 stated Resident 7's CP did not reflect the IDT recommendations discussed on 3/21/2023. The MDSC 1 stated that the fall could have been prevented if licensed nurses had followed the care plan intervention that indicated that Resident 7 required 1 person assistance during toileting. During a review of the Medication Administration Record (MAR) dated 3/1/2023, the MAR indicated, on 3/20/2023 Resident 7's pain level was a 3 (physician's order dated 5/11/2022 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Acetaminophen (pain reliever) 650 milligrams was administered. Resident 7 reported a pain level of 5 and Acetaminophen 650 milligrams was administered, 3/23/2023 Resident 7 reported a pain level of 4 and Acetaminophen 650 milligrams was administered, 3/25/2023. Resident 7 reported a pain level of 8 and Acetaminophen 650 milligrams was administered, 3/29/2023. Resident 7 reported a pain level of 7 and Acetaminophen 650 milligrams was administered, 3/30/2023. During a review of the Medication Administration Record (MAR) dated 3/1/2023, the MAR indicated, on 3/25/2023 Resident 7's pain level was a 6 (physician's order dated 3/25/2023 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Ibuprofen (pain reliever) 400 milligrams was administered. Resident 7 reported a pain level of 5 and Ibuprofen 400 milligrams was administered, 3/28/2023. Resident 7 reported a pain level of 6 and Ibuprofen 400 milligrams was administered, 3/29/2023. Resident 7 reported a pain level of 8 and Ibuprofen 400 milligrams was administered, 3/31/2023. During a review of the Medication Administration Record (MAR) dated 4/1/2023, the MAR indicated, on 4/4/2023 Resident 7's pain level was a 9 (physician's order dated 5/11/2022 indicated, monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible .) and Tramadol (pain reliever) 50 milligrams was administered. Resident 7 reported a pain level of 9 and Tramadol 50 milligrams was administered, 4/4/2023. Resident 7 reported a pain level of 9 and Tramadol 50 milligrams was administered, 4/5/2023. Resident 7 reported a pain level of 5 and Tramadol 50 milligrams was administered, 4/7/2023. Resident 7 reported a pain level of 6 and Tramadol 50 milligrams was administered, 4/10/2023. Resident 7 reported a pain level of 6 and Tramadol 50 milligrams was administered, 4/11/2023. Resident 7 reported a pain level of 6 and Tramadol 50 milligrams was administered, 4/12/2023. During an observation and interview on 5/25/2023 at 1:10 p.m., on the unit, in Resident 7's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, [Resident 7] should have blue socks, has not been enforced. I know

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as being a fall risk, with a history of falls in the facility, and a known behavior of getting up unassisted, received adequate supervision and assistance to prevent falls and injuries when Resident 1 was left unattended sitting in her wheelchair and was not provided one on one supervision in accordance with the comprehensive care plan. This failure resulted in Resident 1's fall, left femoral fracture (broken bone in the hip) with ejection of left hip prosthetic device which required an open reduction and internal fixation (ORIF- is a type of surgery used to stabilize and heal a broken bone), 11 day hospitalization from [DATE] to 2/22/2021 and associated pain and suffering. Resident 1 was discharged to home with home health care following hospitalization . Findings: During a telephone interview with Certified Nursing Assistant (CNA) 1, on 3/2/2021, at 4:43 p.m., CNA 1 stated she had been working in the facility for [AGE] years. CNA 1 stated she was familiar with Resident 1's care. CNA 1 stated Resident 1 was a new admit in the facility and was high fall risk. CNA 1 stated, [Resident 1] is confused. She is hopelessly confused. You turn around and she gets up. Every time you turn around, she is very fast . We don't have staff for one on one [supervision] . [Management] has not been utilizing [staffing] registry. [Having registry] is better than residents getting hurt . During a concurrent telephone interview and record review with Registered Nurse (RN) 1, on 3/2/2021 at 6:15 p.m., RN 1 reviewed Resident 1's progress notes dated 2/11/2021 which indicated, . At [approximately] 0230 [a.m.] resident was noted sitting on the floor by the foot of the bed of room 23 B. Resident states she fell down. Resident in 23 B called for nurse and stated she saw Resident 23 C [Resident 1] stand up at the foot of bed of 23 B and fall down. Resident denies hitting head. Resident surgical site to left hip is intact . Nursing staff took turns watching patient 1 on 1 while up in wheelchair by nursing station [due to] constant attempts to get out of chair and bed . attempting to get out of bed unassisted, having to be assisted back into bed. Resident crawling on floor by her bed . RN 1 stated Resident 1 fell on his shift [night shift] and was a very high risk for falls. RN 1 stated Resident 1 kept getting up unassisted and required one on one supervision of staff to prevent falls. RN 1 stated he informed the morning shift Licensed Nurse (LVN 1) Resident 1 fell on his shift and required one on one constant supervision. During a telephone interview with CNA 2, on 3/2/2021, at 10:15 p.m., CNA 2 stated Resident 1 was a high risk for falls and required constant supervision. CNA 2 stated, . [Resident 1] needs constant supervision all the time because she kept getting up. It's not safe to leave her alone by herself. I told the a.m. shift [CNA 1] during the report shift change on 2/11/21 [Resident 1] needs one on one constant supervision . During a telephone interview with CNA 1, on 3/4/2021, at 3:30 p.m., CNA 1 stated Resident 1 required one on one constant supervision. CNA 1 stated Resident 1 fell on [DATE] at 9:30 a.m. because she stood up from her wheelchair unassisted. CNA 1 stated Resident 1 fell again on 2/11/2021 at 11:30 a.m. across her room. CNA 1 stated she did not supervise and provide one on one supervision for Resident 1 because she was busy with other activities of daily living with other residents assigned to her. CNA 1 stated there was no staff member assigned specifically to constantly supervise Resident 1. CNA 1 stated, . [Resident 1] is extremely confused. There is no way you could tell or give her directions not to stand up unassisted. Within a few minutes, she will stand up. I remember the 11:30 a.m. fall. I saw several staff in the doorway across her room. I was on the next room providing care to another resident. She fell in the doorway next to her room. She was not assigned on one on one. She was supposed to be one on one supervision. [Her] left leg was protruded, and she was in so much pain. [The fall] would have been prevented if she was placed on one on one supervision but it did not happen . During a concurrent telephone interview and record review with Licensed Vocational Nurse (LVN) 1, on 3/6/2021, at 8:37 a.m., LVN 1 reviewed Resident 1's progress notes and was unable to find documentation on how Resident 1 fell on [DATE] at 11:30 a.m. LVN 1 stated she should have documented how Resident 1 fell and how they found Resident 1 when she fell on [DATE] at 11:30 a.m. and it was not done. LVN 1 stated Resident 1's fall happened on 2/11/2021 and it has been 23 days since Resident was sent out for evaluation in the General Acute Care Hospital (GACH) and she did not know whether Resident 1 would come back to the facility. LVN 1 stated she should have documented the details of how Resident 1 fell on [DATE] in Resident 1's clinical record before her shift ends and it was not completed. LVN 1 reviewed Resident 1's nurses notes dated 2/11/2021 at [4:24 p.m.] which indicated, . Called [name of MD] regarding resident fall at 11:30 [a.m.]. as per [name of MD], wants left hip x-ray to be done . LVN 1 stated Resident 1 was very confused, disoriented and was a high risk for falls. LVN 1 stated Resident 1 fell two times on her shift. LVN 1 reviewed Resident 1's progress notes dated 2/11/2021 at 9:58 a.m., which indicated, . As per staff, resident was sitting in her wheelchair, stood up, pivot to right side and slide on the floor, did not hit head, resident confuse, resident up in wheelchair sitting in front of nurse's station. Resident has to be frequently reminded of not getting up from her wheelchair . LVN 1 stated Resident 1 was very confused and could not follow directions such as not getting up unassisted. LVN 1 stated, . [Resident 1] is very confused, disoriented, very restless and could not remember anything. One minute she will get up again. She fell across her room. She was sitting up on the nurse's station. We are busy . It was a busy time. It happened noon time. The CNA's were passing lunch trays . [Resident 1] was not on one on one supervision . I don't know the facility protocol on one on one supervision. I know she is on frequent checks. I don't know what one on one supervision is . [Resident 1] needs constant supervision . LVN 1 stated there was no staff assigned to provide one on one supervision with Resident 1. LVN 1 reviewed Resident 1's plan of care dated 2/11/2021 which indicated, . 1 on 1 monitoring until restlessness resolved . LVN 1 stated Resident 1's plan of care was not followed and Resident 1 should have been provided one on one supervision while being restless and it did not happen. LVN 1 stated when Resident 1 fell on [DATE] at 11:30 a.m., she was in pain and she administered a pain medication to Resident 1. LVN 1 stated. She was screaming. She was in pain. I called the doctor and he ordered an x-ray . LVN 1 stated RN 1 informed her during the shift report that Resident 1 fell on the night shift and RN 1 was the one who put Resident 1 on one on one supervision and it was not implemented in her shift. LVN 1 stated, It is very important to follow care plan. [Resident 1] was not put on one on one supervision . During a review of the facility's Policy and Procedure (P&P) titled, Late Entry Documentation dated 10/2005, indicated, If a nurse or health care professional discovers that he/she has failed to document pertinent information regarding a resident in their medical record (after a short period of time has passed), the documentation of a Late Entry will be permitted . The facility document titled, Licensed Vocational Nurse Job Description dated 6/2018, indicated, . Essential Job Functions . Adhere to state rules and regulations concerning delivery of care and assures that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process . Implements appropriate nursing interventions consistent with the resident plan of care, plans for episodic nursing care and documents appropriately in the medical record. Assists with the modification of the plan of care through appropriate documentation in the medical record regarding resident surveillance and monitoring, observation for signs and symptoms and changes in resident condition . Implement plan of care consistently, effectively . with focus on resident centered outcomes. Identify rationale and anticipated outcomes for each nursing intervention. Assume responsibility for care interventions consistent with skill level and professional standards of care . Utilize professional and sound judgement in delivery of care which is cost efficient but does not jeopardize safe, effective care delivery . Supervise Certified Nurse Assistants and other personnel . Coach, counsel and assign Certified Nurse Assistants to provide quality resident care . During a concurrent telephone interview and record review with the Director of Nursing (DON), on 3/9/2021, at 9:16 a.m., The DON reviewed Resident 1's plan of care dated 2/11/2021 which indicated, . 1 on 1 monitoring until restlessness resolved . The DON stated Resident 1 was very confused and unable to follow simple commands and directions. The DON stated Resident 1 was a high risk for falls and had history of falls prior to getting admitted in the facility. The DON stated Resident 1's plan of care indicated Resident 1 was supposed to be on one on one supervision and it was not implemented. The DON stated, . Monitoring is different from one on one supervision. [Resident 1] should not be left by herself on the nurse's station or hallway because she is a high risk for falls . During a review of Resident 1's face sheet (a document with personal and medical information), dated 2/9/2021, the face sheet indicated Resident 1 was admitted to the facility with diagnoses which included fracture of the left femur (upper bone of the leg), history of falling, presence of left artificial hip joint, pain in left hip, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and Alzheimer's disease (irreversible, progressive disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). During a review of Resident 1's fall risk evaluation dated 2/9/2021, the fall risk evaluation indicated Resident 1's fall risk score was 20 which indicated Resident 1 was a high risk for falls. During a review of Resident 1's general acute care hospital (GACH) notes dated 2/11/2021, the GACH notes indicated, . History . [status post] fall this a.m. Pain in left hip, rotated left lower limb .[patient] had a fall at comfort care center with trauma to left leg in the a.m. Patient is confused . Impression . Acute displaced fracture of the proximal shaft (femoral head pointed in a medial, superior and slightly anterior direction) of left femur . Left hip prosthesis, the inferior end of which is displaced and outside the bone . Assessment . left femoral fracture with ejection of left hip prosthetic device . During a review of Resident 1's GACH Discharge Summary notes dated 2/22/2021, the discharge summary notes indicated, . Hospital Course . This is an [AGE] year old severely demented female who came to [GACH] on 2/11/2021 from [name of skilled nursing facility] with left femur fracture. Patient had a fall at [name of skilled nursing facility] with trauma to left leg on the day of presentation. Patient was confused. She has severe dementia. She was recently living in [name of skilled nursing facility] . X-ray of the pelvis shows . acute displaced fracture of proximal shaft of femur and left hip prosthesis . Patient was taken to the [Operating Room] on 2/15/2021 and had ORIF done of left femur with revision of components. She also had an open wound close to her left elbow with her bones showing . Spoke to her son, multiple times . Her son was adamant about . not sending her to rehab again since she had fallen at the rehab . Patient will be discharged home with home health . During a review of the facility's P&P titled, Comprehensive Care Plans dated 11/2017, indicated, . Purpose . To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental, and psychosocial needs . Policy . The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each residents that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment . Guidelines . 1. The care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences . 4. Interventions identified by the comprehensive care plan will be provided by qualified, competent persons. 5. Services provided or arranged by the facility, as outlined by the comprehensive care plan will meet professional standards of quality . 7. The care plan will be person-specific with measurable objectives, interventions, and timeframes. It will address goals, preferences, needs and strengths of the resident. 8. Care plan will include . a. The services the facility will provide to assist the resident to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing . 12. Resident care needs and care plan interventions will be communicated to direct care staff . During a review of the facility's P&P titled, Quality of Care, Accident Hazards/Supervision/Devices dated 7/2018, indicated, . Purpose . To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents . Policy . The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents . Guidelines . 1. The facility will develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. 2. The facility recognizes the high-risk nature of the facility population and setting . 4. All levels of staff, residents and families will be included in training and discussions on safety . 6. Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Interventions will be modified when necessary . 8. Individualized interventions will be developed to reduce the potential for accidents. 9. The facility system may include . 1. Identification of potential hazards in the resident environment and the risk of a resident having an avoidable accident. b. Evaluation of hazards and accident risk data, which may include prior accidents/incidents and trends. c. Analysis to identify the root causes of hazards and accident risks. d. Identification of or development of interventions based on the severity of the hazard and immediacy of risk. 10. Interventions will be based on the results of the evaluation and analysis of information related to hazards and risks. Interventions will be consistent with professional standards. 11. Resident specific interventions will be reflected in the resident's person-centered, individualized care plan. 12. Care plan intervention will be monitored for effectiveness and modified as necessary to increase the effectiveness. 13. Monitoring and modification process may include: a. Verifying that interventions are implemented as planned; b. Evaluating the effectiveness of interventions; c. Modifying or replacing interventions as needed, and d. Evaluating the effectiveness of new interventions. 14. The facility may use supervision as an intervention to mitigate accident risk . Risks and Environmental Hazards . 2. Various factors influence resident vulnerability. These may include functional status, medical condition, cognitive abilities, mood, and health treatments. Resident vulnerability may change over time and need on-going assessment . Falls . 2. When a resident experience a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent, and individualized interventions to reduce the likelihood of future occurrences. 3. The facility will initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls .

