Every finding on record at Guadalupe Valley Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 residents (Resident #2) reviewed for infection control. The facility failed to ensure CNA C changed gloves during incontinent care for Resident #2. This failure could place residents at risk of cross contamination and infections.The findings include: Record review of Resident #2's electronic face sheet dated 06/30/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: cerebral infarction (blood vessel supplying the brain becomes blocked, resulting in lack of oxygen) and chronic kidney disease, stage 3A (moderate kidney damage). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected that others could understand her and she could understand others. She scored an 8 of 15 on her BIMS which signified her cognitive status was moderately impaired. She required moderate assistance with ADLs. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's comprehensive care plan dated 01/09/2026 reflected Problem, has an ADL self-care performance deficit r/t weakness, poor balance, Interventions, TOILET USE, occasionally incontinent of bowel and bladder and requires staff to assist with incontinent care. Observation on 06/30/2026 at 1:15 pm of CNA C as she performed incontinent care for Resident #2 revealed CNA C did not change her gloves and sanitize hands after she completed wiping the back side of the resident and proceeded to put clean linen on the bed and a clean brief onto the resident. During an interview on 06/30/2026 at 1:30 pm CNA C stated she forgot to change gloves and sanitize or wash hands and said not doing so could cause cross contamination and infection. She stated she was trained to sanitize hands and to change gloves. During an interview on 06/30/2026 at 4:30 pm, the DON stated CNA C should have changed her gloves and sanitized her hands prior to placing clean items on Resident #2. She stated she was accountable for the nursing care in the facility, and she stated cleaning hands and changing gloves helped to prevent the spread of infection. During an interview on 06/30/2026 at 5:00 pm, the ADM stated he was accountable for everything that happened in the building to include infection control. He stated cleaning hands and changing gloves during and after incontinent care for residents prevented cross contamination. Record review of CNA C's Incontinent Care Skills Checklist dated 06/04/2026 reflected With new wipe or cloth, cleanse the entire buttock area and surrounding hip area. Turn over surface of wipe to cleanse other side of buttock, wash and sanitize hands. Apply clean gloves. Record review of the facility's policy and procedure titled Infection Prevention and Control Program dated 05/13/2023 reflected hand hygiene shall be performed in accordance with our facility's established hygiene procedures.

Based on observation, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1of 5 residents (Residents #1) reviewed for resident assessments. The Facility failed to ensure Resident #1's active diagnosis of repeated falls (two or more falls within a 12-month period) was reflected on the annual MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care.The findings include: Record review of Resident #1's electronic face sheet dated 06/30/2026 reflected an [AGE] year-old female admitted on [DATE]. Her diagnoses included: repeated falls, diagnosis date: 05/29/2026 ranked #7 on her list of diagnoses. Record review of Resident #1's annual MDS assessment dated [DATE] reflected that she could sometimes understand others and be understood by others. Resident #1 was not a candidate for a BIMS which signified her cognitive status was severely impaired. She required moderate assistance with ADLs and did not ambulate independently. She relied on the use of a w/c for locomotion. She was noted to have had falls since admission/entry or reentry or prior assessment and 2 or more with no injuries. Review of the MDS section I-Active Diagnoses did not reflect her diagnosis of repeated falls. Record review of Resident #1's comprehensive care plan dated 03/10/2026 reflected Problem, has had actual falls with/without injury r/t poor balance and impulsive behavior, Interventions, scoop mattress, fall mat X2 (one by each side of bed. Observation on 06/30/2026 at 10:00 am of Resident #1 revealed she was in her room, lying on a low bed with a scoop mattress and a mat on both sides of her bed. Resident #1 was not interview able. During an interview on 06/30/2026 at 2:45 pm, MDS A stated she did not complete Resident #1's annual MDS assessment and that the repeated falls diagnosis was not coded as an active diagnosis because it lacked a physician note. She confirmed Resident #1 had fall interventions that were ordered and signed by the physician which equated to provider documentation. She stated that an accurate MDS was important for the right type of care for a resident and their needs could be missed. During an interview on 06/30/2026 at 4:15 pm, LVN B stated Resident #1 was at high risk for falls and had a low bed with a scoop mattress and floor matts positioned on each side of the bed. During an interview on 06/30/2026 at 4:20 pm, NA D stated Resident #1 had falls and the bed was in a low position, scoop mattress on the bed and there was a floor mat on each side of her bed for her safety. During an interview on 06/30/2026 at 4:30 pm, the DON stated Resident #1 was assessed to be at high risk for falls and had a history of repeated falls. She stated Resident #1's fall prevention interventions were noted in her physician orders such as the fall matts and scoop mattress. She stated the importance of an MDS to be accurate because it reflected the residents and what they needed. She stated an inaccurate MDS could result in falsification for reimbursement and care not provided as required. During an interview on 06/30/2026 at 5:00 pm, the ADM stated he was accountable for everything that happened in the building to include the accuracy of the MDS assessments. He stated the MDS assessment's accuracy was important for claims and resident care, and a potential existed for a negative outcome. He stated the facility did not have a policy and procedure that addressed MDS accuracy because they referred to the RAI manual. Record review of Resident #1's Active Orders as of: 06/30/2026 reflected check fall mat X2 (one to each side of bed) check placement every 4 hours, start date 05/18/2026. Further review reflected Scoop mattress, start date 05/11/2026. Record review of Resident #1's FRA dated 06/17/2026 reflected she scored a 19 which signified If the score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Further review of the FRA reflected B. History of falls in past 3 months, 3.3 or more. Record review of the facility incidents and accidents from March 2026 through June 2026 reflected Resident #1 had 2 falls on 03/16/2026, and 1 fall on 05/08/2026 and 06/16/2026. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observations, interviews and record reviews, the facility failed to ensure residents who had the right to reside received services in the facility with reasonable accommodation of resident needs and preferences for 3 residents (Residents #6, #14 and #44) of 32 residents reviewed. 1.The facility failed to ensure Resident #6's call light was within reach. 2.The facility failed to ensure Resident #14's call light was within reach. 3.The facility failed to ensure Resident #44's call light was within reach. This facility failure could place residents at risk of not having a way to call for help or assistance when needed.The findings included: 1.Record review of Resident #6's electronic face sheet dated 03/25/2026 reflected an [AGE] year-old female admitted on [DATE]. Her diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), major depressive disorder (a serious mental health condition characterized by a persistent low mood, loss of interest of pleasure in activities, and significant impairment in daily functioning), dysphagia (a medical condition characterized by difficulty swallowing, solids, liquids or both, which can lead to choking, coughing , or the sensation of food being stuck in the throat)and presence of 1 cardiac pacemaker (has an implanted device to regulate or maintain a normal heart rhythm, usually due to a slow or irregular heartbeat). Record review of Resident #6's significant change in status MDS dated [DATE] reflected that she rarely understood and could rarely be understood. Resident #6 was not a candidate for a BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. Record review of Resident #6's comprehensive care plan dated 02/12/2026 reflected Problem, at risk for falls r/t unaware of safety needs, Interventions, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation on 03/24/2026 at 10:31 a.m. Resident #6 was lying on a low bed with a floor mat next to the bed on the right side. Her call light was near the headboard on the floor. Resident #6 was not interview able. 2. Record review of Resident #14's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Huntington's disease (genetic neurodegenerative disorder characterized by involuntary dance like movements along with cognitive and psychiatric symptoms), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), aphasia (a disorder that affects language abilities due to brain damage, usually from a stroke or injury) and dysphagia (characterized by difficulty swallowing, solids, liquids or both, which can lead to choking, coughing , or the sensation of food being stuck in the throat). Record review of Resident #14's MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She required minimal to moderate assistance with ADLs. Record review of Resident #14's comprehensive care plan dated 01/21/2026 reflected Problem, resident has an ADL self-care performance deficit r/t weakness, Interventions, Encourage the resident to use bell to call for assistance. Observation and interview on 03/25/2026 at 2:03 p.m., Resident #14 was laying on a low bed with a floor mat to the right side of her bed. Her call bell was lying on the floor mat out of reach. CNA D, who was assigned to Resident # 14, entered the room to get the resident and take her for a shower. Resident #14 was not inter-viewable. CNA D stated she forgot to put Resident #14's call bell within reach. She stated it was important to have the call bell within reach in case the resident needed help. She did not know why she forgot to place the call bell within Resident #14's reach. 3. Record review of Resident #44's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: cerebral palsy (a group of conditions that affect movement and posture.), Barrett's esophagus (a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach becomes damaged by acid reflux), peripheral vascular disease (a systematic disorder of narrowed peripheral blood vessels resulting from a buildup of plaque), sick sinus syndrome (a type of heart rhythm disorder) and chronic obstructive pulmonary disease. (a common lung disease causing restricted airflow and breathing problems). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected that she scored 12 of 15 on her BIMS which signified her cognitive status was moderately impaired. She was dependent on staff for ADLs. She could understand others and be understood. Record review of Resident 344's comprehensive care plan dated 06/03/2026 reflected Problem, is at risk for falls r/t impaired balance, impaired communication, Interventions, be sure call light is within reach and encourage her to use it for assistance as needed. Observation on 03/24/2026 at 3:56 p.m., Resident #44 was lying in bed, groaning, complaining of discomfort. Her call light was wrapped around the bed rail on the right side of her bed hanging down below the mattress and not within her reach. During an interview on 03/24/2026 at 4:00 pm, Resident #44 stated she could not reach her call light, and she would like to see the nurse. During an interview on 03/24/2026 at 4:05 pm, CNA C stated she must have forgotten to put Resident #44's call light within her reach because she was a two-person mechanical lift transfer, and they had just put her to bed. She stated she realized it was important to have the resident's call light within reach in case they needed to call for help in an emergency. She stated the nurse was aware of Resident #44's discomfort. During an interview on 03/27/2026 at 1:30 p.m., the DON stated he was not aware Residents #6, #14 and #44 did not have their call lights within reach. He stated he was accountable for the nursing care in the facility, and it was everyone's responsibility if they notice a residents call light not within reach to move it to be accessible. He stated that residents might need help and needed the call lights to be within their reach. During an interview on 03/27/2026 at 1:45 pm, the ADM stated it was important for resident call lights to be within reach in case they needed something or had an emergency. Record review of the facility's policy and procedure titled Call Lights: Accessibility and Timely Response dated 10/13/2022 reflected Staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to ensure all open items being stored in the walk-in refrigerator were labeled and dated with the use by date.The facility failed to ensure all open items being stored in the reach-in cooler were labeled and dated with the use by dateThe facility failed to take the temperatures of all foods served to residents. These failures could place residents at risk for food borne illness. Findings include:Observation of the facility's kitchen reach-in cooler on 03/24/2026 at 9:11 AM revealed one open half gallon of chocolate milk open with no open date. The kitchen's service line had a container with greater than 10 individually portioned slices of bread in bags without labels or dates. Observation of the facility's kitchen on 03/26/2026 at 11:20 AM revealed dietary aide B opened 5 cans of individual portions of soup and poured them into 5 separate bowls then placed plastic lids on the bowls. Dietary aide B then placed the bowls of soup on the prep area.Observation of the facility's meal service on 03/26/2026 at 11:55 AM revealed the dietary manager took temperatures of food items on the steam table prior to serving. The dietary manager was not observed taking the temperature of food items served from the stove top, deep fryer or the soup heated in the microwave. Three pans; one with cabbage, one with mashed potatoes, and one with cooked hamburgers; were observed on the stovetop along with chicken nuggets and fries in fryer baskets rested over the deep fryer. The dietary manager was observed plating resident 19 plates with chicken nuggets and mashed potatoes, resident 133, resident 42 and resident 47 plates with cabbage, resident #46 and resident #105 plates with soup, and resident 60's plate with a burger and fries.Interview with Dietary Aide B on 03/26/2026 at 11:25 AM revealed she poured the soup into bowls for the residents who requested soup for lunch. Dietary Aide B stated she would heat the soup as needed for resident's trays.Interview with Resident #19 on 03/26/2026 at 1:23 PM revealed she was happy with her lunch and it came to her warm. Resident 19 stated she had received cold food from the kitchen in the past, but it had been warm recently.Interview with Resident #60 on 03/26/2026 at 1:24 PM revealed he received a burger and fries for lunch. Resident #60 stated his food could have been hotter, but it was warm enough to eat comfortability.Interview with Resident #105 on 03/26/2026 at 1:26 PM revealed she received soup for lunch. Resident stated her soup was not hot but was warm enough to eat. Resident stated she did not have any concerns with the temperature of her food.Interview with Resident #133 on 03/26/2026 at 1:28 PM revealed she had cabbage with her lunch. Resident stated her lunch was warm but never hot. Resident stated if she needed it warmed up, she could have asked but did not need it warmed up at that time.Interview with Resident #42 on 03/26/2026 at 1:32 PM revealed he received cabbage with lunch. Resident #42 stated he liked his lunch, and it was warm. Resident #42 stated he did not have any concerns with the temperature of the food.Interview with Resident #47 on 03/26/2026 at 1:35 PM revealed she received cabbage with lunch. Resident #47 stated her lunch was warm but had no flavor. Resident 47 stated she could ask to have her food warmed up if it was cold.Interview with Dietary Aide A on 03/26/2026 at 1:40 PM revealed all items being stored in the reach-in cooler and the service line should be labeled with the date it was opened or prepared. Dietary Aide A stated if items in the reach-in cooler or the service line were not labeled there was no way of knowing how old the items were. Dietary Aide A stated there was the potential for spoiled foods to be served to the residents causing illness. Dietary Aide stated it was the responsibility of anyone storing open or prepared food items to label it before storing it. Dietary Aide stated it was the responsibility of the cook to take temperatures of the food before serving it to the residents.Interview with Dietary Manager on 03/26/2026 at 1:45 PM revealed items in the reach-in cooler and portioned items should be labeled with the date prepared/opened and the date to be used by. Dietary Manager stated all staff preparing or storing food items were responsible for labelling them. Dietary Manager stated labeling items would prevent spoiled food from being served and would prevent the residents from getting sick. Dietary Manager stated it was the responsibility of the cook to take the temperatures of food items prior to serving them to the residents. Dietary Manager stated she took the temperatures of the items on the steam table. Dietary Manager stated because the alternates such as the burgers, cabbage, mashed potatoes were kept on the stove top and the chicken nuggets, fries and soup were heating at the time they were served she did not take the temperatures. Dietary manager stated that by not taking the temperatures of the alternate food items she was not able to ensure the food was served at a safe and comfortable temperature. Dietary manager stated the residents could have been served foods that were too cold or too hot causing them to burn themselves.Interview with Dietary Aide B on 03/26/2026 at 1:50 PM revealed food items that had been prepared or opened then stored in the reach-in cooler or serving line should have been labeled with the date opened or prepared. Dietary Aide B stated it was the responsibility of Dietary Aide A to label items before they stored. Dietary Aide B stated unlabeled foods could become spoiled and served to residents causing illness. Dietary Aide B stated it was the responsibility of the cook to ensure food temperatures were taken before they were served to the residents.Record review of facility policy titled Food Storage, date revise June 1, 2019, revealed Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Record review of facility policy titled Taking Temperatures, date revised June 1, 2019, revealed The facility will take and record the temperatures of all foods prior to service.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 32 residents ( residents #14 and #107) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure a care plan was developed to address Resident #14's fall interventions. 2.The facility failed to ensure a care plan was developed to address Resident #107's indwelling urinary catheter leg strap. This failure could place residents at risk of not receiving the type of care required and result in unmet needs. The findings included: 1.Record review of Resident #14's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Huntington's disease (genetic neurodegenerative disorder characterized by involuntary dance like movements along with cognitive and psychiatric symptoms), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), aphasia (a disorder that affects language abilities due to brain damage, usually from a stroke or injury) and dysphagia (characterized by difficulty swallowing, solids, liquids or both, which can lead to choking, coughing , or the sensation of food being stuck in the throat). Record review of Resident #14's MDS assessment dated [DATE] reflected that she was not a candidate for a BIMS which signified her cognitive status was severely impaired. She required minimal to moderate assistance with ADLs. Record review of Resident #14's comprehensive care plan dated 01/21/2026 reflected Problem, resident has an ADL self-care performance deficit r/t weakness, Interventions, Encourage the resident to use bell to call for assistance. It did not reflect the low bed and floor mat. Record review of Resident #14's FRA dated 01/20/2026 reflected she was at high risk for falls. Observation on 03/24/2026 at 10:40 a.m. of Resident #14's room revealed her bed was in a low position with a floor mat on the right side. Observation on 03/25/2026 at 2:03 p.m., Resident #14 was laying on a low bed with a floor mat to the right side of her bed. Her call bell was lying on the floor mat out of reach. CNA D, who was assigned to Resident # 14, entered the room to get the resident and take her for a shower. Resident #13 was not inter-viewable. During an interview on 03/25/2026 at 2:03 p.m., CNA D stated she forgot to put Resident #14's call bell within reach. She stated Resident #14 had a low bed with a mat on the floor because she was at high risk for falls. 2. Record review of Resident #107's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on 11/102020. Her diagnoses included: contracture of muscles, left and right lower legs (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). Record review of Resident #107's quarterly MDS assessment dated [DATE] reflected that she understood and was able to understand others. She scored 6 of 15 on her BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She had an indwelling urinary catheter. Record review of Resident #107's comprehensive care plan dated 12/30/2025 reflected Problem, has indwelling urinary catheter r/t skin breakdown, interventions, position catheter bag, and tubing below the level of the bladder. The comprehensive care plan did not reflect the need for a leg strap to secure the tubing. Record review of Resident #107's Active orders as of: 03/25/2026 reflected Check Foley Catheter, every shift use leg strap to secure Foley in place, start date 12/30/2026. Observation on 03/24/2026 at 10:30 a.m. of Resident #107 revealed Resident #107 was lying in bed, she had an indwelling urinary catheter bag hanging down with a privacy cover. During an interview on 03/24/2026 at 10:35 a.m., Resident #107 stated she had the catheter, but could not recall a strap on her leg. During an interview on 03/27/2026 at 1:22 p.m., LVN F stated Resident #14 was at high risk for falls and that needed to be in her care plan, and she did not know why it was not. She stated Resident #107's urinary catheter strap was part of her Foley care. During an interview on 03/27/2026 at 1:30 p.m., the DON stated the care plan for Resident #14 needed to reflect her risk for falls and interventions and Resident #107's leg strap needed to be in her care plan as part of her catheter care. During an interview on 03/27/2026 at 1:45 p.m. with the ADM, he stated the care plan needed to reflect the resident, or care could be missed. Record review of the facility policy and procedure titled Comprehensive Care Plans dated 10/24/2022 reflected It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 10 rooms (room [ROOM NUMBER]) and 1 of 3 shower rooms (#600 hall).The facility failed to ensure the vent that had excessive dust collected in the return vent in room [ROOM NUMBER] was cleaned.The facility failed to ensure a shower room on #600 hall was cleaned after use of a shower chair with feces, a bag with soiled towels, and a bag with a soiled brief.These failures could place residents at risk for respiratory illness and the spread infections and or diseases.The findings included: During observation of room [ROOM NUMBER] on 3/24/2026 at 11:14 AM the return vent in the ceiling was covered with thick dust. Observation and interview on 3/24/2026 at 11:34AM the shower room on the #600 hall there was a bag with soiled towels and a bag with garbage. There was one shower chair sitting in the shower stall with stool on the seat. CNA G said the shower chair and soiled items in the shower room should be cleaned after each, immediately. CNA G said it was important to clean the shower chair to prevent the spread of disease and to maintain infection control practices and to discard the bag with the soiled brief and the used towels should have been sent to laundry. CNA G said she had infection control in-service and 1:1 in-service with the ADON with hand washing and observations.Interview on 3/24/2026 11:37AM CNA H said it was important to clean the shower chair to prevent the spread of illness and to keep infection control. CNA H said the bag with the soiled brief and the bag with the used towels should have been placed with laundry and the bag with the soiled brief should have been placed in the garbage so that the shower room was clean for the next resident that needed to use the shower room. CNA H said she had infection control training about 2-3 months ago and the ADON did 1:1 with the CNAs.Interview on 3/26/2026 at 10:00AM Residents #146 and #147 in room [ROOM NUMBER] said the dust in the vent did not bother them. Resident #147 said, I didn't even pay attention to it until you said something about it.Interview on 03/27/2026 8:50 AM the MD said the return vent takes the air from the room to be recirculated into the room. The MD said there was a filter and the vents being dirty would affect the efficiency of the air conditioner unit and could affect the quality of air if not adequately filtered. The MD said it was the responsibility of housekeeping to make sure the vents were cleaned. Interview on 3/27/2026 at 9:55AM the DON said the chair left in the shower room with stool should have been cleaned after use for infection control and to prevent the spread of diseases. The DON said the bags should have been properly discarded or placed in laundry after use to ensure the shower room was cleaned for the next time it was used.Interview on 3/27/2026 at 10:30AM the ES said housekeeping was responsible for ensuring the vents were cleaned in the room. The ES said it was part of a weekly task and when the rooms were deep cleaned monthly. The ES said it was important to clean the vents to protect the residents from illness that could come from dirty vents. Record review of trainings for CNA G and CNA H revealed they had the training for infection control and maintaining a clean environment January 2026.Record review of facility policy titled Resident Rights dated 2022 stated, Residents have the right to live in a safe, decent, and clean environment.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 2 of 32 residents (Residents #4 and #107) reviewed for resident assessments. 1.The facility failed to ensure Resident #4's therapeutic diet was accurately reflected on her Quarterly MDS assessment dated [DATE]. 