Based on interview and record review, the facility failed to provide pain management services consistent with professional standards of practice and facility policy and procedure for one of three sampled residents (Resident 1) when Resident 1 was admitted on [DATE] with severe pain caused from surgical repair of right leg fracture (broken bone) and effective pain medication was not administered. Resident 1 experienced uncontrolled severe pain from 12/22/19 at 9 p.m., through 12/23/19 at 5 a.m., (eight hours) and Registered Nurse (RN) 1 did not provide effective pain relief medication, License Nurses (LN) did not reassess pain within an hour after administering pain medication and did not call the physician and pharmacy to expedite medication delivery. These failures resulted in Resident 1 experiencing severe pain and prolonged suffering from 12/22/19 through 12/23/19 and was not able to sleep all night. Resident 1 made the independent decision to call 911 emergency services on 12/23/19 to be transported to an acute care hospital emergency department to seek effective pain management at the acute care hospital. Findings: During a telephone interview on 12/30/19, at 10:07 a.m., with Resident 1, Resident 1 stated on 12/22/19 at 8 p.m., she experienced severe pain 10 out of 10 pain (10 - worst possible pain) and had received pain medication. Resident 1 stated the pain medication she received at 8 pm was not effective. Resident 1 stated she notified registered Nurse (RN) 1 that she experienced severe pain to her right hip that prevented her from sleeping all night. Resident 1 stated at 1 a.m., on 12/23/19 she asked RN 1 for pain medication and RN 1 told her that he could not give her pain medication until 4:00 a.m. Resident 1 stated by 3:00 a.m. she was screaming, yelling out in pain, (10 out of 10 pain) and hitting her bedside table stating, Please bring me my (pain) medication. Resident 1 stated no matter how long she yelled and screamed, RN 1 would not bring her pain medication. Resident 1 stated because she could not tolerate the severe, unrelieved pain she had no other choice than to call 911 on 12/23/19 requesting an ambulance to take her to an acute care hospital in order to obtain relief of her pain. Resident 1 stated the acute care hospital emergency room gave her pain medications to control her pain. Resident 1 stated she did not want to return to the facility and requested to be discharged to her home. During a review of the clinical record for Resident 1, the Face Sheet (document containing resident personal information), undated indicated, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 1's Brief Interview for Mental Status (BIMS- assessment of a resident's cognitive status) dated 12/21/19, the BIMS indicated Resident 1 was cognitively intact. During a review of Resident 1's Progress Notes, dated 12/21/19, at 2:46 a.m., the Progress notes indicated, .Patient states medication is q (every) 4 hours, patient states she needs pain prevention to keep hre (her) pain under control and [MEDICATION NAME] (controlled narcotic (a drug that relieves pain) that can only be obtained with a doctor's prescription) q (every) 8 hrs (hours) is not soon enough .spoke to MD .orders received to start [MEDICATION NAME] 5mg give 2 tabs po (oral) q 4 hrs prn (as needed) . During a review of Resident 1's Physician Order dated 12/21/19, at 2:46 a.m., indicated, [MEDICATION NAME] HCL ([MEDICATION NAME]) - 5 MG (milligrams - unit of measure) Give 2 tablets by mouth every 4 hours as needed for pain. During a review of Resident 1's admission Pain Evaluation dated 12/20/20 indicated, .What makes pain worse? (Resident 1's response) moving, going a long time without medication .pain? 10 out of 10 . Does pain negatively impact (Resident 1's) sleep and rest, social activities, appetite, physical activity and mobility, (and) emotions . (Resident 1's response) yes . Treatments/modalities: describe all methods of alleviating pain and their effectiveness (staff treatment plan response) re positioning, evaluation (sic) and (give) pain medication . During a concurrent interview and record review on 1/8/20, at 8:21 a.m., with RN 1, RN 1 reviewed Resident 1's physician order script (prescription), dated 12/21/19, at 2:46 a.m., which indicated, [MEDICATION NAME] HCL tablet 5 MG Give 2 tablets by mouth every 4 hours as needed for severe pain . RN 1 stated Resident 1 was in a lot of pain and he could not get Resident 1's pain under control. RN 1 stated he called Resident 1's physician on 12/21/19 and obtained an order to administer [MEDICATION NAME] every 4 hours as needed for sever pain. RN 1 stated he faxed the script to the physician and the pharmacy to obtain the pain medication on 12/21/19 at 2:49 a.m. RN 1 stated the pharmacy called him and informed him that the script needed to be signed and dated by Resident 1's physician to make the script valid. RN 1 stated he faxed a blank script to the pharmacy and Resident 1's physician and the physician needed to fill out the script with the DEA (number issued by the U.S. Drug Enforcement Administration) number, medication name and dispense (number of tablets sent by pharmacy), refills, maximum daily dose, physician signature and date. RN 1 stated once he faxed the pharmacy the incomplete script, he did not check with pharmacy to ensure the script was completed by the physician and faxed back to the pharmacy. RN 1 stated he did not inform the oncoming shift nurse that he had faxed an incomplete physician script to the pharmacy for Resident 1's pain medication for the oncoming nurse to check with the pharmacy and ensure the pain medication was received. RN 1 stated on 12/22/19 at 8 p.m. the last dose of [MEDICATION NAME] for severe pain was administered to Resident 1. RN 1 stated on 12/23/19 at approximately 3 a.m. Resident 1 requested pain medication because she had severe pain. RN 1 stated he observed Resident 1 was moaning in pain, was short of breath, and had facial grimacing. RN 1 stated Resident 1's [MEDICATION NAME] 5 mg was not available for Resident 1. RN 1 stated the prescription was not filled by the pharmacy because Resident 1's script was not valid. RN 1 stated at approximately 4:30 a.m. Resident 1 called 911 for an ambulance and was taken to the hospital for pain control. RN 1 stated Resident 1 was taken to the hospital by the ambulance at approximately 4:45 a.m. RN 1 stated Resident 1's pain and suffering could have been avoided if he had ensured the script was completed by the physician on 12/21/19 prior to faxing the script to the pharmacy. During a review of the facility document titled, Job Description: Registered Nurse dated 6/2018, indicated, Job Summary: Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit. Assess resident needs . administer nursing care, evaluate nursing care . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . During a review of Resident 1's EMS (emergency medical service) Ambulance report dated 12/23/19, indicated, Call received (at) 4:38 am .at PT (patient) side 4:46 am .PER PT SHE HAS BEEN IN PAIN ASKING FOR MEDICATION FOR THE PAST 4 HOURS. THE RN SAID THAT THEY DO NOT HAVE ANY MORE MEDICATION TO GIVE HER AND THE MD (medical doctor) WAS NOT ANSWERING PHONE CALLS. PT QUESTED TO BE TRANSPORTED TO THE ER (emergency room ) FOR PAIN CONTROL . Transport (from facility) 5:05 a.m., (arrived at hospital) door at 5:25 a.m. During a review of Resident 1's Hospital emergency room (ER) report dated 12/23/19, at 6:27 a.m., indicated, . (Resident 1) (complaint R (right) hip pain s/p (status [REDACTED].course/duration of symptoms is constant . right hip .Pt report having hip surgery 6 days ago, and states she has not been receiving medication as scheduled . active problems: Post-operative pain (and) [MEDICAL CONDITION] .plan . ( [MEDICATION NAME] (strong pain medication), [MEDICATION NAME] (anxiety medication) and [MEDICATION NAME] (pain medication) were administered) . During a concurrent interview and record review on 1/8/2020, at 8:40 a.m., with RN 1, RN 1 reviewed the facility policy and procedure titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, dated 1/1/12 indicated, .Facility should ensure that all medications and Biological orders are written, dated and signed by Physician/Prescriber .Orders that may not be accepted by the pharmacy .Orders with missing or incomplete information .Orders that are not accepted by the Pharmacy are rejected .Facility should contact Physician/Prescriber when staff is notified by Pharmacy of an order requiring clarification . RN 1 stated the facility's policy was not followed when he did not follow up to ensure the script was valid. RN 1 stated he should have not left his shift on 12/21/19 until he ensured the script was valid. During a review of name of pharmacy fax sent to facility, dated 12/24/19, the fax indicated, PT (Resident 1) . Please follow up (with) prescriber for valid prescription to dispense controlled medication: [MEDICATION NAME] IR 5 mg tab(let) .pharmacy tried to call the Dr. (doctor) for a verbal (prescription) on the following dates and times 12/21/19 at 10:31 am . 12/23/19 at 9:20 am . and 12/24/19 at 8:35 am and 9 :30 am Pharmacy faxed above note to the Dr . and the facility within the following dates and times 12/21/19 at 10:34 am and 12/24/19 at 8:34 am (times) 2 . During a telephone interview on 12/24/2020, at 10:48 a.m., with Staff Pharmacist (SP), SP stated pharmacy reached out to the facility on [DATE] to inform them that the order to change [MEDICATION NAME] every 4 hours was invalid since it did not have a date, physician signature and a DEA number. The SP stated it was the facility's responsibility to ensure the script was completed with all required information to be considered a valid script. During a concurrent interview and record review on 1/8/2020, at 12:00 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's physician order script for [MEDICATION NAME], dated 12/21/19 and stated the script was missing the DEA number, and the date the script would have been written by the physician. The DON stated the pharmacy would not fill the prescription when it was not complete with missing information such as the DEA number, physician signature and date. The DON stated licensed nurses should have followed up with the physician and pharmacy before the medication ran out. The DON stated Resident did not receive her pain medications in accordance with the physician orders and her pain was left untreated. During a review of the facility policy and procedure titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, dated 1/1/12, indicated, For hard - copy medical record, facility should ensure that all medications and biologicals orders are written, dated and signed by Physician/Prescriber .Orders that may not be accepted by the pharmacy from the electronic medical record system include the following . Orders missing or incomplete information . Orders that are not accepted by the Pharmacy are rejected and order rejection is communicated to the Facility customer for correction or clarification via phone, fax, or secured electronic transmission . During a review of Resident 1's clinical record, the Pain care plan dated 12/20/19, indicated, Problem: The resident (1) has pain r/t (related to) Fracture to right hip . Goal: the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain .Interventions: Evaluate the effectiveness of pain interventions EVERY SHIFT Review for . alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition . During a concurrent interview and record review on 1/8/20, at 9:20 a.m., with RN 2, RN 2 reviewed Resident 1's MAR indicated [REDACTED]. On 12/21/19 RN 2 administered [MEDICATION NAME] for a pain level of 7 of 10 at 11:59 a.m., and Resident 1 was not reassessed until 4:26 p.m. (5 hours later) by RN 3, Resident 1's pain level was 0. On 12/22/19 RN 2 administered [MEDICATION NAME] for a pain level of 7 of 10 at 8:16 a.m. and did not reassess the Resident 1 until 12:03 a.m., (3 hours 47 minutes later) Resident 1's pain level was 7. On 12/22/19 RN 2 administered [MEDICATION NAME] for a pain level of 7 of 10 at 1:05 p.m. and Resident 1 was not reassessed until 2:58 p.m., (1 hours 53 minutes later) zero pain level. RN 2 stated she would reassess Resident 1's pain level when it was time for the next dose to be administered. During a concurrent interview and record review on 1/8/2020, at 10:20 a.m., with RN 1, RN 1 reviewed Resident 1's Medication Administration Record [REDACTED]. RN 1 stated he documented in the Progress Notes that he reassessed Resident 1's pain level at 5:57 a.m., (3 hours after administration of pain medication) and Resident 1's pain level was 7 out of 10. On 12/22/19 RN 1 administered [MEDICATION NAME] 5 mg two tablets at 3:16 a.m. for a pain level of 10 of 10 and did not conduct a pain reassessment until 5:11 a.m., (1 hour 55 minutes later) and Resident 1's pain level was 7 out of 10. RN 1 stated the standard of practice was to reassess resident pain within 45 minutes to an hour after administering pain medication. RN 1 stated he should not have waited more than an hour to reassess Resident 1's pain to ensure she was receiving effective pain management and he did not do that. During an interview on 1/8/20, at 11:34 a.m., with the Director of Staff Development (DSD), the DSD stated the standard of practice was to reassess resident pain within 30 minutes after administering oral pain medication. The DSD stated licensed nurses should not have waited more than an hour to reassess pain after administering pain medication. The DSD stated the purpose of reassessing pain levels was to monitor effectiveness of the medication administered. The DSD stated if a resident used as needed pain medication around the clock the physician should have been notified to reevaluate the resident pain management for possible modifications and new interventions. During an interview on 1/8/20, at 12:15 p.m., with the DON, the DON stated the standard of practice was to reassess resident pain levels within 45 minutes after administering pain medications and that did not occur with Resident 1. During a review of the facility policy and procedure titled Pain Assessment and Management dated 3/2015, indicated, The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .The pain management program is based on a facility-wide commitment to residents comfort .Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .Assessing the potential for pain; effectively recognizing the presence of pain; identifying .pain .addressing the underlying causes of the pain; developing and implementing approaches to pain management .using specific strategies for levels and sources of pain .Monitoring (assess) for the effectiveness .Review the Medication Administration Record [REDACTED].Assessing pain . During a review of the Professional Reference titled, Improving Reassessment and Documentation of Pain Management dated 2008, http://heilbrunnfamily.rucares.org/assets/file/pain%20management.pdf indicated, .Pain should be reassessed after each pain management intervention, once a sufficient time has elapsed for the treatment to reach peak effect (for example, 15 to 30 minutes after a [MEDICATION NAME] medication and 1 hour after oral medication or nonpharmacologic intervention) .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person centered care plan for four of 10 sampled residents (Residents 46, 460, 101, and 60) when: 1. Resident 46 had a total of 21 falls between 1/3/18 and 10/3/18 and licensed nursing staff did not develop an individualized fall prevention care plan and implement effective interventions after each fall to prevent additional falls. These failures led to Resident 46's twenty-first fall on 10/3/19 which resulted in a nondisplaced fracture (the bone breaks either part or all of the way through but maintains its proper alignment) of distal nasal bone and uncontrolled nasal bleeding for a three-hour period. 2. Resident 460 was assessed as having impulsive behaviors, with poor safety awareness. Resident 460 was assessed as requiring two-person assistance with transfers, extensive assistance of one staff with dressing and toileting, and limited assistance with ambulation. Resident 460 had a total of 21 falls between 1/21/18 through 10/13/18. Fall risk prevention interventions for Resident 460's assessed needs were not developed and implemented on the care plan. This failure resulted in Resident 460 sustaining a skin tear to his nose and bleeding from the right knee after the 14th fall and a skin tear on top of the left hand after the 19th fall. 3. Resident 101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This failure resulted in Resident 101 falling on 5/16/19, transported to the hospital for treatment of [REDACTED]. 4. Resident 60's medication, [MEDICATION NAME] (treat and prevent chest pain), did not have an individualized care plan. This failure had the potential for Resident 60 to not receive appropriate care and needs to be able to attain the highest well-being. Findings: 1. During a review of the clinical record for Resident 46, the Face sheet (a document with personal identifiable information) dated 10/19/18, indicated Resident 46 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. in the blood supply to the brain). During a review of the clinical record for Resident 46, the Minimum Data Set (MDS) assessment (a resident assessment tool used to develop a plan of care) dated 9/19/18, indicated Resident 46's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 5 of 15 points, which indicated severe cognitive (pertaining to memory, judgement, and reasoning) impairment. The MDS assessment indicated Resident 46 required extensive assistance (staff provided weight-bearing support) to transfer from bed to chair. The MDS assessment indicated Resident 46 was unsteady when moving from one surface to another and was only stabilized with staff assistance. During an observation on 10/19/18, at 8:10 a.m., Resident 46 propelled himself in a wheelchair between two rooms across from the nurses' station. During an interview with Certified Nursing Assistant (CNA) 8, on 10/19/18, at 8:15 a.m., he stated Resident 46 was at high risk for falls and fell two weeks ago. During an interview with CNA 9, on 10/19/18, at 8:24 a.m., she stated Resident 46 had more than one fall. Resident 46 had poor balance and was unsteady when he walked. Resident 46 required assistance of one person when transferring from the bed to the wheelchair and to the toilet. During an interview with Resident 46, with non-English speaking staff present, (CNA 9), on 10/19/18 at 8:30 a.m., Resident 46 stated he did not use the call light but yelled for help if assistance was needed. CNA 9 stated Resident 46 did not use his call light to ask for help when needed because he had confusion and did not know how to use the call light. During an interview with CNA 9, on 10/19/18, at 8:43 a.m., she stated Resident 46 had a short term memory problem and had difficulty following direction. Resident 46 had multiple episodes of attempting to transfer himself from the bed without assistance. CNA 9 stated Resident 46 could take short steps but was unable to walk independently and used a wheelchair to move around. Resident 46 was able to hold his weight while standing beside the toilet when assisted by one person. During an interview with the Unit Manager (UM), on 10/19/18, at 8:51 a.m., she stated Resident 46 was pleasantly confused and was unable follow directions due to his confusion. During an interview with the Director of Nursing (DON), on 10/19/18, at 8:55 a.m., she stated after Resident 46's last fall on 10/3/18, a shorter wheelchair was provided, and dycem (a non-slip material) was placed on Resident 46's seat cushion. During a concurrent observation and interview with CNA 10, on 10/19/18, at 10 a.m., she stated, I can't remember when the dycem was in place. Right now he (Resident 46) doesn't have one. CNA 10 stated most of the falls happened during transfers. During a concurrent interview and record review with the DON on 10/19/18, at 10:36 a.m., she stated Resident 46 had 21 falls between 1/3/18 and 10/3/18. Twelve of 21 falls happened when the resident fell from the wheelchair on the following dates: 1/9/18, 2/2/18, 2/7/18, 2/23/18, 5/20/18, 5/24/18, 5/30/18, 6/28/18, 7/19/18, 9/6/18 (x2), and 9/26/18. Eight of 21 falls occurred from the bed on the following dates: 1/3/18, 3/18/18, 5/27/18, 6/16/18, 6/23/18, 8/31/18, 9/29/18, and 10/3/18. One of the 21 falls happened (8/25/18) when Resident 46 was ambulating. During a concurrent interview with the DON and the Minimum Data Set Coordinator (MDSC), on 10/19/18, at 10:40 a.m., the DON stated each of Resident 46's falls should have had a new intervention written on the care plan to attempt prevention of further falls. The DON stated the care plan did not have fall prevention interventions after each fall. During an interview with LVN 8, on 10/19/18 at 11:04 a.m., he stated each fall should have a short term care plan with individualized goals and interventions. LVN 8 stated when the short term care plan was resolved the applicable intervention would then be added to the long term care plan. LVN 8 reviewed the fall care plan and stated interventions after each fall were not implemented to prevent additional falls. LVN 8 stated the interventions that were added to the care plan would not prevent falls. During an interview with LVN 8, on 10/19/18, at 11:19 a.m., LVN 8 stated he had been providing care to Resident 46 for less than a year. LVN 8 stated Resident 46 required one staff to assist with activities of daily living (ADLs). LVN 8 stated it was not safe for Resident 46 to transfer without assistance as he was confused most of the time. LVN 8 stated Resident 46 called for help verbally when in the wheelchair and bed, and waved at staff for help. LVN 8 stated, Not even one moment that he (Resident 46) used his call light to my knowledge. LVN 8 stated a new intervention that was not previously used should have been added to the fall care plan after every fall. LVN 8 stated new interventions were added to the fall care plan but none of the interventions added would prevent falls. During a concurrent interview and record review with the DON on 10/19/18, at 1:53 p.m., she provided a fall care plan in which the interventions listed were marked with the date when the fall happened. The care plan intervention indicated, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Date Initiated 10/4/17. During a review of the facility policy and procedure titled, Falls and Fall Risk, Managing dated 12/07, indicated, Policy Statement (:) Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Prioritizing Approaches to Managing Falls and Fall Risk . 1, The staff . will identify appropriate interventions to reduce the risk of fall . 4. If falling recurs despite initial interventions, staff will implement additional of different interventions . 5. staff will try various interventions . until falling is reduced or stopped, or until the reason for continuation of falling is identified as unavoidable . During an interview with the DON, on 10/19/18, at 2:20 p.m., the DON stated, The resident has the potential to sustain a new injury without a new intervention in place. The DON was asked if the care planning policy was followed for falls that occurred without new documented interventions. The DON responded, No. During an interview with the DON on 1/17/19, at 11:04 a.m., the DON stated Resident 46 was assessed as having a BIMS score of 5 (cognitive impairment). The DON stated the intervention to encourage the usage of the call light was not appropriate for Resident 46 as he was unable to remember the instruction. The DON stated using this intervention alone would not prevent a fall and was not safe for the resident. The DON stated if an appropriate intervention were developed and implemented after each fall, succeeding falls could have decreased. The DON stated an intervention should be patient-centered and focused on the resident's specific needs and that did not occur. During a concurrent interview and record review with the DON on 1/7/19, at 12:15 p.m., she stated on 5/30/18 (Fall # 10) Resident 46 fell from the wheelchair. The care plan intervention following this fall, indicated, Demonstrated to resident how to use the call light and had resident demonstrated back. Make sure call light is within reach. The DON stated using a call light or demonstrating the use of a call light was a generic intervention and not a patient-centered intervention that would not prevent falls. During a concurrent interview and record review with the DON, on 1/7/19, at 12:30 p.m., she stated on 6/16/18 (Fall #11) Resident 46 fell from the bed. The care plan intervention indicated, Continues to educate the importance of calling for assistance to prevent further falls. The DON stated the intervention listed was not appropriate because Resident 46 had difficulty following direction, making his needs known and was confused. The DON stated the intervention would not prevent falls. During a concurrent interview and record review with the DON, on 1/7/19, at 2:05 p.m., the DON reviewed the care plan for falls and stated on 6/23/18 (Fall #11) Resident 46 fell from his bed. The DON stated, I don't know why there was no intervention developed for this fall. During a concurrent interview and record review with the DON, on 1/7/19, at 2:07 p.m., she stated on 6/28/18 (Fall #13) Resident 46 fell from a wheelchair. The fall care plan intervention indicated, Continue to encourage resident to use call light or to call for help and until help is arrive. The DON stated the use of a call light had been the intervention used repeatedly on previous falls and would not prevent additional falls. During a concurrent interview and record review with the DON, on 1/7/19, at 2:10 p.m., she stated on 7/19/18 (Fall #14) Resident 46 fell from the wheelchair. The fall care plan intervention indicated, Notify MD (Medical Doctor) for acute changes. The DON stated, No, it (new intervention added) does not prevent a fall from happening. During a concurrent interview and record review with the DON, on 1/7/19, at 2:20 p.m., she stated on 8/31/19 (Fall #16) Resident 46 fell from the bed. The intervention added to the care plan at that time was frequent monitoring. The DON stated, Frequent monitoring has been used (before). No, it's not a new intervention. During a concurrent interview and record review with the DON, on 1/7/19, at 2:23 p.m., she stated on 9/6/18 (Fall #17 & 18) Resident 46 fell from the wheelchair twice on this date. The fall care plan intervention dated 9/7/18 indicated, Reinforce and replace dycem as needed. The DON stated Resident 46 kept removing the dycem from the wheelchair. The dycem was used during the first fall on 1/3/18, and no intervention was added after the falls of 9/6/18. During a concurrent interview and record review with the DON, on 1/7/19, at 2:23 p.m., she stated on 9/29/19 (Fall #20) Resident 46 fell from the bed. The care plan for falls indicated, Continue interventions on at risk care plan. The DON stated there were no new interventions developed or added to the care plan. The DON stated not all falls have a new intervention. During a concurrent interview and record review with the DON, on 1/17/19, at 2:35 pm, she stated on 10/3/18 Resident 46 fell from bed while trying to reach for his wheelchair across the room. A nasal x-ray was done and the result showed a non-displaced (bone breaks in part or all the way through but maintains proper alignment) nasal fracture. The DON stated an Occupational Therapy (OT) referral was made to assess for a reacher (a device with an extended arm to assist with reaching objects). The DON stated the intervention did not work due to Resident 46's confusion and inability to understand how to use the reacher device. The DON stated a new intervention was not developed after the 21st fall. During a clinical record review for Resident 46, the Progress Notes, dated 10/3/18, indicated, Observed resident falling face forward on the floor approximately 1420 (2:40 p.m.) noted copious (abundant in quantity) amount of blood coming out of his nose. pt (patient) complained of forehead pain . During a clinical record review for Resident 46, the Progress Notes, dated 10/4/18, indicated, (Nursing Notes at 2:36 a.m.) WAS REPORTED BY LVN (LICENSED V[NAME]ATIONAL NURSE) APPROX 1455 (2:55 p.m.) . HAD A WITNESSED FALL WITH FACIAL INJURY TO NOSE . RESIDENT CONTINUES TO HAVE A NOSEBLEED FOR APPROX (approximately) 3 HOURS. RES (Resident) NOSTRIL WERE PACKED WITH GAUZES AND CHANGED AS NEEDED WHEN GAUZE BECOMES HEAVILY SATURATED WITH BLOOD. RESIDENT IS TAKING (name of medication) 10 MG (milligram, a unit of measure) FOR BLOOD THINNING. CONTINUES TO MONITOR Q (every) 10-15 MIN (minutes) FOR RISK FOR ASPIRATION (fluid into the lungs) .NOSEBLEED FINALLY STOPPED @ (AT) 17:45 (5:45 p.m.) . During a clinical record review for Resident 46, the Progress Notes, dated 10/4/18, indicated, IDT (Interdisciplinary Team - a team represented by different disciplines which included nursing, OT, Physical Therapy (PT), dietary, Activities, and social services) MET TO DISCUSS RESIDENTS (Resident 46) FALL ON 10/3/18. RESIDENT HAD AA (A) FALL FROM BED TRYING TO GET HIS WHEELCHAIR L[NAME]ATED UNDER THE TV. RESIDENT HAS HISTORY OF FALLS AND BEING NON COMPLAINT WITH ASKING FOR ASSISTANCE. HE HAS POOR SAFETY AWARENESS, IMPULSIVE BEHAVIOR . AFTER FALL RESIDENTS (Resident 46) NOSE WAS BLEEDING COPIOUS AMOUNTS OF BLOOD OF BLOOD DUE TO BLOOD THINNER . NASAL X-RAY SHOWED NON DISPLACED FRACTURE TO DISTAL NASAL BONE . IDT RECOMMENDATION IS TO REFER TO OT FOR ADL AND TO BE ASSESSED FOR A REACHER . During a clinical record review for Resident 46, (name of company) Diagnostics, indicated, . PR[NAME]EDURE: NASAL BONES 3 VIEWS (done on 10/3/18) FINDINGS: Nondisplaced fracture distal nasal bone(.) IMPRESSION: Nasal bone fracture . 2. During a review of the clinical record for Resident 460, the Face sheet dated 10/19/18, indicated Resident 460 was admitted on [DATE] with medical [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 460, the MDS dated [DATE], indicated Resident 460's BIMS score was 4 of 15 points, which indicated severe cognitive impairment (for memory, judgment and reasoning). The MDS indicated Resident 460 required extensive assistance of two staff persons from the bed to the chair transfer, extensive assistance of one staff with dressing and toileting. The MDS indicated Resident 460 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. During an interview with the DON, on 10/19/18, at 2:45 p.m., she stated Resident 460 had twenty-one falls. During a concurrent interview and record review with the DON, on 10/19/18, at 3 p.m., she provided a list that contained 20 falls and stated that another fall happened on 10/13/18 which was not on the list. The DON stated there were twenty-one total falls which happened between 1/21/18 to 10/13/18. The DON stated fourteen of twenty-one falls happened from the wheelchair on the following dates: 1/21/18, 2/17/18, 3/7/18, 4/28/18, 6/19/18, 6/21/18, 6/26/18, 7/6/18, 7/24/18, 8/23/18, 9/13/18, 9/26/18, 10/2/18, and 10/6/18. Seven of the twenty-one falls happened from the bed on the following dates: 2/18/18, 3/9/18, 3/10/18, 3/17/18, 6/17/18, 7/8/18, and 10/13/18. The DON stated Resident 460 was a high risk (risk of falling was high due to unsteadiness and the history of prior falls) for falls, was very impulsive and had been very challenging to care for as he did not follow direction well from staff due to his confusion. During a clinical record review for Resident 460, untitled, undated, indicated, Focus: . The resident is at risk for falls r/t (related to) poor safe(ty) awareness. Poor communication/comprehension, Unsteady gait . During a clinical record review for Resident 460, untitled, dated 10/24/17, indicated, Focus: . The resident has an ADL self-care performance deficit r/t (related to) [MEDICAL CONDITION] (a joint disease manifested by swelling and pain) . Interventions (:) Transfer: . requires limited assistance of (1) staff person. Toilet use: .requires limited assistance of 1 staff for toilet use . Dressing: . requires limited assistance by (1) staff to dress . During a concurrent interview and record review with the DON on 1/18/19, at 8 a.m., each of the twenty-one falls were reviewed with the DON. The DON stated on 7/8/19 (Fall #14) Resident 460 fell from the bed to the floor, sustained a skin tear to the nose and right knee bleeding. The intervention documented was, RNA (Restorative Nursing Assistant, exercises performed by trained nursing assistant) (program) increased to 7x (times) a week. The DON stated the intervention had not addressed the fall, and stated a landing pad should had been used as a new intervention but no landing mat was placed. The DON stated the RNA (Restorative Nursing Assistant) program would not prevent any injury in the future should the fall happen from the bed and was not an appropriate intervention for this fall. During a concurrent interview and record review with the DON on 1/18/19, at 10:14 a.m., she stated on 8/23/18 (Fall #16) Resident 460 fell in the bathroom. The DON stated Resident 460 stood up to wash his hands, slipped and fell . The DON stated, No staff was present that I can gather. The DON stated the anti-roll back brake was not working at the time of the fall, and if it had been working, the fall could possibly have been prevented. During a concurrent interview and record review with the DON, on 1/18/19, at 10:35 a.m., she stated on 9/13/18 (Fall #17) Resident 460's wheelchair moved when he was putting his shoes on and fell . The DON stated the IDT recommendation was to have the maintenance staff assess the wheelchair and anti-roll back brakes. The DON stated there was no new intervention for this fall, It shows that we are at fault and would not consider maintenance as an intervention to prevent a fall. The DON stated the intervention listed on the care plan was Assess resident's room for any safety hazards. The DON stated, This was a daily routine that we do, this is not a new intervention. During a concurrent interview and record review with the DON, on 1/18/19, at 10:55 a.m., she stated on 10/2/18 (Fall #19) Resident 460 was found sitting on the floor between the bed and the wheelchair. Resident 460's wheelchair brakes were unlocked and he was not wearing any foot wear. The DON stated as a result of the fall Resident 460 sustained a skin tear on top of the left hand. The DON stated the intervention listed on the care plan was, Resident to be provided and encouraged to wear skid proof socks at night. The DON stated this intervention was already used on the sixteenth fall that occurred, which was not an appropriate intervention to use because Resident 460 did not have the capability to put the socks on unaided. During a concurrent interview and record review with the DON on 1/18/19, at 11 a.m., she stated on 10/18/18 (Fall #20) Resident 460 was found on the social dining room floor, and that he tried to transfer himself from his wheelchair to a regular chair. The DON stated Resident 460 was too weak to transfer himself, the dining room was unsupervised and there were no other residents or staff present. The DON stated Resident 460 required the assistance of one staff to transfer. The facility policy and procedure titled, Comprehensive Care Plans dated 11/19, indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychological need. Guidelines: 1. The care plan . It will drive the typical care and services that a resident receives and will describe the resident's . needs and preferences; as well as how the facility will assist in meeting these needs and preferences . 7. The care plan will be person-specific with measurable objectives, interventions, and timeframe. It will address goals, preferences, needs, and strengths of the resident. The services the facility will provide to assist the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being . 