2.The facility failed to ensure Resident #107's Bipap was accurately reflected on her quarterly MDS assessment dated [DATE]. This deficient practice could place residents at risk of missed or inaccurate care. The findings included: Record review of Resident #4's face sheet dated 03/27/2026, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included: end stage renal disease, and type 2 diabetes mellitus with diabetic neuropathy, unspecified. Record review of Resident #4's Quarterly MDS assessment, dated 02/20/2026 Section K0520 Nutritional Approaches: D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) not coded While a Resident. Record review of Resident #4's care plan, initiated date of 03/15/2023, revealed Resident #4 had a focus of [resident name] has potential fluid volume overload r/t Kidney failure with intervention of Diet as ordered. Record review of Resident #4's physician order summary dated, 03/27/2026, read, Renal-Liberalized diet Pureed texture, Nectar Thickened Liquids consistency, SMALL STARCH PORTIONS with an order date of 01/22/2026. Observation on 03/24/2026 at 12:26 p.m. 300 hall resident trays being passed with Resident #4 observed sitting up in her bed with head of bed elevated, eating independently and had been provided a renal/pureed diet with nectar thick liquids. During an interview on 03/27/2026 at 2:05 p.m. the Care Management LVN F stated Resident #4's renal diet should have been coded for therapeutic diet on the Quarterly MDS Assessment, and she was going to go ahead and modify the MDS Assessment. The Care Management LVN F stated she did not know why she had not coded the therapeutic diet and it could have been an oversight. The Care Management LVN F stated she was the one who completed the section of Resident #4's Quarterly MDS Assessment. The Care Management LVN F further stated the MDS assessment should be a reflection of the resident and care that was being provided for the resident. The Care Management LVN F stated my miscoding the MDS assessment could affect care planning resident needs. During an interview on 03/27/2026 at 2:48 p.m. the DON stated the MDS nurse (Care Management LVN) was responsible for the accuracy of the MDS assessments. The DON further stated accuracy of the MDS assessment was important to make sure they had the correct plan of care. During an interview on 03/27/2026 at 2:52 p.m. the Regional [NAME] President stated MDS nurse (Care Management LVN) was responsible for the MDS assessment accuracy. The Regional [NAME] President stated importance of accuracy of the MDS assessment was to make sure they provided accurate and complete care to the patient. He further stated care could be missed or done incorrectly if the MDS assessment was not completed accurately. 2. Record review of Resident #107's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on 11/102020. Her diagnosis was hypoxia (deficiency of the amount of oxygen reaching the tissues). Record review of Resident #107's quarterly MDS assessment dated [DATE] reflected that she understood and was able to understand others. She scored 6 of 15 on her BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She had an indwelling urinary catheter. The MDS assessment did not reflect her use of Bipap. Record review of Resident #107's comprehensive care plan dated 12/15/2025 reflected Problem, has oxygen therapy r/t ineffective gas exchange, Interventions, Bi pap per orders. Record review of Resident #107's Active orders as of: 03/25/2026 reflected Bipap on at HS at bedtime for hypoxia, start date 05/09/2025. Observation on 03/24/2026 at 10:30 a.m. of Resident #107 revealed Resident #107 was lying in bed. She had a Bipap machine on her nightstand in a plastic bag. During an interview on 03/24/2026 at 10:35 a.m., Resident #107 stated she used Bipap at night to help her breathing. She stated she used it every night. Record review of Resident #107's MAR dated 01/1/2026 to 01/31/2025 reflected she had used her Bipap during the week of her quarterly MDS assessment. During an interview on 03/27/2026 at 1:22 p.m., LVN F stated the Bipap should have been coded on Resident #107's quarterly MDS assessment dated [DATE]. She stated she did not know how she missed the Bipap. She stated the MDS accuracy was important because it reflected the person and the care they required, and if it were not accurate it could mean they could have needed care missing. She stated she was accountable for MDS accuracy. During an interview on 03/27/2026 at 1:30 p.m., the DON stated the MDS reflected a resident and the care they required. The MDS needed to reflect accurately or care could be missed. During an interview on 03/27/2026 at 1:45 p.m. with the ADM, he stated the MDS nurse was accountable for the MDS accuracy, and the accuracy reflected the individual and care required. He stated the facility followed the RAI manual and did not have a separate policy and procedure for MDS accuracy. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status. Record review of Resident #4's face sheet dated 03/27/2026, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included: end stage renal disease, and type 2 diabetes mellitus with diabetic neuropathy, unspecified. Record review of Resident #4's Quarterly MDS assessment, dated 02/20/2026 Section K0520 Nutritional Approaches: D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) not coded While a Resident. Record review of Resident #4's care plan, initiated date of 03/15/2023, revealed Resident #4 had a focus of [resident name] has potential fluid volume overload r/t Kidney failure with intervention of Diet as ordered. Record review of Resident #4's physician order summary dated, 03/27/2026, read, Renal-Liberalized diet Pureed texture, Nectar Thickened Liquids consistency, SMALL STARCH PORTIONS with an order date of 01/22/2026. Observation on 03/24/2026 at 12:26 p.m. 300 hall resident trays being passed with Resident #4 observed sitting up in her bed with head of bed elevated, eating independently and had been provided a renal/pureed diet with nectar thick liquids. During an interview and observation on 03/27/2026 at 2:05 p.m. the Care Management LVN F stated Resident #4's renal diet should have been coded for therapeutic diet on the Quarterly MDS Assessment, and she was going to go ahead and modify the MDS Assessment. The Care Management LVN F stated she did not know why she had not coded the therapeutic diet and it could have been an oversight. The Care Management LVN F stated she was the one who completed the section of Resident #4's Quarterly MDS Assessment. The Care Management LVN F further stated the MDS assessment should be a reflection of the resident and care that was being provided for the resident. The Care Management LVN F stated my miscoding the MDS assessment could affect care planning resident needs. During an interview on 03/27/2026 at 2:48 p.m. the DON stated the MDS nurse (Care Management LVN) was responsible for the accuracy of the MDS assessments. The DON further stated accuracy of the MDS assessment was important to make sure they had the correct plan of care. During an interview on 03/27/2026 at 2:52 p.m. the Regional [NAME] President stated MDS nurse (Care Management LVN) was responsible for the MDS assessment accuracy. The Regional [NAME] President stated importance of accuracy of the MDS assessment was to make sure they provided accurate and complete care to the patient. He further stated care could be missed or done incorrectly if the MDS assessment was not completed accurately.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 5 residents (Resident # 77) reviewed for oxygen therapy. The facility failed to replace or clean dirty and dusty oxygen filters in Resident #77's oxygen concentrator. This deficient practice could place residents at risk of respiratory infection and difficulty breathing. The findings included: Record review of Resident #77's electronic face sheet dated 03/27/2026 reflected an [AGE] year-old male admitted on [DATE]. His diagnoses included: chronic respiratory failure (a long-term condition that happens when the lungs cannot get enough oxygen in the blood)and dementia (the loss of cognitive functioning-thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities. Record review of Resident #77's admission MDS assessment dated [DATE] reflected he could usually understand and usually be understood by others. He scored 12 of 15 on his BIMS which signified his cognitive status was moderately impaired. He required substantial assistance with ADLs. He received oxygen therapy while he was a resident. Record review of Resident #77's comprehensive care plan dated 01/06/2026 reflected Problem, has oxygen therapy r/t ineffective gas exchange, Interventions, oxygen settings as ordered. Record review of Resident #77's Active Orders as of: 03/27/2026 reflected Oxygen at 4 L/min via nasal cannula. Observation on 03/24/2026 at 10:30 a.m. of Resident #77 revealed he was in his room with his oxygen on via nasal cannula. The black sponge filters on both sides of the oxygen concentrator were coated gray with dust and dirt particles. During an interview on 03/24/2026 at 10:35 a.m., Resident #77 stated in Spanish he used the oxygen daily to breath. Observation on 03/25/2026 at 2:00 p.m. of Resident #77 revealed he was in his room with his oxygen on via nasal cannula. The black sponge filters on both sides of the oxygen concentrator were coated gray with dust and dirt particles. Observation on 03/27/2026 at 2:00 p.m. with the DON of Resident #77 revealed he was sitting in his room with his oxygen on via nasal cannula. The DON checked the oxygen filters and stated they needed to be cleaned or changed, and that is supposed to be done every Sunday night and as needed. He stated dirty oxygen filters could cause problems for the resident to breath and block the air flow. Record review of the facility's policy and procedure titled Oxygen Safety dated 01/26/2026 reflected It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment.

Based on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent with bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident of 2 residents (Resident #107) reviewed for catheter care. The facility failed to ensure Resident #107 had a leg strap to secure her indwelling urinary catheter tubing. This deficient practice could place residents' risk of complications and infection from movement at the insertion site. The findings included: Record review of Resident #107's electronic face sheet dated 03/25/2026 reflected a [AGE] year-old female admitted on 11/102020. Her diagnosis was: contracture of muscles, left and right lower legs (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). Record review of Resident #107's quarterly MDS assessment dated [DATE] reflected that she understood and was able to understand others. She scored 6 of 15 on her BIMS which signified her cognitive status was severely impaired. She was dependent on staff for ADLs. She had an indwelling urinary catheter. Record review of Resident #107's comprehensive care plan dated 12/30/2025 reflected Problem, has indwelling urinary catheter r/t skin breakdown, interventions, position catheter bag, and tubing below the level of the bladder. The comprehensive care plan did not reflect the need for a leg strap to secure the tubing. Record review of Resident #107's Active orders as of: 03/25/2026 reflected Check Foley Catheter, every shift use leg strap to secure Foley in place, start date 12/30/2026. Observation on 03/26/2026 at 10:43 am of Resident #107 revealed she was lying in bed with an indwelling urinary catheter and did not have a leg strap in place. During an interview on 03/24/2026 at 10:35 a.m., Resident #107 stated she had the catheter, but could not recall a strap on her leg. During an interview on 03/27/2026 at 1:25 p.m., LVN E stated Resident #107 should have had a leg strap for her indwelling urinary catheter. She stated she did not notice there was not one and she performed wound care for the resident. She stated the strap was a standard of care to prevent discomfort and pulling. During an interview on 03/27/2026 at 1:30 p.m., the DON stated that unless Resident #107 had an issue such as skin irritation, she should have had a urinary catheter leg strap in place to hold the tubing. He stated the strap stabilized the tubing and kept it from pulling and dislodgment which could cause discomfort for the resident. He stated they did not have a policy or procedure to address urinary catheters or use of leg straps.

Based on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans, in that. The facility failed to update Resident #1's care plan to reflect Resident #1 was attempting to eat non-food items. This failure could affect residents who have care areas not addressed by the care plans by not having their needs met and putting them at risk of not receiving appropriate care.The findings included: Record review of Resident #1's admission record, dated 02/21/2026, reflected an [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), need for assistance with personal care, mild protein calorie malnutrition, dysphagia (difficulty in swallowing), and major depressive disorder. Record review of Resident #1's quarterly MDS assessment, dated 02/11/2026, reflected Resident #1 had a BIMS of 8 out of 15, indicating moderate cognitive impairment. Record review of Resident #1's care plan, undated, reflected no mention of Resident #1 attempt to eat non-food items. Record review of Resident #1's Comprehensive Encounter, dated 02/17/2026 and authored by NP, reflected .[Family member] reports patient has been trying to eat non-food items such as pennies and curtain hooks. Interview on 02/22/26 at 04:26PM, CNA B and CNA C revealed they knew Resident #1 would eat non-food items and had to keep an eye on Resident #1 more frequently. They revealed they knew about how to care for a resident by looking at Resident #1's care plan and verbal report from nursing staff on previous shifts. They revealed for this behavior they were unsure if it was in the care plan but that they knew about this from other staff members. Interview on 02/23/26 at 10:06 AM, the DON revealed he was not made aware that Resident #1 was trying to eat non-food items and he would update the care plan to include this for resident care. Interview on 02/23/26 at 11:46AM, the ADM revealed he supposed that Resident #1 attempting to eat non-food objects could be added to the care plans for the nursing staff to address these issues as needed. Observation and attempted interview on 02/21/2026 at 12:33 PM, Resident #1 appeared confused and would not respond appropriately to interview. There was no observation made of Resident #1 attempting to eat non-food items. Record review of facility's policy Care Plan Revisions Upon Status Change, dated 10/24/2022, reflected 1. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change.