3. During a review of the clinical record for Resident 101, the Nursing Progress Note dated 5/16/19, at 3:14 p.m., indicated, Around (1:45p.m.) was notified by CNA that Resident (101) had fell out of his wheelchair in the hallway while being taken to his [MEDICAL TREATMENT] (appointment). When went to assess, saw Resident (101) laying (sic) face down in the hallway wheelchair. Upon assessment noted Resident (101) bleeding from a laceration (A torn or jagged wound) to left forehead. Pressure to forehead applied. Resident awake but was not responding to writer. When asked what happened, transportation driver (TD) stated, He leaned forward and fell , I tried to grab him from his sweater but couldn't. The record indicated Resident 101 was sent to the hospital emergency room (ER) for evaluation and treatment. The progress note indicated Resident 101 was unable to answer questions when assessed by the nurse. Resident 101 was found lying facedown on the floor with the wheelchair behind him. During an interview with CNA 1, on 6/21/19, at 11:40 a.m., she stated Resident 101 used a regular wheelchair and had a tendency to lean forward while sitting in the chair. CNA 1 stated Resident 101 always needed to be reminded to sit back in his chair because he would lean forward and he was at risk of falling. CNA 1 stated prior to transportation to the [MEDICAL TREATMENT] center, Resident 1 was taken to the nurses' station to be picked up by the transport driver (TD). CNA 1 stated normally a licensed nurse would give a report to the TD before sending Resident 101 to the [MEDICAL TREATMENT] center. During an interview with CNA 2, on 6/21/19, at 12:00 p.m., she stated Resident 1 required a 2 person assist, total transfer and used a mechanical lift (used to move resident who are unable to stand on their own or whose weight makes it unsafe to move) for transfer from the bed to the wheelchair. CNA 2 stated Resident 1 was placed in an upright position and would suddenly move into a slouch position (a gait or posture characterize by an ungainly stooping of the head and shoulder). CNA 2 stated Resident 101 needed assistance to lift himself up because he was unable to do it on his own. CNA 2 stated Resident 101 was taken to the nurses' station on 5/16/19 when he was ready for transport and waited for the TD to arrive. During a telephone interview with the TD, on 6/21/19, at 12:50 p.m., the TD stated she arrived to the facility at around 1:20 p.m. on 5/16/21, to pick up Resident 101 to transport him to the [MEDICAL TREATMENT] center. The TD stated she had been picking up Resident 101 to transport to the [MEDICAL TREATMENT] unit three times a week for the past two weeks. The TD stated Resident 101 used his own regular wheelchair. The TD stated she saw Resident 101 at the nurses' station awake, but he didn't seem to be his normal self on 5/16/19 because he would, even when in pain, talk to her about his family. The TD stated the only response she got from Resident 101 was in a low tone ah. The TD stated Resident 1 was sitting in a wheelchair leaning forward wearing an oxygen cannula (tubing placed in the nares connected to an oxygen source). The TD asked for help from the staff to reposition Resident 101 in the wheelchair because he was leaning too far forward, but no one came to assist her. The TD stated when she asked the nurses in the nurses' station if Resident 101 was ready to go to the [MEDICAL TREATMENT] center the nurse said yes. The TD stated she told the nurses Resident 101 was leaning too far forward in the chair and a nurse responded, He (Resident 101) always does that. The TD stated she was not trained to reposition residents and would be unable to reposition the resident safely. The TD stated she was only the transport driver. The TD stated she had asked Resident 101 to sit back but Resident 101 did not respond. The TD stated as she wheeled Resident 101 out of the facility, approximately 5 yards from the nurses' station, Resident 101 leaned forward and fell out of the wheelchair. The TD stated she was not fast enough to catch Resident 101. The TD stated when she called for help two nurses arrived and picked up Resident 101. The TD stated Resident 101's face was covered in blood. During an interview with the DON, on 6/21/19, at 3:00 p.m., she stated, Resident (101) does not lean forward. It was not reported to TD because positioning was not an issue. The DON stated she was not notified about Resident 101's leaning forward while sitting in his wheelchair on 5/16/19. During a review of the clinical record for Resident 101, the Face sheet dated 6/21/19, indicated Resident 101 was admitted to the facility 3/29/19 with [DIAGNOSES REDACTED]. waste, salt, and extra water to prevent them from building up in the body). During a review of the clinical record for Resident 101, the MDS assessment dated [DATE], indicated Resident 101's BIMS score was 14 of 15 points, which indicated Resident 101 was cognitively intact (pertaining to memory, judgement, and reasoning). The MDS assessment indicated Resident 101 required extensive assistance in bed mobility, movement on unit and off unit, dressing, and personal hygiene. The MDS assessment indicated Resident 101 required total staff assistance with transfer from bed to chair and on and off the toilet. The MDS assessment indicated Resident 101 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. During a telephone interview with TD, on 7/8/19, at 6:13 p.m., she stated I was not given report about Resident 101's condition and proper positioning. TD stated she should have waited for the nurses to help her position Resident 101 in his wheelchair. TD stated she should have waited for the nurses to give a proper report about Resident 101's health condition before taking Resident 101 down the hallway. TD stated the fall could have been avoided If the staff would have made sure Resident 101 was checked and made sure he was safe to take to his [MEDICAL TREATMENT] appointment. TD stated no one came to help Resident 101 when she asked the staff for help him sit right or to check him to make sure he was okay to go to [MEDICAL TREATMENT]. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 8/6/19, at 3:45 p.m., LVN 2 stated she was the nurse assigned to Resident 101 on 5/16/19. LVN 2 stated at around 1:38 pm she was notified by a CNA that Resident 101 fell out of his wheelchair in the hallway while being taken to [MEDICAL TREATMENT] unit. LVN 2 stated when she arrived, Resident 101 was lying face down in front of his wheelchair and bleeding profusely from a laceration to his left forehead. LVN 2 applied a pressure dressing to his forehead. LVN 2 stated Resident 101 was awake but not responding when asked a question. The Unit Manager (UM) had also arrived and was assisting. The UM directed LVN 2 to call EMS (emergency medical services- emergency services which treats illnesses and injuries that requires an urgent medical response). LVN 2 stated she notified the doctor and attempted to contact all emergency contacts of Resident 101's family but no response, so she left a voice message. LVN2 stated vital signs (pulse rate, body temperature, respiration rate, and blood pressure,) at 1:03 showed a (blood pressure of (the pressure caused by your heart contract and the pressure when your heart relaxes and fills with blood )149/79, pulse rate at (the number of times your heart beats in one minute) 61 beats per minute and temperature at 97.8 Fahrenheit which was taken before TD wheeled the patient out of the facility. LVN 2 stated she saw the TD twice in the facility to pick up Resident 101 and assumed she knew the condition of Resident 101 because she was the regular driver who had transported Resident 101 to [MEDICAL TREATMENT] in the past. LVN 2 stated she did communicate with the driver to give report on Resident 101. LVN 2 stated she did not have a conversation with the driver prior to incident. She spoke with the driver after the incident and asked the driver what had happened. LVN 2 stated TD told her that Resident 101 leaned forward and fell out of the wheelchair. TD tried to grab him from his sweater but was unable to catch him. LVN 2 stated the nurse only gave TD report if it was a new driver who was not familiar with the resident. LVN 2 stated the TD who came to pick up residents for appointments usually communicates with the licensed nurse and asks about behavior and mental status of the resident. During a review of the hospital clinical record for Resident 101, the Hospital History and Physical dated 5/16/19, indicated, (Resident 101) sustained a fall at (facility) . Pt (patient) was in a chair and fell flat on to his face. Most likely syncopal episode .Pt came to ER (emergency room ) as trauma. Had a large laceration above L (left) eyebrow s/p (status [REDACTED]. During a review of the Hospital clinical record for Resident 101, the CT (Computed tomography-Detailed images of internal organs (brain) obtained by this type of X-ray device) dated 5/16/19, indicated FINDINGS: Brain: there is a 3 mm (millimeter- unit of measurement) acute/subacute (sudden onset or rapid change) subdural hematoma ( a condition in which blood collects on the brain's surface beneath the skull) along the right aspect of the falx (brain) . During an interview with LVN 2, on 8/7/19, at 3:55 p.m., LVN 2 stated Resident 101 had a history of [REDACTED]. LVN 2 stated Resident 101 returned from the hospital to the facility on ,[DATE]

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for three of nine sampled residents (Residents 46, 29, and 101) when: 1. Resident 46 who was assessed with [REDACTED]. The facility staff did not ensure adequate supervision was maintained to prevent ongoing falls. This failure led to Resident 46's twenty-first fall on 10/3/19 which resulted in a non-displaced fracture (the bone breaks either part or all of the way through but maintains its proper alignment) of distal nasal bone and uncontrolled nasal bleeding for a three-hour period. 2. Resident 29 with known [DIAGNOSES REDACTED]. These failures resulted in Resident 29 spilling the hot coffee onto his lap, suffered second [MEDICAL CONDITION](an injury to the outer and middle layers of the skin) to both of his upper legs and experienced pain after the burns. 3. On 5/16/19 Resident 101 was leaning forward in his wheelchair and waiting in the hallway near the nurses station for the Transport Driver to take him to [MEDICAL TREATMENT]. Nursing staff did not respond to the TD request for assistance to address the leaning forward position of Resident 101. TD proceeded to wheel Resident 101 down the hallway and he fell forward onto the floor striking his head. Nursing staff were aware of Resident 101's history of leaning forward in his wheelchair and did not develop and implement measures to prevent a fall. These failures resulted in Resident 101's avoidable fall from his wheelchair, striking his head and suffering an open wound with excessive bleeding and transport to the local hospital emergency department for care and treatment. The hospital records indicated Resident 101 suffered a subdural hematoma as a result of the fall. Findings: 1. During a review of the clinical record for Resident 46, the Face sheet (a document with personal identifiable information) dated 10/19/18, indicated Resident 1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. neurological dysfunction resulting from an interruption in the blood supply to the brain). During a review of the clinical record for Resident 46, the Minimum Data Set (MDS) assessment (a resident assessment tool used to develop a plan of care) dated 9/19/18, indicated Resident 46's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 5 of 15 points, which indicated severe cognitive (pertaining to memory, judgement, and reasoning) impairment. The MDS assessment indicated Resident 46 required extensive assistance (staff provided weight-bearing support) from bed to chair during transfer. The MDS assessment indicated Resident 46 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. During an interview with Certified Nursing Assistant (CNA) 8, on 10/19/18, at 8:15 a.m., he stated Resident 46 was at a high risk for falls (due to diagnoses, medications, prior history of falls, imbalances) and fell two weeks ago. During an interview with CNA 9, on 10/19/18, at 8:24 a.m., she stated Resident 46 had more than one fall. Resident 46 had poor balance and an unsteady gait. Resident 46 required one-person to assist when transferring from the bed to the wheelchair and toilet. During an interview with Resident 46, on 10/19/18, at 8:30 a.m., Resident 46 stated he did not use the call light and yelled for help if assistance was needed. CNA 9 stated and validated Resident 46 did not use his call light button to ask for help. During an interview with CNA 9, on 10/19/18, at 8:43 a.m., she stated Resident 46 had short term memory loss and had difficulty following direction. CNA 9 stated Resident 46 would usually attempt to transfer himself from his bed without asking for assistance. CNA 9 stated Resident 46 could take short steps, but was unsteady when he walked and used a wheelchair to move around. During an interview with Unit Manager (UM), on 10/19/18, at 8:51 a.m., she stated Resident 46 was pleasantly confused and was unable to follow directions due to his confusion. During an interview with CNA 10, on 10/19/18, at 10 a.m., CNA 10 stated all staff who cared for Resident 46 was aware Resident 46 was a high risk for falls and fell frequently. CNA 10 stated Resident 46's falls happened more during the day time when he would attempt to transferred himself from bed to chair without asking for assistance. CNA 10 stated the night shift staff reported that Resident 46 did not sleep throughout the night and would get restless when he needed to use the toilet. CNA 10 stated Resident 46 had a tendency to look for his urinal and would get out of bed unassisted to use the toilet if he did not find his urinal. CNA 10 stated the call light was near him but she had not seen him use it. During a clinical record review for Resident 46, the care plan dated 10/4/17, indicated, The resident is at risk for falls .secondary to impaired cognitive function, poor safety awareness, impulsiveness, continues to attempt to ambulates despite of balance impairment . Interventions . Anticipate and meet the resident's needs. Be sure to use the resident's call light is within reach and encourage the resident to use it for assistance as needed . A note was added to the care plan after the fall on 2/23/18, Make falls as safe as possible. Documentation after a fall that happened on 5/30/18, Demonstrated to resident how to use the call light and had resident demonstrated it back. Make sure call light is within reach. After fall on 6/16/18, the care plan indicated, Continues to educate the importance of calling for help to prevent further fall. On 6/28/18, the care plan indicated, continue to encourage the resident to use the call light or to call for help and wait until help arrives. During a concurrent interview with the Director of Nursing (DON) and review of the clinical record for Resident 46, on 10/19/18, at 10:36 a.m., she stated Resident 46 had 21 falls between 1/3/18 and 10/3/18. Twelve of 21 falls occurred from his wheelchair on the following dates: 1/9/18, 2/2/18, 2/7/18, 2/23/18, 5/20/18, 5/24/18, 5/30/18, 6/28/18, 7/19/18, 9/6/18 (x2), and 9/26/18. Eight of 21 falls occurred from the bed on the following dates: 1/3/18, 3/18/18, 5/27/18, 6/16/18, 6/23/18, 8/30/18, 9/29/18, and 10/3/18. During an interview with the DON, on 1/17/19, at 11:04 a.m., she stated Resident 46 was assessed as having a BIMS score of 5 (severe cognitive impairment). The DON stated using the call light was not an appropriate or realistic intervention because Resident 46 did not have the capacity to remember to use it. The DON stated using the call light as an intervention alone would not prevent falls. The DON stated if an appropriate intervention had been developed and implemented after each fall, succeeding falls could have prevented. The DON stated the nurse should have implemented interventions that were resident-centered and focused on resident specific needs to prevent falls. The DON stated Resident 46 required close supervision and to prevent falls and that did not occur. During a concurrent interview and record review with the DON, on 1/17/19, at 11:30 a.m., she stated Resident 46's first fall occurred on 1/3/18 from his bed. The DON stated the new intervention added to Resident 46's care plan dated 1/2/19, indicated, Resident has dycem (a non-slip material) to chair (wheelchair). Resident takes it off and has to be reminded to leave it in chair. The DON stated the new intervention would not prevent falls from his bed. During a review of the clinical record for Resident 46, the Interdisciplinary Team (IDT - group of professional/managers, the DON, Administrator, licensed nurse, MDS Coordinator, who review resident care needs and create recommendations to be implemented in the residents plan of care) Notes dated 1/10/18, indicated, . IDT met to discuss resident fall (second fall) on 1/9/18 in the bathroom . he has poor safety awareness and tries to transfer himself all the time and does not ask for assistance. The IDT indicated Resident 46 had been going to the bathroom many times, but he cannot go (constipation). The IDT recommended a stool softener. During a review of the clinical record for Resident 46, the IDT Notes dated 2/5/18, indicated, . IDT met to discuss resident fall (third fall) on 2/2/18. Resident had a fall from the wheelchair in hallway . Resident has history (hx) of falls and noncompliant with self-transferring. The IDT recommended to have therapy (Rehabilitation Department) assess the wheelchair. During a review of the clinical record for Resident 46, the IDT Notes dated 2/8/18, indicated, . IDT met related to fall in bathroom (on 2/7/19, fourth fall). Resident does (not) ask for help when needed. The IDT recommended scheduling toileting before meals. During a review of the clinical record for Resident 46, the IDT Notes dated 2/26/18, indicated, . IDT met to discuss residents. Resident has a fall on 2/23/18 (fifth fall). Resident slide from wheelchair. The IDT recommended to have Physical Therapy (PT) work with wheelchair positioning for safety and transfer. During a review of the clinical record for Resident 46, the Physical Therapy Plan of Care dated 3/1/18, indicated, . Current level of function: The patient is able to transfer from bed < > (to and from) wheelchair requiring minimal assistance (1-25% assist). Goal: The patient will safely transfer from bed < > wheelchair increasing to contact guard assist (contact with patient due to unsteadiness) . During a review of the clinical record for Resident 46, the IDT Notes dated 3/19/18, indicated, . IDT met related to fall from bed attempting to transfer to wheelchair (on 3/18/18, sixth fall). The IDT recommended moving Resident 1 closer to the nurses' station. During a review of the clinical record for Resident 46, the IDT Notes dated 5/21/18, indicated, . IDT met to discuss residents fall (5/20/18, seventh fall). Resident had a fall from wheelchair trying to self-transfer to use the restroom. The IDT recommended a toileting program before meals and at bed time to anticipate Resident 1's need to prevent from falling. There was no documentation of consistent toileting before meals and before bedtime. Resident 46 nurse note dated 5/25/19 indicated fell on [DATE], eighth fall. The clinical record did not contain documented evidence of an IDT meeting after the fall of 5/25/18 (eighth fall). During a review of the clinical record for Resident 46, the IDT Notes dated 5/29/18, indicated, . IDT met to discuss residents fall on 5/27/18 (ninth fall). Resident had a fall from wheelchair to bed. The IDT recommended to transfer Resident 46 to bed between 6:30 p.m. and 7 p.m. to prevent resident from transferring himself, and for PT to evaluate. Resident 46 nurse note dated 5/30/19 indicated fell on [DATE], eighth fall. The clinical record did not contain documented evidence of an IDT meeting after the fall of 5/30/18 (tenth fall). During a review of the clinical record for Resident 46, the IDT Notes dated 6/18/18, indicated, .IDT met to discuss residents fall on 6/16/18 (11th fall)). Resident had a fall in room from wheel chair. The IDT recommended PT to assess the use of self-releasing Velcro belt. Resident 46 nurse note dated 6/23/19 indicated fell on [DATE], 12th fall. The clinical record did not contain documented evidence of an IDT meeting after the fall of 6/23/18 (12th fall). During a review of the clinical record for Resident 46, the IDT Notes dated 6/29/18, indicated, . IDT met to discuss the fall occurred on 6/28/18 (13th fall). Resident had a fall in room from wheel chair. The IDT recommended Restorative Nursing Assistant (RNA) to perform repetitive transfer from bed to chair for safety. During a review of the clinical record for Resident 46, the IDT Notes dated 7/20/18, indicated, . IDT met related to fall that occurred on 7/19/18 (14th fall) from bed. The IDT recommended PT evaluate transfer pole. During a review of the clinical record for Resident 46, the IDT Notes dated 8/27/18, indicated, . IDT met related to fall that occurred when Resident 46 was walking to the bathroom on 8/25/18 (15th fall). The IDT recommended PT evaluate transfer and balance. During a review of the clinical record for Resident 46, the IDT Notes dated 8/31/18, indicated, . IDT met related to fall that occurred when Resident 46 was found on his buttock on the floor in his room [ROOM NUMBER]/30/18 (16th fall). The IDT recommended to give Resident 46 a bell to use to call for help. During a review of the clinical record for Resident 46, the IDT Notes dated 9/7/18, indicated, . IDT met related to two falls on 9/6/18 (17th and 18th fall). Resident was found on the ground lying on his right side on the left side of the bed holding his blanket and on the 18th fall resident stated he had been reaching for his bedside table and rolled off the bed. The IDT recommended therapy to assess wheelchair for repositioning. During a review of the clinical record for Resident 46, the IDT Notes dated 9/27/18, indicated, . IDT met to discuss the fall that occurred from wheelchair (w/c) on 9/27/18 (19th fall). The IDT recommended to order a smaller wheelchair for better wheelchair positioning. The clinical record did not have documentation a smaller wheelchair was provided. During a review of the clinical record for Resident 46, the IDT Notes dated 10/1/18, indicated, . IDT met to discuss the fall on 9/29/18 (20th fall) . The note indicated Resident 29 had an un-witnessed fall trying to get into his wheelchair which was not by his bed. The IDT recommended to place wheelchair next to the bed to prevent resident from trying to get up and get wheelchair from across the room. During a review of the clinical record for Resident 46, the IDT Notes dated 10/4/18, indicated, . IDT met to discuss the fall on 10/3/18. Resident has aa (a) fall from bed trying to get his wheelchair located under the television (TV) . After the fall residents (resident's) nose was bleeding copious (large) amount of blood due to taking blood thinners . Nasal x-ray showed non dis placed (nondisplaced) fracture to distal nasal bone . IDT recommendation is to refer to Occupational Therapy (OT) for activities of daily living (ADL) and to be assessed for a reacher (a hand held device to reach objects), CNAS to place locked wheelchair next to his bed .when he is in bed to prevent resident from trying to self-ambulate. During a review of the clinical record for Resident 46, the Progress Notes dated 10/3/18, indicated, . Observed resident falling face forward on the floor (at) approximately 1420 (2:40 p.m.) noted copious amount of blood coming out of his nose. pt (patient), complained of forehead pain . During a review of the clinical record for Resident 46, the Progress Notes dated 10/4/18, indicated, . ( written on 10/4/18 at 2:36 a.m.) WAS REPORTED BY LVN (LICENSED V[NAME]ATIONAL NURSE) APPROX 1455 (2:55 p.m.) . HAD A WITNESSED FALL WITH FACIAL INJURY TO NOSE . RESIDENT CONTINUES TO HAVE A NOSEBLEED FOR APPROX (approximately) 3 HOURS. RES (Resident) NOSTRIL WERE PACKED WITH GAUZES AND CHANGED AS NEEDED WHEN GAUZE BECOMES HEAVILY SATURATED WITH BLOOD. RESIDENT IS TAKING (name of medication) 10 (milligram, a unit of measure) MG FOR BLOOD THINNING. CONTINUES TO MONITOR Q (every) 10-15 MIN (minutes) FOR RISK FOR ASPIRATION .NOSEBLEED FINALLY STOPPED @ (AT) 17:45 (5:45 p.m.) . During a review of the clinical record for Resident 46, the Order Summary Report (physician's orders [REDACTED]. (name of drug) chewable 81 milligrams (mg, a unit of measure) Give 1 tablet by mouth one time a day for blood thinner. (name of drug) [MEDICATION NAME] (HCl) tablet Give 10 mg by mouth one time a day for blood thinner. During a concurrent observation and interview with Resident 46, in Resident 46's room, on 7/15/19, at 9:56 a.m., he was able to state his name. Resident 46 was pleasant and confused. Resident 46 stated if he needed to use the restroom he would go to the nurse's desk to tell the staff. Resident 46 stated when he was in bed he gets up from bed to get help and then staff helps him. Resident 46 was unable to indicate what a call light was and pointed to a sensor on the right side of the wall. During an interview with CNA 4, on 7/15/19, at 10:29 a.m., she stated Resident 46 had periods of confusion and periods of being alert and oriented. CNA 4 stated Resident 46 did not know how to use the call light and did not remember if he had to use the call light to call for assistance. CNA 4 stated Resident 46 had a history of [REDACTED]. CNA 4 stated she would monitor Resident 46 only when she had time between her assigned tasks. CNA 4 stated when she had time to check on Resident 46 she would ask him if he needed to use the bathroom or getting him a drink of water. CNA 4 stated she would provide supervision when she had an opportunity to do so. CNA 4 stated she would attempt to check on him every 15 minutes but she was unable to because she did not want to hover over Resident 46. CNA 4 stated she was unable to provide every 15 minutes checks because she had other residents she needs to provide care to. CNA 4 stated Resident 46's falls were related to going to the bathroom on his own, getting in and out of bed. CNA 4 stated she would try to provide Resident 46 assistance getting him in and out of bed when she would see him trying to get out of bed to make sure it's done safety but if she was busy she will tell her coworkers to check on Resident 46. CNA 4 stated she did not know how frequently her coworkers checked on Resident 46 because they also had resident they had to provide acre for. CNA 4 stated there was no designated times she was to monitor Resident 46. CNA 4 stated she checked on him as frequently as she could. During an interview with CNA 11, on 7/15/19, at 11:20 a.m., she stated Resident 46 had moments where he was alert but he was confused. CNA 11 stated when Resident 46 needed assistance he would tap his hands on the bedside table or use hand gestures to get attention. CNA 11 stated the CNA who was assigned to Resident 46 was responsible to monitor and supervise Resident 46. CNA 11 stated Resident 46's assigned CNA would not be able to be with him all the time to monitor and supervise. CNA 4 stated CNAs did the best they could. CNA 11 stated they would try their best to keep Resident 46 safe. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 8, on 7/15/19, at 12:58 p.m., he reviewed Resident 46's Admission Record and fall care plan intervention. LVN 8 stated Resident 46 had a history of [REDACTED]. LVN 8 stated Resident 46 had two sensor alarms on the sides of his bed so when he attempted to move it would notify the nurse at the nurse's cart. LVN 8 stated all staff were responsible to monitor Resident 46. LVN 8 stated when a staff member assigned to care for Resident 46 went to break or lunch there was no one assigned to monitor Resident 46. LVN 8 stated he was not always able to monitor Resident 46 because he would be busy doing his documentation or medication administration, but another staff member would try to check on him. LVN 8 stated monitoring times were never specified but if staff saw him moving around on the bed or wheelchair they would ask Resident 46 if he needed something. LVN 4 stated the main supervision was assigned to be provided by his assigned CNA and LN. LVN 8 reviewed Resident 46's fall care plan and stated the care plan did not indicate the type of supervision required for Resident 46. LVN 8 stated an effective fall prevention intervention to keep Resident 46 safe would have been to place him on a one on one (one staff member assigned to only one resident for safety), but was unsure why the management staff had not provided that type of supervision. LVN 8 stated his expectation on the CNA's providing monitoring would be as much as possible. LVN 8 stated Resident 46's last fall occurred on 5/13/19 when he was found on the floor in his bathroom. During a concurrent interview and record review with the DON, on 7/15/19, at 2:17 p.m., she reviewed the IDT notes and stated Resident 46 had 3 additional falls from 12/24/18 through 5/13/19. The DON stated the fall of 12/24/18 occurred while he was in bed self-transferring, on 1/9/19 while he picked up his cup from the floor, and 5/13/19 while he using the bathroom on his own. The DON stated Resident 46 would not call for assistance or have the capacity to call for help with his call light. The DON she had observed Resident 46 attempt to transfer himself from his wheelchair to the lobby chairs. The DON stated staff needed to be more diligent observing where Resident 46 was location. The DON stated she would like to be able to place a one on one with Resident 46 but was not able to do that. The DON stated what they would be able to do was try to anticipate his needs before he tries to transfers on his own. The DON stated supervision had not been addressed so the staff needed to be observant to prevent Resident 46 from falling and hurting himself again. The DON stated the intervention in Resident 46's care plans were not appropriate and some were repeated interventions that were not effective. During a concurrent interview and record review with the DON, on 7/31/19, at 3:30, she stated I was unable to find the IDT notes for 5/24/18 (fall #8), 5/30/18 (fall #10), and 6/23/18 (fall #12). During that time there was no process in place to monitor Resident 46 and/or prevent additional falls. The DON stated the IDT did not meet and did not develop new intervention for the falls that occurred on 12/24/18, 5/30/18, and 2/23/18. The DON stated the IDT should have meet and should have developed interventions to try to prevent ongoing falls. The facility policy and procedure titled, Falls and Fall Risk, managing dated 12/07, indicated, Policy Statement (:) Based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff . will identify appropriate interventions to reduce the risk of fall . 4. If falling recurs despite initial interventions, staff will implement additional of different interventions . 5. staff will try various interventions . until falling is reduced or stopped, or until the reason for continuation of falling is identified as unavoidable . Monitoring Subsequent Falls and Fall Risk . 3. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current intervention . 2. During a concurrent observation and interview with Family Member (FM) 1, in Resident 29's room, on 4/24/19, at 12:25 p.m., Resident 29 was lying in bed and was unable to answer questions or greetings. Resident 29's FM 1 was sitting at his bed side. FM stated she was visiting her husband on 4/22/19 and the staff told her that her husband spilled his coffee on himself and burned his legs. FM 1 pulled back the covers exposing Resident 29's legs. Resident 29's right and left upper thighs were wrapped in white gauze. FM 1 became tearful stated [MEDICAL CONDITION](to the right and left thigh) are bad. FM 1 stated Resident 29 got [MEDICAL CONDITION] he was in the activity room on 4/22/19 at 10 a.m. FM 1 stated Resident 29 was given a cup of hot coffee and he spilled it on his legs. FM 1 stated I come every day to see (Resident 29) and help him eat .he shakes . FM 1 stated the staff told her Resident 29 was in the activity room and was given a cup of hot coffee in a regular one handled cup and spilled the coffee on his thighs. FM 1 stated she did not remember who told her she was so warried about her husband. During a review of the clinical record for Resident 29, the face sheet indicated Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 29, the MDS assessment dated [DATE], indicated Resident 29 's BIMS score was two out of 15 which indicated Resident 29 suffered from severe cognitive impairment. The MDS assessment section G indicated Resident 29 required one-person physical assistance from staff for mobility, and eating. During an interview with CNA 13, on 4/24/19, at 12:45 p.m., she stated I have been caring for Resident 29 for two years and (I) am familiar with his care and needs. Resident 29 is able to feed himself at times, but needs supervision and assistance. CNA 13 stated Resident 29's shake and he cannot move. CNA 13 stated Resident 29 should have a two handled spill proof sippy cup for all drinks (hot or cold) because Resident 29's hands are unsteady and shake all the time. CNA 13 stated all residents with adaptive equipment cups were to be provided the correct cups to prevent injuries. During a concurrent interview with LVN 9 and review of Resident 29's clinical record, on 4/24/19, at 1:20 p.m., LVN 9 stated reviewed Resident 29's progress notes dated 4/22/19 at 10:30 a.m., and stated CNA 13 came to her to report Resident 29 had marks to his thighs and was sitting in his wheelchair in his room. LVN 9 stated when she entered Resident 29's room, Occupational Therapist (OT) 2 was with Resident 29. LVN 9 stated OT 2 informed her that Resident 29 had spilled his hot coffee on himself in the dining room. LVN 9 stated she conducted an assessment of the Resident 29's thighs. LVN 9 stated Resident 29's thighs [MEDICAL CONDITION] large areas of both of his thighs. LVN 9 reviewed Resident 29's progress note and stated she documented her findings in Resident 29's progress note on 4/22/19 at 11:33 a.m. which indicated Resident 29 had red areas on right upper thigh measuring 26 centimeters (cm - unit of measure) x (by) 17.5 cm with blister (a small bubble on the skin filled with serum and caused by friction, burning, or other damage). LVN 9 stated Resident 29 had a red area on the right inner thigh measuring 12 cm x 6.5 cm, a red area on top of the thigh with blister measuring 2 cm. x 4 cm., and a red area to left upper thigh measuring 12 cm x 10 cm with a blister measuring 5 cm x 2 cm. During an interview with the DON, on 4/24/19, at 2:55 p.m., she stated, I was alerted to the hot coffee spill injury by (LVN 9) on 4/22/19 at 9:30 a.m. The DON stated I did not go see Resident 29 or see his injuries and I should have . The DON stated LVN 9 had informed her that Resident 29 [MEDICAL CONDITION] his thighs. The DON stated she did not conduct an assessment or investigated how the accident occurred. During an interview with Activities Assistant (AA), on 4/25/19, at 1:30 p.m., she stated I provide refreshments for residents who come to activities. The AA stated Resident 29 was brought to activities by staff three to four times a week. The AA stated Resident 29 has minimal participation during activities because he is unable to talk to others and his movements are stiff. The AA stated Resident 29 preferred to drink hot coffee or hot chocolate in the activity/dining room. AA stated the kitchen staff gave her a pot of hot water and a pot of hot coffee. AA stated she prepared the drinks for the resident sin the activities room. AA stated she poured Resident 29's hot coffee into a two handled cup. During a telephone interview with Occupational Therapist (OT) 2, on 4/26/19, at 11:36 a.m., she stated Resident 29 was on her caseload for therapy services and was looking for Resident 29 on 4/22/19. OT 2 stated walked into the activity room and saw Resident 29 at a corner end of the room trying to stand from his wheelchair. OT 2 stated she alerted AA to help Resident 29 before he fell . OT 2 stated she and AA walked toward Resident 29 and saw Resident 29 with his shirt and pants wet. OT 2 stated Resident 29 seemed agitated and was trying to stand up which was something Resident 29 was unable to normally do. OT 2 stated due to Resident 29's [DIAGNOSES REDACTED]. OT 2 stated she took Resident 29 back to his room by wheelchair to be changed. OT 2 stated CNA 13 helped her remove Resident 29's pants and saw his legs were really red and blistered. OT 2 stated both her and CNA 13 were surprised and CNA 13 rushed to go get the nurse for Resident 29. OT 2 stated she remained with Resident 29 until the nurse arrived to the room and then she left Resident 29 under the care of his nurse. During a telephone interview with the Activities Director (AD), on 4/26/19, at 11:48 a.m., she stated I did not see the incident when (Resident 29) spilled his coffee because I was in a meeting. The AD stated she spoke with the Activities Assistant (AA) who was present at the time of the incident. The AD stated the AA served Resident 29 hot coffee in a two handled sippy cup with a few pieces of ice. The AD stated the two handled sippy cup had a big hole where Resident 29 could drink from. The AD stated AA informed her that AA left the two handled sippy cup with hot coffee on the table next to Resident 1 and walked away to serve other residents in the activity room. The AD stated the AA informed her that she had added a few pieces of ice in the hot coffee because the coffee was really hot. During an interview with AA, on 4/29/19, at 18:15 a.m., The AA stated on 4/22/18 Resident 29 was sitting alone at a table when she served Resident 29 coffee in a two handled sippy cup because Resident 29 has tremors to both of his hands. AA stated after she served Resident 29 his coffee she walked away and continued to serve all other resident in the activity room their drinks. AA stated her back was turned toward Resident 29 as she was interacting and serving other residents. AA stated the OT 2 walked into the activity room and told her to look at Resident 29 because he was trying to stand up from his wheelchair. AA stated Resident 29 was not able to stand on his own so she was surprised. AA stated she and OT 2 ran to help Resident 29 sit back down and noticed Resident 29's shirt and pants were wet. AA stated Resident 29 was not able to tell her what happened but he was very anxious and his eyes were wide open like he was surprised. AA stated she touched Resident 29's pants and they were hot from the spilled coffee. AA stated I found the two handled sippy cup under the table where (Resident 29) sitting at with the lid on and empty. AA stated the two handled sippy cup could hold six ounces of fluid. AA stated, The coffee I served him was really hot .I have been burned myself with the hot coffee in