Based on interviews, observation, and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 6 residents (Resident #1) reviewed for consents for accurate medical records. 1. The facility failed to ensure that there was a doctor order on 01/21/2026 in Resident #1's electronic medical record to reflect that 1 enema (a procedure in which liquid or gas is injected into the rectum, typically to expel its contents) was given to Resident #1. 2. The facility failed to ensure the bathing documentation for Resident #1, accessed on 02/22/2026, was complete and included Resident #1 had a bed bath on 02/17/2026, resident refused on 02/16/2026, and bathing was not applicable on 02/13/2026. These failures could place residents at risk for inaccurate medical records.The findings included:Record review of Resident #1's admission record, dated 02/21/2026, reflected an [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), need for assistance with personal care, colostomy status (surgical opening for the colon in the abdomen), major depressive disorder, and Parkinson's disease (a movement disorder of the nervous system that worsens over time. Record review of Resident #1's quarterly MDS assessment, dated 02/11/2026, reflected Resident #1 had a BIMS of 8 out of 15, indicating moderate cognitive impairment. It further revealed Resident #1 needed substantial/maximal assistance for showering/bathing. Record review of Resident #1's care plan reflected [Resident #1] has an ADL self-care performance deficit r/t Parkinson's exacerbation, initiated 12/03/2025, reflected Provide supportive care, assistance with mobility as needed. Document assistance as needed. 1.Record review of Nurse's Note, dated 01/21/2026 and authored by LVN A, reflected Received new order for enema x1 and start MiraLAX daily for constipation. Record review of discontinued doctor's orders reflected Miralax Oral Powder 17 GM/SCOOP was ordered on 01/21/2026 by LVN A to Give 1 scoop by mouth in the morning for constipation. There was no order for an enema that was reflected. Interview on 02/23/2026 at 12:22 PM, LVN A revealed she received verbal orders from the NP to give Resident #1 an enema. LVN A was not at the facility to confirm or deny that there was not a doctor's order for an enema in Resident #1's electronic medical record. She revealed she could not recall if she had put this order into resident's electronic medical record, but she was trained to do this. She revealed it was important to have a doctor's order reflected in Resident #1's electronic medical record, so that it was known what time the enema was given to Resident #1 and if it was effective. 2. Record review of Resident #1's bathing documentation, accessed on 02/22/2026 at 04:02PM, reflected resident had a shower 02/02/2026, 02/05/2026, 02/12/2026, and 02/19/2026. Record review of Resident #1's updated bathing documentation, accessed 02/23/2026 at 10:05AM, reflected resident had a shower 02/02/2026, 02/05/2026, 02/12/2026, and 02/19/2026. The update accurately reflected Resident #1's complete bathing documentation as follows: a bed bath on 02/17/2026 (CNA unknown), resident refused on 02/16/2026 (CNA unknown), and bathing was not applicable on 02/13/2026 (CNA unknown). Observation and attempted interview on 02/21/2026 at 12:33 PM, Resident #1 appeared confused and would not respond appropriately to interview. Resident #1 appeared clean with no foul odors. Interview on 02/22/26 at 04:26PM, CNA B and CNA C revealed they gave Resident #1 showers regularly, They revealed they were trained and needed to document showers or baths in the residents' electronic medical record to keep track of resident's showers or baths. Interview on 02/23/26 at 10:06 AM, the DON revealed the showers for Resident #1 were not updated in her medical record and they should be up to date. He revealed the bathing documentation was now up to date with showers/baths that Resident #1 received. He revealed he could not find the doctor's order for an enema in Resident #1's electronic medical record, but the nurse had received a verbal order from Resident #1's NP. He revealed this order should be reflected in the electronic medical record. Interview on 02/23/26 at 11:46AM, the ADM revealed he would expect the electronic medical records for residents to be up to date to ensure accuracy for the treatment of residents. Record review of facility's policy Activities of Daily Living (ADLs), dated 05/26/2023, reflected Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.6. Documentation shall be completed at the time of service, but no later than the shift in which the care service occurred. Record review of facility's policy Documentation in Medical Record, dated 10/24/2022, reflected Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater for 1 of 5 residents (Resident #12). The facility had a medication error rate of 45% based on 5 errors out of 11 opportunities. LVN D failed to administer medications as ordered to Resident #12 by administering Gabapentin (for neuropathy), Cyclobenzaprine (for pain), Colace (for constipation), Carboxymethylcellulose Sodium ophthalmic gel (dry eyes), and Rosuvastatin (for high cholesterol) 2 hours and 12 minutes before the scheduled time. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) and Hyperlipidemia (elevated cholesterol). Record review of Resident #12's Order Summary Report, dated 9/26/25, revealed: Gabapentin oral tablet 100 mg, give 1 tablet by mouth two times a day; Cyclobenzaprine oral tablet 10 mg, give 1 tablet by mouth two times a day; Colace capsule 100 mg, give 100 mg by mouth two times a day; Rosuvastatin oral tablet, give 1 tablet by mouth at bedtime; Carboxymethylcellulose Sodium ophthalmic gel 1%, instill 1 drop in both eyes two times a day. Observation and interview on 9/25/25 at 3:38 pm, revealed LVN D administered: Gabapentin oral tablet 100 mg, give 1 tablet by mouth two times a day; Cyclobenzaprine oral tablet 10 mg, give 1 tablet by mouth two times a day; Colace capsule 100 mg, give 100 mg by mouth two times a day; Rosuvastatin oral tablet, give 1 tablet by mouth at bedtime; Carboxymethylcellulose Sodium ophthalmic gel 1%, instill 1 drop in both eyes two times a day to Resident #12. LVN D said the medications were not due yet but was going to administer them. LVN D further stated that some residents liked their medications administered at a specific time. LVN D said she had not read the bottle of eye drops and had not realized it was not the correct dose. During an interview on 9/26/25 at 10:32 am, Resident #12 said she did not know what medications she received, when she received it or how many drops LVN D put in her eyes on 9/25/25. During an interview on 9/26/25 at 5:35 pm, ADON B said medications ordered to be administered BID where to be administered at 6 am - 10 am and 6 pm - 10 pm, unless specified in the order. ADON B further stated HS medications were to be administered between 6 pm - 10 pm. ADON B said staff should not administer medications over 2 hours before the specified time because, depending on the medication, it could affect the efficacy of the medication. Record review of the facility's policy Medication Administration revised 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.11. Compare medication source.to verify resident name, medication name, form, dose, route, and time.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.Medication timing. BID 9 am, 9 pm HS 9pm.

Based on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled substances was maintained and periodically reconciled for 8 of 17 residents (Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) and 4 of 6 medication carts (MC #1, MC #2, MC #4 and MC #6) reviewed for pharmaceutical services. 1. The facility failed to ensure discontinued/expired medications were removed from the medication carts on (4) occasions.2. The facility failed to ensure the administration and count of controlled substances were reconciled on (3) occasions.3. The facility failed to ensure counts of controlled medications were completed/signed for on (28) occasions. These deficient practices could put residents at risk for diversion and reduced effectiveness of medications. Findings included: 1. Record review of Resident #4's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: History of Malignant Neoplasm of Breast (uncontrollable cell growth that destroy body tissue), Dementia (group of thinking and social symptoms that interferes with daily functioning), Congestive Heart Failure (condition in which the heart can't pump blood well enough to meet the body's needs), Anxiety (feeling of dread, fear, or uneasiness) and Spondylosis (degeneration of the bones and discs of the spine).Record review of Resident #4's Order Summary, dated 2/24/25, revealed: LORazepam Oral Tablet 0.5MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for anxiety.for 14 days. Record review of Resident #4's Individual Resident's Controlled Substance Record revealed LORAZEPAM 0.5 MG TABLET TAKE ONE TABLET BY MOUTH EVERY 12 HOURS AS NEEDED FOR 14 DAYS. Further review of this record revealed the last administration of Lorazepam was on 3/6/25. Observation of controlled substance reconciliation on 9/24/25, beginning at 11:48 pm, revealed a blister pack with tablets labeled LORAZEPAM 0.5 MG Tablet for Resident #4. Further observation revealed AS NEEDED FOR 14 DAYS . During an interview on 9/24/25 at 11:50 pm, LVN A said when a medication was ordered for a specific number of days, the medication was discontinued after the number of days it was ordered for, removed from the cart and given to the DON. Record review of Resident #6's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), Pain in Shoulders. Record review of Resident #6's Order Summary, dated 9/26/25, revealed: TraMADol HCl Tablet 50 MG Give 1 tablet by mouth three times a day for pain.Order Date 06/26/2024. Observation of controlled substance reconciliation on 9/24/25, beginning at 11:48 pm, revealed a blister pack with tablets labeled TRAMADOL 50 MG take 1 tablet by mouth 4 times a day PRN for pain, 1 of 2 expiration date 6/22/25, for Resident #6. Further observation revealed a second blister pack with tablets labeled TRAMADOL 50 MG take 1 tablet by mouth 4 times a day PRN for pain, 2 of 2 expiration date 6/22/25, for Resident #6. Record review of Resident #6's September MAR, dated 9/26/25, revealed Tramadol 50 mg PRN was not administered. Record review of Resident #11's admission Record, dated 9/26/26, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning).Record review of Resident #11's Order Summary, dated 9/26/25, revealed: Lorazepam oral concentrate 2 mg/mL, give 0.25 mL by mouth every 4 hours PRN.Observation of controlled substance reconciliation on 9/25/25, beginning at 2:09 pm, revealed a bottle labeled Lorazepam Oral Concentrate 2 MG/ML with an expiration date of 3/31/26; however, the box had a use by date of 8/2/25. Record review of Resident #11's September MAR, dated 9/26/25, revealed Lorazepam oral concentrate 2 mg/mL was not administered. 2. Record review of Resident #5's admission Record, dated 9/25/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Atherosclerosis of Arteries of Bilateral Legs (The build-up of fats, cholesterol, and other substances in and on the artery walls), Pain in Right Foot, and Non-pressure Chronic Ulcer (wound that does not heal within 6 weeks) of Right Foot. Record review of Resident #5's quarterly MDS assessment, dated 9/9/25, revealed the resident had a BIMS score of 15 (suggesting intact cognition). Record review of Resident #5's Order Summary, dated 9/25/25, revealed: HYDROcodone-Acetaminophen Oral Tablet 7.5-300 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain.Order Date 02/24/2025. Observation, on 9/25/25, of medication administration with LVN G, beginning at 11:42 am, revealed: Resident #5's blister pack of Hydrocodone-APAP 7.5-300 mg, 1 tablet orally q6 hours PRN, contained 6 tablets prior to administration. Record review of Resident #5's Individual Controlled Substance Record for Hydrocode-APAP 7.5-300 mg (pain medication) 1 tablet orally q6 hours PRN, last entry revealed: Name of person administering - LVN A, date - 9/24/25, time - 5:50 am, amount on hand - 8, amount given - 1, amount remaining - 7. Record review of Resident #5's September MAR, dated 9/25/25, revealed: Resident #5's pain level was 6 and Hydrocode-APAP 7.5-300 mg (pain medication) 1 tablet orally q6 hours PRN for pain was administered by LVN A on 9/25/25 at 5:40 am. Record review of Resident #7's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning) and Down Syndrome (a genetic disorder causing developmental/intellectual delays).Record review of Resident #7's Physician Order, dated 9/24/25 at 7:14 pm, revealed: ALPRAZolam Oral Tablet 0.5 MG (Alprazolam) Give 0.5 mg by mouth one time only.Confirmed By: [LVN A] Printed Date: Sep 24, 2025, 19:56:42 [7:46 pm] . Observation, on 9/24/25, of medication administration and count reconciliation of controlled substances, beginning at 11:48 pm, revealed: Resident #7's blister pack of Alprazolam 0.5 mg, take one tablet by mouth q12 hours PRN, contained 25 tablets.Record review of Resident #7's Individual Controlled Substance Record for Alprazolam 0.5 mg, take one tablet by mouth q12 hours PRN, last entry revealed: Name of person administering - illegible, Date - 9/12/25, time - 12:00 pm, amount given - 1, amount remaining - 26.Record review of Resident #7's September MAR, dated 9/26/25, revealed: Alprazolam Give 0.5 mg by mouth one time only was administered by LVN A on 9/24/25 at 7:30 pm. During an interview on 9/24/25 at 11:50 pm, LVN A said he had just received an order for Resident #7's alprazolam on 9/24/25. LVN A said he administered the alprazolam at around 9:00 pm. LVN A said the expectation was to sign out controlled substances immediately after administering the medication but he needed to document the resident's behavior and why the medication was ordered.Record review of Resident #8's admission Record, dated 9/26/25, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning), Generalized Anxiety Disorder (severe and ongoing that is ongoing and interferes with daily activities) and History of Falling.Record review of Resident #8's quarterly MDS assessment, dated 9/8/25, revealed the resident's cognitive skills for daily decision making was moderately impaired. Record review of Resident #8's Order Summary, dated 9/26/25, revealed: Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 2 hours as needed for agitation/anxiety for 365 Days.Order Date 08/20/2025. Observation, on 9/25/25, of count reconciliation of controlled substances with LVN G, beginning at 1:56 pm, revealed: Resident #8's bottle of lorazepam 2 mg/mL, give 0.5 mL q4 hours PRN, contained 16 mLs of liquid medication. Record review of Resident #8's Individual Controlled Substance Record Lorazepam 2 mg/mL, take 0.5 mL (1 mg) by mouth q4 hours PRN for anxiety, last entry revealed: Name of person administering - RN C, Date - 9/14/25, time - 10:00 pm, amount given - 0.5, amount remaining - 17.5. Record review of Resident #8's September MAR, dated 9/26/25, revealed: Lorazepam 2 mg/mL give 0.5 mLs by mouth q2 hours PRN for agitation/anxiety for 365 days was administered by RN C on 9/14/25 at 11:35 am. During an interview on 9/25/25 at 12:13 pm, LVN G said the facility's policy for controlled substance discrepancies was to identify the missing medication and let the DON know that the count was off as soon as it was identified. LVN G further stated nurses were responsible for ensuring there were no discrepancies with controlled substance counts. LVN G said he did not count the controlled substances in his medication cart at the beginning of his shift on 9/25/25 because he was overwhelmed with shift report, forgot and just started working. LVN G further stated it was his responsibility to count controlled substances with the previous shift to ensure the counts were correct because they were controlled substances and staff want the correct count 100% of the time for accountability. LVN G said it was important to avoid discrepancies to avoid double dosing a resident and causing possible adverse reactions. 