Based on observation, interview, and record review, the facility failed to ensure pain management measures were maintained and implemented for one of three sampled residents (Resident 454) when Resident 454 yelled and moaned in pain and staff did not respond when he was calling for help; pain medication was not available upon his admission. This failure resulted in Resident 454 experiencing pain and suffering for prolonged periods of time. Findings: During a concurrent observation and interview with the Unit Manager (UM), on 8/6/19, at 8:15 a.m., through 8:30 a.m., Resident 454's call light was audible and visible out in facility hallway while Registered Nurse (RN) 1, License Vocational Nurse (LVN) 4 and Certified Nursing Assistant (CNA) 4 passed by Resident 454's room and did not respond to Resident 454's call for help. Registered Nurse (RN) 1 was pushing his medication cart in the hallway and passed by Resident 454's room while the call light was sounding and did not respond to Resident 454's call for help. Resident 454 was heard out in the hallway screaming out for help and was loudly moaning in pain. The UM stated Resident 454's call light was on and Resident 454 was clearly heard screaming and moaning in pain out in the hallway and the staff did not respond. The UM stated staff should have answered Resident 454's call for help. During a concurrent observation and interview with the UM, in Resident 454's room, on 8/6/19, at 8:33 a.m., the UM responded to Resident 454's call for help. Resident 454 stated, I have nine out of 10 pain in my stomach. Resident 454 pointed to his abdominal (stomach) binder (a wide compression belt around the abdomen to help improve blood circulation to the surgical location) and stated he had an incision from an abdominal surgery. Resident 454 stated he was upset because the licensed nurses had not given him his pain medication and he was in severe pain. Resident 454 rated his pain as 9 of 10 (a pain scale which indicated a 1 was the mildest pain and a 10 was the worse imaginable). Resident 454 stated, I want to talk to the Administrator (ADM). I want out of this place. I turned the call light on for 30 minutes and nobody is answering my calls for help. I am in so much pain. The UM stated, (Resident 454's) call light should have been answered promptly by staff. The staff that passed by the room should have answered the call light timely especially since (Resident 454) was moaning and complaining of nine out of 10 pain . The facility policy and procedure titled, Answering the Call Light dated 10/2010, indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs . 8. Answer the resident's call as soon as possible . Steps in the Procedure . 3. Listen to the resident's request. 4. Do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance . During a concurrent observation and interview with RN 1, on 8/6/19, at 8:38 a.m., RN 1 stood next to the medication cart across from Resident 454's room. RN 1 stated he was the nurse assigned to Resident 454. RN 1 stated he walked by Resident 454's room and had not noticed Resident 454's call light was turned on (for 15 minutes). RN 1 stated he should have noticed and responded to Resident 454's call for help. During a review of the clinical record for Resident 454, the face sheet (a document containing resident profile information and medical diagnosis) dated 8/3/19, indicated Resident 454 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. opening into a body cavity into the bladder for removing fluid). During a review of the facility document titled, Job Description: Registered Nurse dated 6/2018, indicated, Job Summary: Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit. Assess resident needs . administer nursing care, evaluate nursing care, and supervise Certified Nursing Assistants and other personnel in the delivery of nursing care . Delivers Resident Care . Promptly respond to call lights and other resident needs . During a concurrent interview with the UM and clinical record review for Resident 454, on 8/6/19, at 8:44 a.m., she reviewed Resident 454's medical [DIAGNOSES REDACTED]. The UM reviewed Resident 454's Medication Administration Record [REDACTED]. [MEDICATION NAME] Tablet 5-325 milligrams (mg- a unit of dry measurement) Give 1 tablet by mouth every 4 hours related to [MEDICATION NAME] (a disease of the small intestine) type T-Cell [MEDICAL CONDITION] . low back pain . [MEDICAL CONDITION] in situ of prostate . The UM stated the nurses note did not have documentation of Resident 454's pain level being re-assessed to make sure the pain medication was effective one hour after [MEDICATION NAME] was administered at 3:53 a.m. The UM stated, (Licensed Nurses) should have re-assess if the pain medication was effective .it was not done. The UM stated Resident 454 needed his medication for pain and the staff did not respond to his need. During an interview with Resident 454, on 8/6/19, at 10:15 a.m., Resident 454 stated he was admitted to the facility on Saturday, 8/3/19 from the hospital and began to have pain right after his admission to the facility. Resident 454 stated he was in pain for 24 hours until he received his [MEDICATION NAME] (narcotic pain medication) dose the next day on 8/4/19. Resident 454 stated he received his last dose of [MEDICATION NAME] at the hospital at 8 a.m. on 8/3/19 and he was supposed to receive a another dose at 8 p.m. when he was admitted to the facility. Resident 454 stated he was in 10 out of 10 pain from 9 p.m. to the time he received a [MEDICATION NAME] tablet on 8/4/19. Resident 454 stated the [MEDICATION NAME] medication worked best to relieve his pain. Resident 454 stated I felt like I was being tortured. I wanted to die. It was stabbing pain in my (surgical) incision. Resident 454 stated he can tolerate pain at a seven out of 10 but not 10 out of 10. Resident 454 stated I told the nurses about the pain, but they told me that they did not have the script (written prescription) from the hospital. Resident 454 stated he wanted to be admitted to hospice services (end of life care) because the pain was so bad. Resident 454 stated he did not want to deal with this pain anymore. During a review of the Hospital Medication Administration Record [REDACTED] During a concurrent interview with LVN 1 and review of the physician orders [REDACTED]. LVN 1 reviewed the pain medication orders which indicated [MEDICATION NAME] Tablet 5-325 mg . Give 1 tablet by mouth every 6 hours as needed for T Cell [MEDICAL CONDITION], low back pain . [MEDICAL CONDITION] in situ (originating from) of prostate . for 14 days and [MEDICATION NAME] Tablet 30 mg Give 1 tablet by mouth every 12 hours . for chronic pain. LVN 1 stated Resident 454 was admitted to the facility with a triplicate (a written order for controlled narcotic medications) for [MEDICATION NAME] 5-325 mg and triplicate was faxed to the facility's pharmacy to be filled the prescription. LVN 1 stated the facility had [MEDICATION NAME] 5-325 mg and 10-325 mg doses available in the emergency kit (a container filled with medications used for new admissions or when routine supply for a resident is not available) for resident use. LVN 1 reviewed the (Nursing) Pain assessment dated [DATE]. She stated, when Resident 454 was admitted on [DATE] at 4 p.m., he complained of four out of 10 pain level. Resident 454 complained that he did not receive his pain medication during his admission. LVN 1 stated LVN 1 stated she received authorization from the pharmacy to remove one dose of [MEDICATION NAME] 5-325 mg from the e-kit during shift change after 9:30 p.m. LVN 1 reviewed the Medication Administration Record [REDACTED]. LVN 1 reviewed the Nurse Note dated 8/3/19 at 8:17 p.m., which indicated, [MEDICATION NAME] sulfate ER (extended release) 30 mg tablet . med(ication) not avail(able). LVN 1 stated Resident 454 did not receive his [MEDICATION NAME] pain medication on 8/3/19. LVN 1 stated Resident 454 requested hospice care because he did not want to have pain anymore. During a document review titled, (Pharmacy name) Controlled Substance Withdrawal Log dated 8/3/19 at 10:36 p.m., indicated .Item Description . [MEDICATION NAME] 5-325 (mg) .Quantity Dispensed (one) . During a review of the pharmacy document titled, Proof of (medication) Delivery . dated 8/8/19, indicated [MEDICATION NAME] 5-325 mg tablet and [MEDICATION NAME] sulfate ER 30 mg tablet were delivered to the facility on [DATE] at 1:38 a.m. and were available for Resident 454. During a concurrent observation of the Emergency kit (e-kit) on South nursing station, interview with RN 1, and record review for Resident 454, on 8/8/19, at 10:37 a.m., he reviewed the progress note dated 8/3/19 at 8:17 p.m. which indicated [MEDICATION NAME] sulfate was not available for Resident 454 on admission. RN 1 stated [MEDICATION NAME] sulfate 30 mg was not available in the e-kit. RN 1 reviewed the e-kit medications and stated the e-kit did contain the medications [MEDICATION NAME] sulfate 15 mg ER and was available for Resident 454 but RN 1 did not administer the prescribed medication. During a concurrent interview with LVN 1 and record review for Resident 454, on 8/8/19, at 11:11 a.m., LVN 1 stated she was the admission nurse for Resident 454 on 8/3/19. LVN 1 reviewed the progress note dated 8/3/19 at 8:17 p.m. and [MEDICATION NAME] was not available for Resident 454 on the day of admission. LVN 1 stated after transcribing Resident 454' prescribed medications into and sending the prescribed orders to the pharmacy, the medications would not be delivered until the next day 8/4/19. LVN 1 stated [MEDICATION NAME] sulfate 30 mg was not available in the e-kit. LVN 1 stated on admission, Resident 454 expressed pain level of four out of 10. LVN 1 stated she checked for his pain during the shift and his pain was changing from eight out of 10 to 10 out of 10. LVN 1 stated she did not document in Resident 454's progress notes of his increased pain level during the shift. LVN 1 stated when she finished her medication pass at around 9:30 p.m., Resident 454 stated his pain was getting worse and was now at a pain level of 10 out of 10. LVN 1 stated she did not call the doctor to ask for a prescription for pain medications to relieve the resident's pain because it would take longer to receive a response from the doctor. LVN 1 stated she had reported the pain issue and informed the RN that [MEDICATION NAME] could be used to resolve Resident 454's pain medication to the oncoming shift nurse RN 2. LVN 1 stated she should have resolved the Resident 454's pain issues and not left it for the oncoming shift nurse. LVN 1 review the e-kit and stated the medication [MEDICATION NAME] was available in the e-kit but was not given to Resident 454. LVN 1 stated she should have called the hospital to have the physician write a Triplicate for the medication that was available in the facility e-kit or call the facility physician and asked if they could give the available [MEDICATION NAME] pain medication one time from the e-kit until the prescription was filled to control the Resident 454's pain. During an interview with CNA 4, on 8/7/19, at 1:16 p.m., she stated, CNA 4 stated Resident 454 was a new resident in the facility and she was informed that he suffered with chronic pain. CNA 4 stated, It's very busy on this side because it's the short term (rehabilitation (rehab- physical therapy)) area. The residents have more needs, they have more pain, we were very busy yesterday (8/6/19). There was only four CNA's and I had 12 residents yesterday. We are short staff even though we are not full census because the resident acuity (level of severity of an illness) and the needs of all these residents are very high. I was doing care with another resident and somebody told me (Resident 454) was on the (call) light for 15 minutes. Whoever was in the hallway should have answered the call light immediately especially since he (Resident 454) has a lot of pain. During an interview with LVN 4, on 8/7/19, at 2:24 p.m., she stated As soon as the (call) light goes on, everybody should answer the call light. Even nurses have to be aware of call lights and answer it immediately. (Resident 454 waiting for) fifteen minutes is a long time to wait. The call light should have been answered immediately because resident (454) might be in pain . LVN 4 stated she had walked past Resident 454's room on 8/6/19, at around 8:15 a.m., through 8:32 a.m., but did not notice Resident 454's call light was on when she passed by his room. LVN 4 stated she should be watching for call lights and respond to those residents that were calling for help and she did not do that. During an interview with RN 1, on 8/7/19, at 2:28 pm, RN 1 stated, (Resident 454) is in the short term rehab area of the facility. It's always busy there because it's the short term rehab side and residents have more needs. RN 1 stated he should have been aware of call lights and answer call lights promptly especially Resident 454's who was always in pain. RN 1 stated Resident 454 waited 15 minutes before the call light was answered by staff so Resident 454 was very upset. RN 1 stated Resident 454 was in a lot of pain and waiting for pain medication to be administered. During an interview with Resident 454, on 8/7/19, at 3:22 p.m., he stated, When I turned my (call) light on yesterday, it took (staff) one hour to answer my call light. I told her (UM), I was in a lot pain. I told her to tell my nurse I need a pain medication but the nurse did not come back so I turned on the call light and nobody came in. When you saw me yesterday, I was in horrible, horrible pain and waiting for a long time to answer the call light made my pain horrible. I wanted to die at that moment. I have (Clostridioides difficile (C. diff.)- a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon.) and the cramping from the [DIAGNOSES REDACTED] is really horrible. They took out a big tumor mass in my stomach so I have an incision too that's why I have an abdominal binder too it's just too much pain for me. I am in so much pain and the cramping made it worse. Why did it take them so long to answer the call light? Don't they hear me moaning? I shouldn't have to wait that long for them to help me with my pain. It's horrible pain. I can't take the pain and they did not answer my call light right away; it made the pain really horrible. I had nine out of 10 stomach pain. They should answer my light so they could check me or give me my pain pill. It was time for another pain medication. It was not right for me to wait for such a long time. I shouldn't have to suffer in so much pain if they answered my call light and not wait for a long time. My pain could have been better but they ignored me. During a review of Resident 454's clinical record, the nurse's progress notes dated 8/7/19, at 4:16 a.m., indicated, . Call received from (laboratory) confirming stool positive for [DIAGNOSES REDACTED]. result faxed to MD (Medical Doctor) . contact precautions in place . During a review of the professional reference titled, [DIAGNOSES REDACTED]icile infection dated 2019 retrieved from https://www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/symptoms-causes/, indicated [DIAGNOSES REDACTED] .symptoms include abdomen swelling and pain . During a concurrent interview and record review with the DON, on 8/8/19, at 9:34 a.m., she reviewed Resident 454's MAR indicated [REDACTED]. The DON stated Resident 454 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The DON stated RN 1 should have made his initial rounds to assess Resident 454 for pain so he could medicate him with [MEDICATION NAME] 5-325 mg. The DON stated, If (Resident 454) was assessed for pain, he could have gotten the pain medication at 7:53 a.m. and he did not. (Resident 454) was in pain and he should have been assessed for pain at the start of the shift (6 a.m.) instead of waiting for the resident to be already in pain. During a review of the clinical record for Resident 454, the care plan dated 8/3/19, indicated, . (Resident 454) has pain related to Prostate (cancer), T-cell [MEDICAL CONDITION] . Interventions . Administer [MEDICATION NAME] (pain medication) as per orders. Give ½ hour before treatments or care . Monitor/document for probable cause of each pain episode. Remove/limit causes of pain where possible . During an interview with the DON, on 8/8/19, at 3:57 p.m., the DON stated she expected the licensed nurses to assess and provide pain medications to residents experiencing pain. The DON stated pain was the fifth vital sign and needed to be addressed by the licensed nurse for Resident 454 once he complained of pain. The DON stated the licensed nurse should have called the doctor to get an order for [REDACTED]. The DON stated the licensed nurse should have acted on the pain issue immediately and they did not. During a telephone interview with RN 2, on 8/9/19, at 9:56 a.m., RN 2 stated when he came on shift at 10 p.m. on 8/3/19, the licensed nurse reported to him Resident 454 was in pain. RN 2 stated Resident 454 had complained to him about pain and not receiving his dose of [MEDICATION NAME] sulfate on 8/3/19. RN 2 stated the (LVN 1) told him there was an order for [REDACTED]. During a telephone interview with the facility's pharmacist (FP), on 8/9/19, at 11:53 a.m., he stated the pharmacy received Resident 454's admission packet with ordered medications and an emergency request authorization for [MEDICATION NAME] 5-325 mg one tablet at 4:10 p.m. on 8/3/19. The FP stated the facility sent the triplicate orders for [MEDICATION NAME] 5-325 mg and [MEDICATION NAME] sulfate 30 mg. The FP stated there was one request to access the e-kit on 8/3/19 at 4:10 p.m. for [MEDICATION NAME] 5-325 mg for Resident 454 and one request to access the e-kit on 8/4/19 at 12:12 a.m. also for [MEDICATION NAME] 5-325 mg for Resident 454. The FP stated the first authorization was given through fax on 8/3/19 at 8:51 p.m. The FP stated the second request was not given due to the routine medication and as needed medication for pain was delivered on 8/4/19 at 1:38 a.m. The FP stated the pharmacy did not receive an authorization request for the medication [MEDICATION NAME] on 8/3/19. The facility policy and procedure titled, . Pain Management dated 11/2017, indicated, Purpose: Residents are assessed and evaluated to identify pain and manage pain/symptoms . assist the resident to attain or maintain his/her highest practicable level of well-being . Policy: Quality of care is a fundamental principle that applies to the treatment and care provided to residents. Based on comprehensive assessment of a resident, the facility coordinates care and treatment that are in accordance with evidence based standards of practice, the comprehensive person-centered care plan, the resident's choices as it relates to pain relief or pain management . Guidelines .resident's care plan reflects their individual need and resident choices and preferences in order to help the resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain . Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated. B. Evaluates the existing pain and the cause(s), and c. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences . Pain Recognition . Expressions of pain .verbal or nonverbal .evaluate residents through complaints of pain, non-verbal indicators, physical symptoms, change in behaviors or loss of function or ADLs . Pain Management . c. Identify and implement resident specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. D. Monitor appropriately for effectiveness and/or adverse consequences . including defining how and when to monitor the resident's symptoms and degree of pain relief; and modify the approaches as necessary .

Based on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 960) did not develop pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when preventive measures were not put into place when Resident 960 was assessed as a high risk for developing pressure ulcers and he was not turned and repositioned for more than two hours. Resident 960 was not provided a pressure relief cushion and ongoing skin assessments were not conducted. These failures resulted in Resident 960 developing a preventable Stage 2 (partial-thickness skin loss into but no deeper than the dermis) pressure ulcer to the coccyx (tailbone) area. Findings: During a concurrent observation and interview in Resident 960's room, on 8/6/19, at 8:43 a.m., Resident 960 was lying in bed grimacing and stated, My butt is sore. Resident 960 pressed the call light and the Director Of Nursing (DON) immediately responded and entered Resident 960's room. Resident 960 stated to the DON that his buttocks hurt and the DON repositioned Resident 960. Resident 960's coccyx (tailbone) appeared to have an open wound. The DON assessed the coccyx wound and stated it was a stage 2 pressure ulcer (partial-thickness skin loss caused by pressure over a bony prominence into but no deeper than the dermis). During an observation on 8/6/19, at 9:48 a.m., in Resident 960's room, Resident 960 was transferred (moved) by nursing staff into his wheelchair and left sitting in his room. During an observation on 8/6/19, at 12:11 p.m., in Resident 960's room, Resident 960 remained sitting in his wheelchair with his eyes closed. During an observation on 8/6/19, at 3:45 p.m., in Resident 960's room, Resident 960 remained sitting in the wheelchair and in the same position. During an interview with Licensed Vocational Nurse (LVN) 4, on 8/6/19, at 4:02 p.m., she stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned (off of his tailbone). LVN 4 stated Resident 960 refused to be transferred back to bed. LVN 4 stated Resident 960 should have been repositioned and not left in the same sitting position for such a long time. During an observation on 8/6/19, at 6 p.m., in Resident 960's room, Resident 960 remained sitting in the wheelchair watching television. During an interview with Certified Nurses Aide (CNA) 4, on 8/7/19, at 1:56 p.m., CNA 4 stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned. CNA 4 stated Resident 960 should have been repositioned at least every two hours to prevent the formation of pressure ulcers. CNA 4 stated Resident 960 did not want to go back to bed and the licensed nurse was notified. CNA 4 stated she did not document Resident 960's wishes to remain up in the wheelchair and not be repositioned every 2 hours in Resident 960's clinical record. During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:24 p.m., she reviewed Resident 960's clinical record titled NSG (Nursing) Admission/Readmission Evaluation dated 7/8/19, which indicated Resident 960's Braden Score (a tool for predicting pressure ulcer risk) was 17 (at risk for pressure ulcers). LVN 4 stated Resident 960 was at risk to develop pressure ulcers, was incontinent of bowel and bladder and required extensive assistance with one person to turn and reposition in bed. LVN 4 stated Resident 960 should not have sat in the wheelchair for longer than two hours without being repositioned. LVN 4 stated Resident 960 should have been encouraged to transfer back into bed. During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:28 p.m., she reviewed Resident 960's care plan titled, Potential for impairment to skin integrity dated 7/16/19, which indicated Resident 960 would maintain or develop clean and intact skin which included the following interventions to avoid scratching to keep body parts from exposure to excessive moisture ., and to use draw sheet or lifting device to move Resident 960. LVN 4 stated Resident 960's care plan did not address measures to prevent pressure ulcers. LVN 4 stated the care plan should have included repositioning every two hours to prevent pressure ulcers. During a review of the clinical record for Resident 960, the NSG Admission/Readmission Evaluation dated 7/8/19, indicated, . Skin . is a skin issue present? Yes . redness to coccyx/buttocks . Bed mobility . The resident requires extensive assistance by (1) staff to turn and repositioning in bed . Transferring . The resident requires Mechanical lift with (2) staff assistance for transfers . During a review of the clinical record for Resident 960, the BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK dated 7/8/19, at 6:42 p.m., indicated, . MOBILITY . Slightly Limited: Makes frequent slight changes in body or extremity position independently . FRICTION & (and) SHEAR . Potential Problem: Moves feebly or requires minimum assistance . Scoring 17 . AT RISK 15-18 . During a review of the clinical record for Resident 960, the Minimum Data Set (MDS) assessment (an evaluation of the resident's cognitive and functional needs) dated 7/15/19, indicated the Resident 960 required two staff members for transfers and was at risk of pressure ulcer development. During a review of professional reference document titled, Pressure Injury Prevention Points dated (YEAR), retrieved from https://npuap.org/page/PreventionPoints, indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address, repositioning, and support surfaces . During a concurrent interview and record review with LVN 4, on 8/7/19, at 2:32 p.m., she reviewed Resident 960's care plan titled, Pressure ulcer to stage 2 to coccyx r/t (related to) Immobility, and incontinent of bowel and bladder dated 8/6/19, which indicated Resident 960 needed to be turned and/or repositioned frequently. LVN 4 stated the care plan intervention for frequent repositioning should have been initiated on admission when Resident 960 was assessed as at risk to develop pressure ulcers and when the stage 2 pressure ulcer to coccyx area was found on 8/6/19. During an interview with LVN 4, on 8/7/19, at 2:35 p.m., she stated Physical Therapy was not consulted for a pressure relieving wheelchair cushion. LVN 4 stated, I thought Physical Therapy was only for rehab(ilitation). During an interview with Occupational Therapist (OT) 1, on 8/7/19, at 2:51 p.m., she stated the licensed nurses should have made a referral to OT for a pressure relieving wheelchair cushion. OT 1 stated residents who are at risk to develop pressure ulcer should be repositioned every two hours. During a concurrent interview and record review with the DON, on 8/7/19, at 3:08 p.m., she reviewed Resident 960's clinical record titled, NSG Admission/Readmission Evaluation dated 7/8/19, which indicated Resident 960's Braden Score was 17 (high score indicated at risk for pressure ulcer development). The DON stated Resident 960 was at risk to develop pressure ulcers. During a concurrent interview and record review with the DON, on 8/7/19, at 3:15 p.m., she reviewed Resident 960's care plan titled, Potential for impairment to skin integrity dated 7/16/19, which indicated Resident 960 would maintain or develop clean and intact skin. The DON stated the care plan included the use of a draw (half sheet often used to assist with repositioning in bed) sheet or lifting device to move Resident 960. The DON stated the care plan should have included interventions like repositioning every two hours to prevent pressure ulcers and it did not. During a concurrent interview and record review with the DON, on 8/7/19, at 3:20 p.m., she reviewed Resident 960's care plan titled, Pressure ulcer to stage 2 to coccyx r/t Immobility, and incontinent of bowel and bladder, dated 8/6/19, which indicated Resident 960 needed to be turned and repositioned frequently or as often as needed. The DON stated the care plan intervention for repositioning should have been initiated on admission when Resident 960 was assessed as at risk to develop pressure ulcers and when the stage 2 pressure ulcer to coccyx area was found on 8/6/19. The DON stated she forgot to include the intervention for repositioning every two hours in the care plan. During an interview with the DON, on 8/7/19, at 3:25 p.m., she stated Resident 960 sat in the wheelchair for longer than two hours without being repositioned. The DON stated she did not consult Physical Therapy for a pressure relieving wheelchair cushion. The DON stated she did not consider utilizing a pressure relieving wheelchair cushion to reduce the risk for developing pressure ulcers. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 8/7/19 at 4:02 p.m., she reviewed the clinical record for Resident 960's. The Minimum Data Set (MDS- a resident assessment tool used to identify healthcare needs) dated 7/15/19, indicated Resident 960 needed extensive two-person physical assist with bed mobility and transfer, was incontinent with bladder and bowel and was at risk to develop pressure ulcers. The MDSC stated Resident 960 was at risk to develop pressure ulcer. The MDSC reviewed Resident 960's care plan for skin impairment dated 7/8/19 and stated the care plan had not addressed interventions for pressure ulcer prevention. The MDSC stated frequent repositioning should be in the care plan. The MDSC stated, I should have reviewed the care plan. I should have done better (document interventions). During a concurrent interview and record review with the MDSC, on 8/8/19, at 1:54 p.m., she reviewed Resident 960's clinical record titled LTC (Long Term Care) Weekly Assessment. The MDSC stated she was unable to find documentation of a weekly skin assessment. The MDSC stated Resident 960 was admitted with redness to his coccyx area. The MDSC stated the licensed nurses should have documented weekly skin assessment to monitor and assess Resident 960's coccyx area. During a telephone interview with LVN 5, on 8/9/19 at 9 a.m., LVN 5 stated she did the admission assessment for Resident 960 on 7/8/19. LVN 5 stated Resident 960 had redness to his coccyx. LVN 5 stated the licensed nurse should have documented a weekly skin assessment to monitor and assess Resident 960 's coccyx area. During a concurrent interview and record review with the DON, on 8/9/19, at 9:40 a.m., she reviewed Resident 960's clinical record titled LTC Weekly Assessment and was unable to find documentation of weekly skin assessments for Resident 960. The DON reviewed the facility policy and procedure titled Quality of Care dated 8/18, which indicated, . The facility will assess resident upon admission, and thereafter, to identify if the resident is at risk for developing or has a PU (Pressure Ulcer)/PI (Pressure Injury), or has pre-existing sign suggesting that tissue damage has already occurred . The DON stated Resident 960 was assessed with [REDACTED]. The DON stated the stage 2 pressure ulcer was new and had not been identified prior to 8/6/19. The DON stated the staff should have performed assessments to ensure the redness did not worsen but no one did that. During a concurrent interview and record review with the DON, on 8/9/19, at 9:50 a.m., she reviewed Resident 960's clinical record titled Care Plan dated 7/8/19, and was unable to find a care plan for redness to coccyx area. The DON stated Resident 960's redness to coccyx area should have been care plan. The DON stated if the redness was care planned the staff would have implemented measures to try to prevent pressure ulcers but they did not do that. The DON stated the stage 2 pressure ulcer was new and could have been prevented if the staff would have addressed the redness. The facility policy and procedure titled QUALITY OF CARE dated 8/18, indicated, To promote the prevention of avoidable pressure ulcers . and provide care and services consistent with professional standards of practice . The facility will implement, monitor and modify interventions to attempt to stabilized, reduce or removed underlying factors . A resident identified as at risk of developing PU (Pressure Ulcer)/PI (Pressure Injuries) will have individualized interventions implemented to prevent PU/PI from developing . The resident's care plan will reflect the interventions . The resident's care plan will reflect the preventative strategies for residents identified as having a PU/PI . The resident's care plan will reflect the treatment strategies for residents identified as having a PU/PI . Prevention and treatment plans will be individualized and consistently provided . Based on the comprehensive assessment and the resident's clinical condition . identified needs . interventions may include . provision of pressure-redistributing support surfaces . if the resident is refusing care . the facility will attempt to identify potential alternatives, as indicated . Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan . Repositioning needs to maintain the resident's skin integrity will be considered for residents who are . seated in a chair or wheelchair, as well as for residents who are lying in bed. Repositioning needs/plan will be reflected in the care plan . Pressure redistribution involves both pressure reduction and pressure relief . Pressure redistribution devices (support surfaces/devices) . Facility staff will monitor residents skin condition and be alert to potential changes in the resident's skin condition. Identified changes will be reported . The IDT will develop a relevant care plan that includes measurable goals and interventions for prevention and management of PU/PIs. Identified interventions will be implemented . A weekly evaluation of the PU/PIs will be documented . During a review of professional reference document titled Pressure Injury Prevention Points dated (YEAR), retrieved from https://npuap.org/page/PreventionPoints, indicated, Consider bedfast and chairfast individuals to be at risk for development of pressure injury . Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address, repositioning, and support surfaces . Inspect the skin at least daily for signs of pressure injury . Assess pressure points, such as the sacrum, coccyx, buttocks . Turn and reposition all individuals at risk for pressure injury . Continue to reposition an individual when placed on any support surfaces . Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs . Reposition weak or immobile .