3. Record review of Resident #9's Individual Controlled Substance Record for Acetaminophen-Codeine #3 (pain medication) 1 tablet orally q12 hours scheduled and 1 tablet q4 hours PRN revealed: Name of person administering - CMA E, date - 9/21/25, time - 5:00 pm, amount given - 1, amount remaining 16. Further review of this record revealed an R (refused) Destroyed and signatures of CMA E and CMA F. During an interview on 9/26/25 at 6:00 pm, CMA E said R meant the resident refused a medication. CMA E said Resident #9 refused Acetaminophen-Codeine #3 on 9/21/25 because he was nauseated. CMA E said she took the dose to the nurse and explained the resident refused the dose. CMA E further stated the nurse, she was pretty sure it was LVN I, saw her put the dose of Acetaminophen-Codeine #3 into the receptacle. CMA E said only one nurse's signature was required when wasting with another CMA. CMA E said the nurse must have forgotten to sign the record after the dose was wasted. CMA E further stated she did not know why it was important for there to be 2 nurses present to waste a dose of a controlled substance. Record review of Resident #10's Individual Controlled Substance Record for Lorazepam (anxiety medication) 0.5 mg take one tablet orally q8 hours PRN revealed: Name of person administering - LVN C, date - 6/9/25, time - 7:45 pm, amount given - 1, amount remaining 24. Further review of this record revealed wasted and one signature which was illegible. During an interview on 9/26/25 at 6:17 pm, LVN C said staff were expected to count controlled substances at the beginning and the end of the shift. LVN C further stated staff were expected to sign outgoing or oncoming controlled substance record, saying the count was right. LVN C said every time a controlled substance count was completed, both staff had to sign the Controlled Drugs Count Record immediately after. LVN C said the signatures were important for accountability, adding that the staff signature was like the staff's word, saying yes, the controlled substances were counted. LVN C further stated she did not think there was ever a time that she had not signed the Controlled Drugs Count Record after a count. Record review of Resident #11's Individual Narcotic Record, Lorazepam Concentrate 2 mg/mL Give 0.25 mL orally q4 hours PRN, revealed it did not contain the name of the person delivering/receiving the medication, date the medication was delivered/received, or time the medication was received.Record review, on 9/24/25, of the Controlled Drugs Count Record September 2025, MC #1, revealed the following shifts had missing signatures: 9/1/25 (2 pm - 10 pm shift) 9/3/25 (10 pm - 6 am shift) 9/4/25 (10 pm - 6 am shift) 9/4/25 (2 pm - 10 pm shift) 9/6/25 (2 pm - 10 pm shift) 9/8/25 (10 pm - 6 am shift) 9/11/25 (2 pm - 10 pm shift) 9/12/25 (2 pm - 10 pm shift) 9/17/25 (10 pm - 6 am shift) 9/18/25 (10 pm - 6 am shift) 9/19/25 (10 pm - 6 am shift) 9/20/25 (10 pm - 6 am shift) 9/21/25 (2 pm - 10 am shift) 9/22/25 (10 pm - 6 am shift) 9/24/25 (10 pm - 6 am shift) Record review on, 9/24/25, of the Controlled Drugs Count Record September 2025 for, MC #2, revealed the following shifts had missing signatures: 9/4/25 (10 pm - 6 am shift) 9/5/25 (2 pm - 10 pm shift) 9/5/25 (10 pm - 6 am shift) 9/6/25 (2 pm - 10 pm shift) 9/6/25 (10 pm - 6 am shift) 9/12/25 (10 pm - 6 am shift) 9/15/25 (10 pm - 6 am shift) 9/16/25 (10 pm - 6 am shift) Record review on, 9/24/25, of the Controlled Drugs Count Record September 2025 for, MC #4, revealed the following shifts had missing signatures: 9/1/25 (6 pm - 6 am shift) 9/14/25 (6 am - 6 pm shift) 9/20/25 (6 pm - 6 am shift) 9/25/25 (6 am - 6 pm shift) Record review on, 9/25/25, of the Controlled Drugs Count Record September 2025 for, MC #6, revealed the following shifts had missing signatures: 9/1/25 (6 pm - 6 am shift) 9/1/25 (6 am - 6 pm shift) 9/2/25 (6 am - 6 pm shift) 9/4/25 (6 am - 6 pm shift) Record review on, 9/25/25, of the Controlled Drugs Count Record September 2025, MC #4, revealed the document was not signed on 9/25/25. During an interview on 9/24/25 at 11:50 pm, LVN A said staff were expected to count controlled substances before every administration and document the amount before and after administration. LVN A further stated he counted controlled substances when he arrived for his shift and before he left. LVN A said he did not check for expiration dates during the controlled substance reconciliation. LVN A further stated he only made sure that the count was accurate. LVN A said he did not remove medications that needed to be removed form the medication carts. LVN A said expired medications should not be administered because the efficacy may be reduced, it may not be the correct dose or affect the resident in another way. During an interview on 9/26/25 at 1:54 PM, the PharmD said he was not sure what the facility policy was for counting controlled substances, but the facility was provided with a Controlled Drugs Count Record for each resident and the facility staff signed for doses every time one was administered, keeping a running count. The PharmD further stated he was not sure if this was the facility's policy. The PharmD said it was important to maintain an accurate count of controlled substances to help prevent diversion. The Pharm D said when a liquid medication has been opened, the facility should use the expiration date on the label unless the bottle/box said a shorter date. During an interview on 9/26/25 at 4:48 pm, ADON A said controlled substances were wasted (disposal of unused dose) by nurses or CMA. ADON A further stated she did not know what the facility policy said regarding wasting controlled substances. ADON A said when a medication was discontinued it was removed from the cart and given to the DON. ADON A further stated discontinued medications should not be in the cart because it might be administered without an active order. ADON A said the staff completing the controlled substance counts should be looking out for medications that were expired or discontinued. ADON A said the ADONs pulled orders every Monday morning for their assigned halls and review the orders for any discontinued medications. ADON A further stated that a prudent nurse would also check for expired or discontinued medications. During an interview on 9/26/25 at 5:35 pm, ADON B said when medications were expired/discontinued, they were pulled from the cart and given to the DON. ADON B said she did not audit medication carts for expired/discontinued medications. ADON B said the pharmacists completed audits of the medication carts monthly. ADON B further stated the CMAs and nurses were responsible for keeping track of expired/discontinued medications. ADON B said she was not aware there were expired/discontinued medications in the medication carts. ADON B said it was important to remove expired/discontinued medications from the carts because they would not want the residents to take that medication because they may experience side effects from the medication, or the efficacy of the medication may decrease. ADON B said staff counting controlled substances at the beginning of the shift, end of the shift, and when working a split shift, any time the cart changes hands. ADON B said staff were expected to sign the Controlled Drugs Count Record once they were done counting the controlled substances. ADON B said the staff with the carts were responsible for ensuring for counting the controlled substances and signing the Controlled Drugs Count Record. ADON B said it was important to count the controlled substances and sign the Controlled Drugs Count Record afterward to ensure the count was correct and there were not any missing doses. ADON B said if there was a discrepancy in the count, staff were expected to notify the DON. ADON B said when controlled substances were delivered by the pharmacy, two nurses needed to verify the amount received was correct. ADON B further stated was the amount was verified the Controlled Drugs Count Record was signed and dated by the delivery person and one nurse. ADON B said this was important because there could be a discrepancy and staff needed to ensure all the medications were accounted for. ADON B said controlled substances should be wasted by two nurses. During an interview on 9/26/25 at 5:55 pm, LVN B said staff were required to count controlled substances at the beginning of the shift before administering medications and at shift change. LVN B further stated 9/4/25 might have been a shift that she picked, but did not remember if she worked. LVN B said it was important to count controlled substances because staff needed to make sure that when they took control of the medication cart, all controlled substances were accounted for because they were narcotics and controlled. During an interview on 9/26/25 at 7:36 pm, LVN D said she always counted the controlled substance on her cart. LVN D further stated she might have forgotten to sign the Controlled Drugs Count Record for MC #6 on 9/1/25 for the 6 am - 6 pm shift. LVN D said it was important to sign the Controlled Drugs Count Record because staff were acknowledging what was in the cart and were responsible for the contents during their shift. Call was attempted to interview LVN G on 9/26/25 at 8:02 pm with no success, a voicemail was left. Call was attempted to interview LVN D on 9/26/25 at 8:08 pm with no success, a voicemail was left. Call was attempted to interview LVN H on 9/26/25 at 8:06 pm with no success, a voicemail was left. Call was attempted to interview LVN I on 9/26/25 at 8:05 pm with no success, a voicemail was left. Call was attempted to interview RN C on 9/26/25 at 8:04 pm with no success, a voicemail was left. Call was attempted to interview LVN A on 9/26/25 at 7:52 pm with no success, a voicemail was left. During an interview on 9/26/25 at 7:54 pm, LVN J said she did not remember counting the controlled substances on 9/1/25, 9/2/25, and 9/4/25 for MC #6. LVN J further stated she had the cart for part of the shifts and staff usually did not count until the end of the shift, not when the cart was changing hands during a split shift. LVN J said she had not been told that controlled substances had to be counted during split shifts, only during the 6 am - 6 pm and 6 pm - 6 am shifts. LVN J further stated that she knew the controlled substance count was correct by the signature on the resident's record. LVN J said that when a 12-hour shift was split between staff, medications were administered using the same cart. Record review of facility's policy Controlled Substance Destruction, dated 10/1/19, read: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedure .2. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal is documented on theaccountability record/book on the line representing that dose.3. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of . Record review of facility's policy Documentation of Controlled Substances, dated 10/1/19, read: .Controlled Substances Record documentation will be maintained accurately. 5. An up-to-date index is kept as part of each Controlled Substances Record. Each individual resident's page lists the resident's name, physician, prescription number, date, name and strength of the drug, directions for use, amount of drug and the name of the pharmacy from which the drug was obtained. 7. Two Licensed Nurses or Medical Aides or combination thereof, are responsible to complete a count of all controlled substances at the change of shift or any time that the narcotic keys are surrendered from one nurse to another. 8. The LICENSED NURSE or MEDICAL AIDE on the shift reporting for duty counts all medication with the LICENSED NURSE or MEDICAL AIDE going off duty. The nurse coming on duty should be overseeing both the Controlled Substances Record and each sealed unit dose card. Each card should be checked back and front for tampering and quality control. Refrigerated controlled medications must be inspected as well. The LICENSED NURSE or MEDICAL AIDE on both shifts will count and sign the Controlled Substances Record in each other's presence. If there is a discrepancy in the count, DO NOT SIGN the record. Report the discrepancy to the Supervisor or the Director of Nursing immediately .Record review of facility's policy Medication Administration, dated 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. If medication is a controlled substance, sign narcotic book.

Based on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 2 residents (Resident #1) reviewed for medical records:The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #1 on 8/2/25, 8/3/25, 8/5/25, 8/8/25, 8/13/25, 8/14/25, and 8/16/25.These failures could place residents at risk for missed treatments and care which could result in the deterioration of the wound and/or development of an infection.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's TAR for August 2025 revealed the following:- Apply zinc base cream to the buttock area every shift (twice daily) for Blanchable redness to bilateral buttocks with start date 7/25/25. The TAR was missing documentation on the following days:8/2/25, Saturday day shift8/3/25 Sunday night shift8/5/25 Tuesday day shift8/8/25 Friday night shift8/13/25 Wednesday night shift8/14/25 Thursday day shift8/16/25 Saturday day shiftRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident. Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 9:45 a.m., LVN G stated the facility had a Wound Care Nurse (LVN), but when she was not on schedule, then the floor nurses were responsible for doing wound care. LVN G stated it was not acceptable to have missing documentation on a MAR/TAR because then there would be a question about whether wound care was done or not done. LVN G stated the electronic MAR/TAR allowed for the nurse to document if a resident refused treatment or whatever.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated, after reviewing Resident #1's August 2025 TAR revealed, missing documentation on the TAR meant the treatment was not done. The Wound Care Nurse (LVN) stated she worked Monday through Friday and sometimes on the weekends. The Wound Care Nurse stated the floor nurses were responsible for doing wound care on the residents when she was not on schedule. The Wound Care Nurse stated if the residents did not receive scheduled wound care, the residents could get worse. The Wound Care Nurse stated she could not account for the missing documentation on the TAR.During an interview on 10/8/25 at 4:29 p.m., the DON stated, if there was documentation missing from the MAR/TAR it would look like it wasn't done; you could assume that is what happened. The DON stated the MAR/TAR were reviewed at morning meetings with the IDT and the review of the 24-hour report would show any missing documentation or a lapse in documentation. The DON stated that the IDT audited those records.During an interview on 10/9/25 at 9:46 a.m., LVN D stated the facility had a Wound Care Nurse (LVN) on staff but when she was off, the floor nurses were responsible for doing wound care. LVN D stated, if there was missing documentation on the MAR/TAR then it could be assumed that the medication or treatment wasn't done. LVN D stated, if scheduled treatments were not done it could affect the resident in a negative way such as delaying the wound getting better. LVN D stated he did not recall Resident #1.During an interview on 10/9/25 at 10:26 a.m., LVN F stated she had done wound care on the residents and if a resident didn't get a treatment, it would still have to be documented in the TAR. LVN F stated, if the TAR had missing documentation, she would assume the treatment was not done. LVN F stated she admitted ly had forgotten to document when she had done a treatment, but would go back and write a late note, sometimes. LVN F stated she did not recall Resident #1.During an interview on 10/9/25 at 10:49 a.m., RN A stated she had done wound care on the residents when she worked on the weekends. RN A stated she could not recall if Resident #1 had a wound and recalled applying a cream. RN A stated missing documentation on the TAR could mean the treatment was not done or the resident went to the hospital. RN A stated, even if the resident went to the hospital, I think you would use the code '6' for hospital. RN A stated, if a resident was not getting scheduled wound care the wound could get worse.Record review of the facility document titled Documentation in Medical Record dated 10/24/22 revealed in part, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.Principals of documentation include, but are not limited to.Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.Sign each entry with name and credentials of the person making the entry.When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as 'late entry'.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 residents (Resident #11) reviewed for medication labeling. The facility failed to ensure medications were correctly labeled. These deficient practices could place residents at risk of medication misuse and drug diversion. Findings included: Record review of Resident #11's admission Record, dated 9/26/25, revealed the resident was admitted on [DATE] with diagnoses which included: Dementia (group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #11's Order Summary Report, dated 9/26/25, revealed: Lorazepam oral concentrate 2mg/mL by mouth every 4 hours PRN. Observation on 9/25/25 at 2:15 pm revealed Resident #11's Lorazepam was in the refrigerator, stored in a plastic baggie. Further observation revealed the baggie contained a box with a label that was partially illegible. Further observation revealed the medication bottle inside the box had a manufacturer label on it, but did not have a label with the resident or prescription information. LVN G said staff knew who the medication was prescribed to because the name was on the box. During an interview on 9/25/25 at 2:17 pm, the DON said the pharmacy said they were unable to send replacement medication labels to the facility. The DON further stated the pharmacy said that they needed to have the medication in hand to properly relabel them. The DON said the facility was unable to send medications back to the pharmacy for labeling because residents would be without their medications. During an interview on 9/26/25 at 1:54 PM, the PharmD said he was not sure what the facility's procedure was but was sure the facility could handwrite labels for medication bottles/syringes. The PharmD further stated that typically the pharmacy labels the bottles/syringes as well, but the facility was supposed to call the pharmacy to let them know if a medication needs labeling so that the medication could be picked up from the facility and labeled. The PharmD said it was important for bottles/syringes be labeled so the staff knew what resident to administer the medication to. Record review of the facility's policy, Pharmacy Provider Requirements dated 10/1/19, read: .4. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to.E. Labeling all medications dispensed.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #1) reviewed for resident rights.The facility failed to notify Resident #1's provider of his change in condition when the Wound Care Nurse identified the resident developed a Stage 2 pressure ulcer on 8/6/25.This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 7/23/25, and dated 10/7/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop dateRecord review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop date- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident. Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse. Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse initially stated she could not recall when she had notified the physician or if she had told the physician at all. The Wound Care Nurse stated, Resident #1 had an irritation to the area, but it was not like a Stage 3 wound whereas a Stage 3 wound was more open and a better chance for an infection. The Wound Care Nurse stated, had the resident developed a Stage 3 pressure wound, then she would have reported it to the physician or the NP who in turn would have referred the resident to the NP Wound Nurse. The Wound Care Nurse then stated she recalled a notification to the physician but didn't document it and could not remember how the physician had responded. The Wound Care Nurse stated when Resident #1's wound to the buttock was identified as a Stage 2 pressure ulcer, it would have been considered a change of condition, and the physician should have been notified which would have prompted a referral to the NP Wound Nurse. A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:07 p.m., and the State Surveyor was re-directed to contact the physician at a facility where he was holding clinic.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:52 p.m., and a message was left requesting a call back.During an interview on 10/8/25 at 4:29 p.m., the DON stated, when Resident #1 was identified with a Stage 2 pressure ulcer, the physician should have been notified.During an interview on 10/9/25 at 8:29 a.m., the NP Wound Nurse stated she made rounds at the facility to look at wounds every Thursday. The NP Wound Nurse stated, if she needed to look at a resident who had wounds, she would have been notified by the Wound Care Nurse. The NP Wound Nurse stated, she had never seen or had Resident #1 referred to her and did not recall his name. The NP Wound Nurse stated, if Resident #1 had been identified with a Stage 2 pressure wound, the resident should have been referred to her. During a telephone conversation on 10/9/25 at 9:06 a.m., the GVN called on behalf of Resident #1's physician and stated she could not find documentation by the physician on notification from the facility regarding a change of condition to Resident #1.During an interview on 10/9/25 at 9:46 a.m. LVN D stated, as part of his duties, he would provide wound care treatments to the residents. LVN D stated, he did not recall doing wound care on Resident #1. LVN D stated, when providing wound care, and if the wound were to change in appearance, he would consider it a change of condition and would notify the Wound Care Nurse, the physician, and the DON. LVN D stated, notification would have been made within the hour, the same day.During an interview on 10/9/25 at 10:13 a.m., RN E stated, as part of her duties, she would provide skin assessments on the residents and if she noted a skin integrity issue she would have reported it to the Wound Care Nurse and the physician.During an interview on 10/9/25 at 10:26 a.m., LVN F stated, as part of her duties, she would provide wound care treatments to the residents. LVN F stated, for residents who developed skin integrity issues she would complete a Change of Condition form, notify the Wound Care Nurse, and see what the next treatment would be. LVN F stated, for wounds, the first course of action would be to tell the Wound Care Nurse and notification should be made within a couple of hours.During an interview on 10/9/25 at 10:49 a.m., RN A stated she could not recall if Resident #1 ever had a wound and didn't do anything other than cream. RN A stated, as part of her duties, she would provide wound care treatments to the residents. RN A stated, as soon as a resident was noted with a change in condition, for a wound, the resident would have been referred to the Wound Care Nurse first, then the physician, and the resident's family.Record review of the facility document titled Notification of Changes, dated 10/24/22 revealed in part, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Definitions.Clinical Complications: Examples - Development of stage 2 pressure injury.Compliance Guidelines.The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Residents #12) reviewed for infection control. The facility failed to ensure LVN D followed proper infection control practices during medication administration on 9/26/25. This deficient practice could place residents at risk for exposure to pathogens causing infection resulting in diminished quality of life. Findings included: Record review of Resident #12's admission Record, dated 9/26/25, revealed the resident was re-admitted on [DATE] with diagnoses which included: Dry Eye Syndrome, Constipation, Hemiparesis (weakness or an inability to move one side of the body), Hemiplegia (paralysis or weakness to one side of the body) and Hyperlipidemia (elevated cholesterol). Record review of Resident #12's Order Summary, dated 9/26/25, revealed: Gabapentin Oral Tablet 100 MG (Gabapentin) Give 1 tablet by mouth two times a day. Observation of medication administration for Resident #12 on 9/26/25 beginning at 3:48 pm revealed LVN D had a capsule lying on a piece of paper on top of the medication cart. Further observation revealed LVN D picked up the capsule with her bare hand and placed it into the medication cup. LVN D said it was a Gabapentin capsule and she had placed it there because she thought Resident #12 required her medications to be crushed. During interview on 9/26/25 at 4:17 pm, LVN D said she had put the Gabapentin aside because it was a capsule and could not be crushed. LVN D further stated she did not have a reason for placing the capsule on top of the paper on the medication cart instead of in a medication cup. LVN D said this could put the resident at risk for infection, adding that medications should be handled in a clean manner, for example: not putting medications on top of the cart and performing hand hygiene. During interview on 9/26/25 at 5:35 pm, ADON B said placing a medication capsule on top of a paper on the medication cart was not acceptable due to cross contamination. ADON B further stated medications should go from the blister pack or bottle straight to a medication cup. ADON B said not following this procedure could cause infection. Record review of the facility's policy Medication Administration revised 10/24/22, read: .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.13. Remove medication from source, taking care not to touch medication with bare hand.