Based on interview and record review, the facility failed to identify discharge needs and develop a discharge care plan for one of 31 sampled residents, (Resident 565) when Resident 565 was discharged to a board and care home without ensuring the board and care home was capable of meeting Resident 565's needs. The facility Interdisciplinary Team (IDT, a team of healthcare providers who meet to plan resident care) did not meet to evaluate Resident 565's need for a safe discharge. Resident 565 was discharged to the board and care home which could not provide Resident 565 with required assistance for bathing and grooming. Resident 565 was transferred without adequate discharge planning, discharge teaching or emotional preparation. As a result of these failures, Resident 565 was not provided with necessary assistance to meet her hygiene and bathing needs and suffered from emotional distress from lack of planning and preparation. Findings: Resident 565's clinical record titled, Face Sheet (record containing resident personal information) indicated Resident 565 was a [AGE] year old female who was admitted to the Skilled Nursing Facility (SNF) on 10/18/17. The Face Sheet indicated Resident 565 had [DIAGNOSES REDACTED]. The Face Sheet indicated Resident 565 was discharged on [DATE] to Private home/apt. Resident 565's clinical record titled, Minimum Data Set (MDS, an assessment tool used to plan resident care) assessment dated [DATE] (date of discharge), indicated Resident 565 had moderate cognitive (pertaining to memory, reasoning and judgement) impairment and required extensive staff assistance for bed mobility (turning side to side and repositioning), dressing, toilet use, personal hygiene (combing hair, brushing teeth) and was totally dependent on staff assistance for bathing. The MDS indicated Resident 565 had not walked in her room in the 7 days prior to discharge. On 4/19/18 at 9:10 a.m., during an interview, the facility Administrator (Adm) stated the facility was notified by Medi-Cal that Resident 565 would no longer be covered (Medi-Cal would no longer pay for Resident 565's stay in the SNF) effective (MONTH) (YEAR). The Adm stated the facility used a placement agency (PA) to find a facility that would accept Resident 565 and the PA arranged placement at the board and care home. The Adm stated the maintenance staff and social services staff drove Resident 565 to the board and care home on 3/26/18 in the facility bus. The Adm stated she thought Resident 565 would do fine in the board and care home. The Adm stated, I did not know that she needs help with hygiene and showers. On 4/19/18 at 9:23 a.m., during an interview, the Assistant Social Services Director (ASSD) stated, Medi-Cal will not renew (Resident 565) benefit so we needed to find her a place. Her coverage ends in (MONTH) of this year. The ASSD stated shortly after the facility found out Resident 565's Medi-Cal coverage would end, the PA notified the facility that a board and care was available and someone would come out to speak to Resident 565. The ASSD stated, I guess a guy came in and evaluated (Resident 565). I didn't get to meet the guy from that board and care place. (Resident 565) and her roommate both said a guy came in. The ASSD stated, I didn't have a good feeling about it (the discharge to board and care). (Resident 565) had a stroke and so I can see why she would need help with her shower. (Resident 565) was surprised she was accepted (by the board and care) with her left sided paralysis. She was low income. She was getting $800 monthly so she didn't have many options for places to go to. On 4/19/18 at 10:13 a.m., during an interview, Certified Nursing Assistant (CNA) 6 stated she was the CNA regularly assigned to provide care to Resident 565 while she was in the SNF. CNA 6 stated Resident 565 was wheelchair bound most of the time, but could walk short distances with assistance wearing a leg brace and using a special walker. CNA 6 stated, She needs help to fasten her briefs (adult garment for incontinence). She definitely needs help with her shower. On 4/25/18 at 10:04 a.m., during an interview, the PA Senior Care Coordinator (SCC) stated she had worked as an in-home care giver for one year and three months before going to the PA as a care coordinator. The SCC stated the PA usually assesses a resident before they attempt to find placement. The SCC stated she and two other PA employees were at the SNF a few days before Resident 565 was discharged . The SCC stated, (Resident 565) was in the activity room so we were unable to talk to her or assess her. (The ASSD) told us not to bother (Resident 565) when she was playing bingo. No, we didn't get to talk to (Resident 565) prior to her discharge. On 4/25/18 at 4:18 p.m., during an interview, the ASSD stated she did not see the PA staff go into Resident 565's room, but the Licensed Nurse Care Coordinator (LNCC) with the PA contacted her and said the board and care home was available for Resident 565. The ASSD stated, In a matter of four days the discharge happened. The nurse called for the discharge order, the Medical Director (MD), and that was that. The ASSD stated the MD ordered home health to follow Resident 565 after discharge. Resident 565's clinical record titled, Physician's Orders dated 3/22/18, indicated, Pt (patient) to D/C (discharge) to (name of facility) board and care on 3/26/18. Will need home health RN (registered nurse) PT (physical therapy) for medication management, progressive strengthening and mobility. D/C with meds (medication). F/U (follow-up) with PCP (primary care provider) in one week. Will need standard wheelchair for 99 + days. The order was signed by the MD. Resident 565's clinical record titled, Progress Notes dated 3/19/18 indicated, (PA) in today to attempt to find placement for (Resident 565). Medi-Cal will not pay for her stay. Information provided and (PA) will follow up in finding placement if possible. Resident 565's Progress Note dated 3/22/18, indicated, (PA) a facility Board and Care will accept (Resident 565). Resident 565's Progress Note dated 3/26/18 at 4 p.m., indicated (Resident 565) was transported to (board and care) today. Transported by the facility bus. Social Service assisted and helped with all personal items. Helped (Resident 565) settle into her new room, helped with clothing. The Progress Note was signed by the ASSD. On 4/25/18 at 4:51 p.m., during a telephone interview, board and care staff member (BCSM) stated he lived at the board and care home with his girlfriend. The BCSM stated, What we do for each person: we cook three meals, clean the bathrooms, wash clothes once a week. This is independent living. We are not caregivers. I went to (the SNF) and talked to (Resident 565). I told her that our place is for independent living. I asked her to check it out first before she decides. The (facility staff) brought (Resident 565) the same day I came to visit her. I was actually surprised. We are not caregivers here so I like the potential client to check first. The BCSM stated the ASSD accompanied Resident 565 on 3/26/18 when she was transferred to the board and care home. The BCSM stated, After bringing in (Resident 565)'s belongings, (the ASSD) left when (Resident 565) was busy talking to other residents. Around dinner time (Resident 565) was looking for (the ASSD). She said she was getting hungry and needed to go back to (the SNF). I told her (the ASSD) left earlier and she was not coming back, that (Resident 565) would be living here now. She got very upset and teary. She was going on and on saying, She dumped me. She dumped me. On 4/25/18 at 5:10 p.m., during a telephone interview, Resident 565 stated, That day (3/26/18) (the ASSD) packed up my belongings, I thought I was going to be moved to a different room or a different part of (the SNF). The paper that I signed and everything they did and asked me to do were all for the move to a different part (of the SNF). Later in the day (the ASSD) took me here (board and care home). I thought we were just checking the place out because (the BCSM) told me that I needed to check this place first because he said it is for independent living. I told him I need help getting cleaned. That's when he said to check it out to see if it would work for me. Before I knew it, (the ASSD) dumped me. I did not get any teachings. She dumped me here. The (ASSD) told me home health will be coming over to help me; but nobody has come. I've had one shower in three weeks because my son came to visit with his wife so my daughter-in-law helped me. Then I have this powder medication that I don't know anything about. Nobody told me anything about it so I'm not taking it. I am so confused because the bottle has my name on it but there is also the word pediatric on it and I know pediatric means children and I am not one. I can't get ahold of my son and it's always like that with him. I can't depend on him to help me. Resident 565 stated she had a stroke in 1998 and could get up for a short distance wearing a leg brace and using a cane. Resident 565 stated when she resided at the SNF the CNAs would wake her up at 2:15 a.m. every day, help her put on her leg brace and walk her to the bathroom. Resident 565 stated at the board and care home she was unable to get her leg brace on by herself quickly. Resident 565 stated, By the time I get it (the leg brace) on I already wet myself. Resident 565 stated she did not have any incontinence briefs available the first two days she resided at the board and care. Resident 565 stated, (The ASSD) didn't tell me that she was going to dump me here. She told me that we were just checking out the place, then she left. I was looking for her around dinner time to go back to (the SNF). (The BCSM) told me she left and I'm staying. I was so upset. She tricked me. I can't shower by myself. I am not prepared to come here at all yet. I am not even able to wheel myself to the store because it is a dangerous area. (The ASSD) keeps telling me that they will take care of me but that's not what they do here. They can't. They are not caregivers. On 4/25/18 at 5:22 p.m., during a telephone interview, the home health agency account executive (HHA) stated, We have not started our service with (Resident 565) because we do not have updated doctor's orders. The HHA stated they could not accept orders from the facility medical director, the order for home health services had to come from the resident's primary physician and those orders were not received. On 4/25/18 at 7:28 p.m., during a telephone interview, the PA Owner (PAO) stated, Our assessment (for placement of a resident) is basically an interview, not a physical assessment. We sit down with the patient, social worker and discharge planner to come up to a decision what's the best placement for the patient. I remember we were told that (Resident 565) was independent and limited income. That's why she was referred to room and board (board and care). The final decision is up to the (SNF) administrator. On 4/26/18 at 10:36 a.m., during a telephone interview, the Director of Nursing (DON) stated, I didn't know that (the PA) did not assess (Resident 565). I did know after the fact that the (home health agency) had not gone out to visit yet. There was not a lot of teaching needed for (Resident 565). Placement was set up, transportation was arranged. There was nothing to teach her or nothing else. The nurse went over the medications and made sure she understood. The ASSD did (Resident 565)'s discharge. She did it within seven days. I did not know that the nurse who discharged (Resident 565) did not do a return demonstration when she went over the medications. Return demonstration is necessary to be sure that what you taught the resident or what you were discussing with that resident was understood clearly. On 4/26/18 at 10:50 a.m., during a telephone interview, Licensed Nurse (LN) 6 stated she was the nurse who discharged Resident 565 on 3/26/18. LN 6 stated, I went over her medications .No I did not have her do it (show how to set up her medications). I should have done a return demonstration. On 4/26/18 at 11:02 a.m., during a telephone interview the Social Services Director (SSD) stated, I spoke with home health this morning. She said finally they got their paperwork .for (Resident 565)'s in-home support (one month after the discharge). On 4/26/18 at 2:48 p.m., during a telephone interview, the DON stated the facility IDT did not meet to plan Resident 565's discharge. The DON stated, It happened pretty quickly, the discharge. I admit we probably didn't do all the necessary steps. I did not check the regulations on discharge. The DON stated the SNF had IDT meetings on a daily basis, but had not met to plan a safe discharge for Resident 565. Resident 565's clinical record titled Post Discharge Plan dated 3/26/18, indicated under Social Services Information: Family/Resident Involved with discharge planning: a box indicating no was checked. The Sections of the Post Discharge Plan for nutritional notes, immunization information, home exercises, doctor in charge of resident's care after discharge, follow-up doctor's appointments, resident training for home and notification of the Long Term Care Ombudsman (resident advocate who by regulation should be notified of all facility initiated discharges) were all left blank. Review of the facility Policy titled Care Planning - Interdisciplinary Team dated Revised (MONTH) 2013, indicated Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker; e. The Activity Director/Coordinator; f. Therapists; g. Consultants; h. The Director of Nursing; i. The Charge Nurse; j. Nursing Assistants; k. Others as appropriate or necessary to meet the needs of the resident. 3. The resident, the resident's family .are encouraged to participate in the development of and revisions to the resident's care plan. The facility policy titled, Comprehensive Care Plans dated 11/20/17 indicated, Purpose: To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Policy: The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment .8. Care plan will include: d. ii. The resident's preference and potential for discharge to the community. NOTE: Facility will document assessments related to return to community and referrals to local agencies. The facility policy titled, Discharging the Resident dated (MONTH) (YEAR), indicated .Preparation: 1. The resident should be consulted about the discharge .4. If discharging the resident to another long-term care facility tell the resident: d. Who will be providing the resident's care .f. Why the discharge is necessary .7. Assess and document resident's condition at discharge .