Based on interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 1 nurse (Wound Care Nurse) reviewed for competent nursing care.The facility failed to ensure the Wound Care Nurse was aware of notification of changes to the RN Unit Manager or designee per facility policy when she identified Resident #1 with a Stage 2 pressure ulcer.These deficient practices affect residents who depend on nursing care and could place residents at risk for injury, infection and a decline in health. The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 7/23/25, and dated 10/7/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop dateRecord review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop date- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum, staged by the Wound Care Nurse (LVN). Resident #1's Skin and Wound Evaluation document revealed on the Additional Care Section, None was checked, and the Notifications section: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse (LVN) on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum staged by the Wound Care Nurse (LVN). Resident #1's Skin and Wound Evaluation document revealed on the Additional Care section, the resident had a moisture barrier and positioning wedge, and the Notifications: Practitioner Notified, Resident/Responsible Party Notified, Dietician Notified, and Therapy (PT, OT, ST) were left blank.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse (LVN) stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse (LVN) initially stated she could not recall when she had notified the physician or if she had told the physician at all. The Wound Care Nurse (LVN) stated, Resident #1 had an irritation to the area, but it was not like a Stage 3 wound whereas a Stage 3 wound was more open and a better chance for an infection. The Wound Care Nurse (LVN) stated, had the resident developed a Stage 3 pressure wound, then she would have reported it to the physician or the NP who in turn would have referred the resident to the NP Wound Nurse. The Wound Care Nurse then stated she recalled a notification to the physician but didn't document it and could not remember how the physician had responded. The Wound Care Nurse (LVN) stated when Resident #1's wound to the buttock was identified as a Stage 2 pressure ulcer, it would have been considered a change of condition, and the physician should have been notified which would have prompted a referral to the NP Wound Nurse.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:07 p.m., and the State Surveyor was re-directed to contact the physician at a facility where he was holding clinic.A telephone interview with Resident #1's physician was attempted on 10/8/27 at 2:52 p.m., and a message was left requesting a call back.During an interview on 10/9/25 at 8:14 a.m., the DON stated, the Wound Care Nurse (LVN) completed Wound Care Certification on 10/10/22, and stated the facility adhered to the Wound Care Nurse's documented training regarding the staging of pressure wounds. The DON stated there was no facility policy on a nurse being able to stage a wound, as that would be determined by the training received for Wound Care Certification.During a follow up interview on 10/9/25 at 8:24 a.m., the Wound Care Nurse (LVN) stated she could not recall if she had received training on staging a wound as part of her certification.During an interview and record review on 10/9/25 at 8:29 a.m., the NP Wound Nurse stated she made rounds at the facility to look at wounds every Thursday. The NP Wound Nurse stated, if she needed to look at a resident who had wounds, she would have been notified by the Wound Care Nurse. The NP Wound Nurse stated, she had never seen or had Resident #1 referred to her and did not recall his name. The NP Wound Nurse stated, if Resident #1 had been identified with a Stage 2 pressure wound, the resident should have been referred to her. The NP Wound Nurse reviewed Resident #1's wound photos and stated, absolutely he (Resident #1) should have been referred to me. The NP Wound Nurse stated, Resident #1 did not have a Stage 2 pressure ulcer, but had a moisture associated lesion and the Wound Care Nurse should not be staging wounds because that was not within her scope of practice as staging a wound was giving a diagnosis. The NP Wound Nurse stated, a lot of nurses don't know that that is diagnosing, and we're not doctors.During a follow up interview on 10/9/25 at 8:52 a.m., the Wound Care Nurse (LVN) stated she reviewed the class legend for the Wound Care Certification and stated, as part of her training, she was shown how to stage a wound.During a telephone conversation on 10/9/25 at 9:06 a.m., the GVN called on behalf of Resident #1's physician and stated she could not find documentation by the physician on notification from the facility regarding a change of condition to Resident #1.Record review of the Wound Care Nurse's (LVN) Wound Care Nurse certification revealed the course was completed in October 2022 and was valid for 4 years after course completion.Record review of the Wound Care Nurse Certification booklet, dated 2022, and provided by the Wound Care Nurse revealed in part, under Course Objectives,.Classification of wounds: Identification and Management. Scope of Practice - Role of Wound Care Nurse: Assessment, Documentation, Infection Control, Consultation and Monitoring.Scope of Practice - Licensed nurses. Registered Nurse (RN)/Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN).Wound care nurse activities require clinical supervision/delegation of a medical provider.Licensed nurse working as a certified wound care nurse shall perform his/her duties per the prescribing medical provider orders with a focus on patient safety, and function within the parameters of the legal scope of practice and in accordance with the federal state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting.Record review of the facility document titled, Pressure Injury Prevention and Management dated 8/15/22 revealed in part, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.The facility shall establish and utilize a systemic approach for pressure injury prevention and management.Licensed nurses will conduct a pressure injury risk assessment, on all residents upon admission/re-admission, or whenever the resident's condition changes significantly.Monitoring.The RN Unit Manager, or designee, will review all relevant documentation regarding skin assessment, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.The attending physician will be notified of.The presence of a new pressure injury upon identification.

Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 1 resident (Resident #2), in the facility reviewed for accidents, in that:The facility failed to ensure Resident # 2 did not have disposable razors in his room.This failure could place residents at risk of injury and contribute to avoidable accidents and a decline in health.The findings include:Record review of Resident #2's face sheet dated 10/07/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, other sequelae following unspecified cerebrovascular disease (lingering affects due to a disruption in blood flow to the brain), major depressive disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease (frequent acid reflux), and long term us of insulin.Record review of Resident #2's MDS dated [DATE] documented a BIMS of 14 out of 15 indicating independent decision making and recorded the needed use of supervision or touching assistance with personal hygiene.Record review of Resident #2's care plan provided on 10/07/2025 recorded a focus area for the following: Resident # 2 has an ADL self-care performance deficit r/t weakness, malnutrition, initiated on 03/22/2023, with interventions including PERSONAL HYGIENE: The resident requires set up assistance to limited assist by 1 staff with personal hygiene and oral care initiated on 03/22/2023.Record review of Resident # 2's care plan provided on 10/07/2025 did not address Resident # 2's ability to keep razors in his room. During an observation on 10/07/2025 at 9:36 a.m., in Resident #2's room there was three disposable razors beside the sink. During an interview on 10/08/2025 at 8:51 a.m., Resident #2 stated he shaved himself and staff have not helped him. Resident #2 stated the staff provide the razor and typically take it back when Resident #2 is finished shaving. Resident #2 stated he prefers to shave himself. During an observation on 10/08/2025 at 8:54 a.m., in Resident #2's room was three disposable razors beside the sink. During an interview on 10/08/2025 at 8:55 a.m., CNA B stated Resident #2 mostly does his hygiene and personal care for himself. CNA B stated Resident #2 showers himself but with shaving staff assist. When asked if Resident #2 can have disposable razors in his room CNA B stated they were not sure if Resident #2 was allowed to have disposable razors in their room but would assume no. When asked if any directive or information had been given regarding residents having disposable razors in their room CNA B stated they have not been told anything about disposable razors being in residents rooms at the facility. When asked where disposable razors come from CNA B stated they get them from the supply closet. When asked what the danger would be for a resident to have disposable razors in their room CNA B stated the resident could hurt themselves, residents could fight, and another resident could potentially hurt themselves. During an interview on 10/08/2025 at 9:06 a.m., LVN C stated Resident #2 required assist times one, and he was a brittle diabetic. When asked about Resident #2's activities of daily living LVN C stated that staff is preferred to supervise Resident #2 during showers and staff shaved him. When asked about the process for shaving Resident #2, LVN C stated nurses get the disposable razors and shaving cream from the locked supply closet and shave Resident #2 at the sink. When asked if Resident #2 can have disposable razors in their room LVN C stated residents are not allowed to have disposable razors in their room due to the possibility of the disposable razor being used as a weapon, or to hurt themselves, or a dementia patient could get ahold of it. When shown where the disposable razors was located in Resident #2's room, LVN C confirmed Resident #2 had three blue disposable razors on the side of the sink and removed them from Resident #2's room.During an interview on 10/08/2025 at 4:30 p.m., the DON stated regarding residents who request to shave two things can happen the first being if the resident has a high enough BIMS score greater than 12 the resident can shave themselves if the resident has BIMS lower than 12 then a CNA or nurse would assist. The DON stated razors are kept in the supply closet which only staff have access to. When asked if Resident #2 can have a disposable razor in their room the DON stated if he could it would have to be documented in Resident #2's care plane. After reviewing Resident #2's care plan the DON stated nothing was found regarding disposable razors or shaving on Resident #2's care plan.During an interview on 10/09/2025 at 8:12 a.m., the Administrator stated that depending on residents BIMS they are technically allowed to have razors in their room but that it needs to be care planned. When asked if Resident #2 could have disposable razors in their room the Administrator stated to their understanding it had not been care planned. When asked about the danger of Resident #2 having had a disposable razor in their room the Administrator stated they want to be able to keep track of things and that it could lead to improper use.At time of exit on 10/09/2025 at 3:32 p.m., the Administrator stated the facility did not have a policy for the above deficiency.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans:The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's pressure wound, refusals for offloading and repositioning and wound care treatments.This failure could place residents at risk of not having their needs and preferences met.The findings included:Record review of Resident #1's face sheet dated 10/7/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on 8/18/25 with diagnoses that included sepsis (condition in which the body's response to infection causes widespread inflammation, leading to tissue damage, organ failure, or death), secondary malignant neoplasm of right lung (cancer has metastasized/spread and it not the original primary cancer), malignant neoplasm of kidney (cancerous tumor that starts at the kidney), acute cystitis without hematuria (a sudden inflammation or infection of the bladder that does not involve blood in the urine), heart failure, severe protein-calorie malnutrition (serious form of undernutrition), dysphagia, oropharyngeal phase (difficulty swallowing that occurs during the first part of swallowing, when food or liquid moves from the mouth through the throat and into the esophagus), muscle wasting and atrophy (the wasting away or decrease in size of a body part, tissue, or organ), weakness, need for assistance with personal care, pain in the right and left hip, hypokalemia (low level of potassium in the blood), and hypertension (high blood pressure).Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with mobility/transfers, had an indwelling urinary catheter, was always incontinent of bowel, and was at risk of developing pressure ulcers/injuries.Record review of Resident #1's discharge MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required partial/moderate assistance with mobility/transfers, was always incontinent of bowel and bladder, and had one unhealed Stage 2 pressure ulcer (a partial-thickness loss of skin involving the epidermis and/or dermis indicating the damage does not extend through the full thickness of the skin or underlying muscle).Record review of Resident #1's Order Summary Report for active orders as of 7/23/25, and dated 10/7/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop dateRecord review of Resident #1's Order Summary Report for active orders as of 8/1/25 and dated 10/8/25 revealed the following:- Mattress: Pressure Reduction for skin protection every shift related to sepsis with order date 7/23/25 and no stop date- Apply zinc base cream to the buttock area, every shift for Blanchable redness to bilateral buttocks with order date 7/25/25 and no stop dateRecord review of Resident #1's comprehensive care plan with initiated date 7/24/25 and revision date 8/20/25 reflected the resident had a potential/actual impairment to skin integrity related to incontinence and impaired mobility with a goal for the resident not to have complications related to gluteal fold peeling and interventions that included assistance with turning and positioning, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, diet as ordered, pressure reduction mattress, and use of a draw sheet or lifting device to move the resident.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 7/31/25 and electronically signed on 8/1/25 revealed the resident had no new wounds.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/6/25 and electronically signed on 8/6/25 revealed the resident had a Stage 2 pressure wound to the sacrum.Record review of Resident #1's Skin and Wound Evaluation document completed by the Wound Care Nurse on 8/13/25 and electronically signed on 8/13/25 revealed the resident had a Stage 2 pressure wound to the sacrum and reflected the Patient noncompliant with turn and repositioning, poor food intake.During an interview on 10/8/25 at 1:41 p.m., the Wound Care Nurse stated Resident #1 had cancer and believed the resident had developed a Stage 2 pressure wound to the sacrum or coccyx. The Wound Care Nurse stated the resident was pleasant and would not resist care, but he did have one or two refusals for wound care.During an interview on 10/8/25 at 4:29 p.m., the DON stated he believed Resident #1 had cancer, possibly prostate cancer, and had metastasized to the upper body. The DON stated he did not recall Resident #1 having had a pressure wound, but with him (Resident #1) not wanting to be turned, not wanting to be moved, a wound would not surprise me.During an interview on 10/9/25 at 10:26 a.m., LVN F stated she did not really participate in care plan revisions. LVN F stated the care plan was important because it helped to prevent further issues and to improve the patient's life and for the staff to know what to do in any given situation. LVN F stated, for a resident who had chronic refusals, notification should be made to the DON, ADON, and the family and probably should be care planned to show the staff what to do for refusals.During an interview on 10/9/25 at 10:49 a.m., RN A stated she recalled Resident #1 and remembered the resident was very ill, and very easy to care for. RN A stated she had participated in developing a baseline care plan but was not involved in revising a care plan. RN A stated the care plan was important because it showed the staff how to care for a resident, and how to address their personal needs.During an interview on 10/9/25 at 1:59 p.m., the MDS Coordinator stated almost everybody modified/updated the care plan. The MDS Coordinator stated that for an acute problem, the ADON and the charge nurse could add an acute problem to the care plan. The MDS Coordinator stated she and the other MDS Coordinator were responsible for updating the comprehensive care plan after the quarterly or comprehensive assessments had been completed. The MDS Coordinator stated if the comprehensive care plan addressed wounds, then the ADON or the Wound Care Nurse were responsible for revising the comprehensive care plan. The MDS Coordinator stated the comprehensive care plan was important because it helped staff to know how to provide a resident with specific care.During an interview on 10/9/25 at 2:19 p.m., the ADON stated she recalled Resident #1, and she was responsible for updating or revising the comprehensive care plan if the resident had developed an infection but did not care plan wounds. The ADON stated the Wound Care Nurse would probably care plan wounds. The ADON stated she only recalled the resident was unable to get up. The ADON stated the comprehensive care plan was important because it helped tell the staff What is going on with the resident.Record review of the facility document titled Care Plan Revisions Upon Status Change, dated 10/24/22 revealed in part, .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable.The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.The team meeting discussion will be documented in the nursing progress notes.The care plan will be updated with the new or modified interventions.Staff involved in the care of the resident will report resident response to new or modified interventions.Care plans will be modified as needed by the MDS Coordinator or other designated staff member.The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care.The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: On 4/20/24, upon the first onset of Resident #1 's symptoms, LVN A failed to recognize significant change of condition until the Resident #1's RP voiced concerns on 4/21/24. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/24/24 at 5:23 p.m. While the IJ was removed on 4/26/24 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure prompt notification of a resident's physician and responsible party. This deficient practice could affect residents with a change in condition and place them at risk of a delay in medical intervention and decline in health. The findings were: Record review of Resident #1's face sheet, dated 4/23/24, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], late onset, muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, weakness, and hypertensive heart [heart problems caused by high blood pressure] and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMs score because Resident #1 was rarely/never understood. Record review of Resident #1's nursing progress notes revealed no progress notes for 4/20/24. There were the following nursing progress notes beginning 4/21/24: - Nursing progress note dated 4/21/24 and written by LVN A: Resident noted to having edema to right hand with coldness to touch more than left hand. [R]ight facial side drooping . [NP B] informed. Ordered venous doppler [an imaging test to check for blood flow] to [right upper extremity.] - Nursing progress note dated 4/22/24 and written by LVN A: [Physician D] was in facility doing rounds on residents. Informed him of resident right hand and facial drooping . [Physician D] saw resident, right hand not as swollen or as cold as yesterday and right side facial not as much. He ordered 3 view x-ray to right hand and wrist. - Nursing progress note dated 4/22/24 and written by the DON: [Resident #1's RP] and another individual unknown to this writer in DON office with concerns of [Resident #1.] She stated that [Resident #1] had a stroke and she knows what a stroke looks like, she asked this writer if [Resident #1] had a stroke, I explained that I was not in a position to give DX's [diagnoses] and explained what [NP B] had ordered and that [Physician D] was in not more than 3 hours ago to assess along with [n]ew orders. - Nursing progress note dated 4/23/24 and written by RN E: [Resident #1's RP] called and voiced her want to send [Resident #1] out to the ER for MRI of head . [NP B] notified of request , yet no order given to send pt to ER at this time . [NP B] voiced she tend to schedule MRI in AM. Record review of Resident #1's physician order, dated 4/23/24 revealed the following order by NP B: STAT CT OF THE BRAIN W/OUT IV CONTRAST R/O CVA. Record review of Resident #1's CT of head/brain, dated 4/23/24, revealed the following: Reason for exam: Facial Drooping . FINDINGS . There is an approximately 4 to 5 cm region of relative parenchyma hypodensity [darker portions of an imaging scan that indicate possible open or fluid-filled spots in the brain tissue] . this region of ischemia [inadequate blood supply] is new since 2021 its exact acuity [onset] is indeterminate. Suggest further evaluation with MRI of the brain . IMPRESSION . since comparison, progressive worsening of ischemic disease of cerebrum including a new cerebral infarct [blood flow disruption in the brain] involving the left parieto-occipital region [the back portion of the brain that involves vision and the brain's ability to comprehend input from your five basic sense.] During an interview on 4/23/24 at 9:07 a.m., Resident #1's RP stated she went to the facility on [DATE] at around 2:00 pm to 2:30 pm and found Resident #1 in her room with her (Resident #1's) face drooping on the right side. Resident #1's RP stated she reported the issue to LVN A, who did not go to assess Resident #1 at the time. Resident #1's RP stated while she was returning to Resident #1's room, CNA C stated yesterday, 4/20/24, Resident #1 had facial drooping and while she (CNA C) attempted to feed her breakfast on 4/20/24 food was falling out of Resident #1's mouth. Resident #1's RP stated when CNA C left, she noticed Resident #1's right hand were swollen and purple. Resident #1's RP stated she went out of Resident #1's room to report the findings to LVN A, who looked at Resident #1 and then left. Resident #1's RP stated another unknown nurse entered the room who stated she will report the findings to NP B. Resident #1's RP stated it was not normal for Resident #1 to have facial drooping and swollen, purple hands. Resident #1's RP stated about one year ago the facility called her (Resident #1's RP) stating Resident #1 had a stroke, but Resident #1's RP stated when she (Resident #1's RP) arrived at the facility Resident #1 was fine, but Resident #1's arm was hanging for a couple days. Resident #1's RP stated Resident #1's symptoms on 4/21/24 were worse than the issue about one year ago. Resident #1's RP stated she was not notified when the symptoms occurred on 4/20/24. During an interview and record review on 4/23/24 at 12:49 p.m., NP B stated Resident #1 had been her patient for three years. NP B stated Resident #1 had exhibited right hand weakness before in May 2023. NP B stated on Sunday at 3:33 p.m., she received a call from the nurse stating Resident #1's RP was in the facility, Resident #1's right hand was swollen, and Resident #1 had facial drooping to the right side. NP B stated, I said, well, [Resident #1's] had right-sided weakness on several occasions that have come and gone. But the cold extremities is concerning if she's not getting blood flow. So I said let's get a doppler and we'll see her the next day. NP B stated she did not believe Resident #1's symptoms was an emergent concern because Resident #1's vital signs were table and Resident #1 exhibited similar symptoms before. NP B stated, Then [Physician D] and his RN came to see [Resident #1] yesterday [4/22/24] at around 7:50 a.m. The nurse reported . [Resident #1's RP's concern], the drooping on her face, the right hand swelling and [Physician D] examined [Resident #1] and he said [Resident #1] didn't have facial drooping now, the extremities are the same temperature. But [Physician D] didn't see evidence of a stroke. I chose not to go there that morning [4/22/24] because [Resident #1 had] already been examined . At 9:30 p.m. that night I get a call from the night nurse that [Resident #1's RP] was requesting [Resident #1] to go to the ER and have an MRI of [Resident #1's] brain . NP B stated the local hospital could not do MRIs after 4:00 p.m. and instead she ordered for a CT scan the next morning, 4/23/24. NP B stated she believed it was a TIA and no irreversible brain damage was done. Resident #1's CT results of her head were reviewed with NP B at this time. Observation on 4/23/24 at 1:28 p.m. revealed Resident #1 was seen lying in bed in position of comfort. Resident was yawning and shifting occasionally. Resident #1 was arousable, but went back to sleep. No facial drooping noted. In a follow-up interview on 4/23/24 at 1:57 p.m., NP B stated she spoke with [Physician D] and they felt nothing needed to be done for Resident #1 because Resident #1's symptoms resolve. During an interview on 4/24/24 at 9:59 p.m., CNA C stated she worked with Resident #1 during the weekend of 4/20/24 - 4/21/24. CNA C stated Resident #1 required total care and requires assistance with transfers. CNA C stated on 4/20/24 at around 7:00 a.m CNA C stated, Something about [Resident #1] didn't look normal.It looked like she had a stroke because her right side, her mouth was drooping on the right side. Her right arm was dangling. Her hand was ice cold. So I went and put her [right] hand over her abdomen and [Resident #1] just like-she mumbles a lot even when she was mumbling, it sounded like she was slurred. And when I fed [Resident #1], some of her food was coming out on the right side of her mouth. I went and reported to the [LVN A at around 7:00 - 7:30 a.m.] I said, 'I think she had a mild stroke or something. Maybe you can go take a look at her.' [LVN A] said, 'ok.' .[LVN A] said, 'that I let the night nurse know to keep an eye on her.' And we got busy so I assumed she went and checked on her. CNA C stated Resident #1's symptoms continued to 4/21/24 and additional on 4/21/24, Resident #1's hands became swollen. CNA C stated she only notified LVN A. During an interview on 4/24/24 at 11:04 a.m., RN F stated she was with Physician D when he examined Resident #1 on 4/22/24. RN F stated she and Physician D examined Resident #1 due to some right arm swelling. RN F stated NP B mostly followed Resident #1. RN F stated, [Physician D and I] examined her arm and [NP B] ordered a doppler. [Physician D] added an x-ray and that was basically our main focus. RN F stated Resident #1's arm was not very swollen and that Resident #1's nurse reported the symptoms started on Saturday, 4/20/24. RN F stated Resident #1 exhibited some facial drooping to the left side, which did not correlate with the swelling on Resident #1's right side. RN F stated an MRI could not be done with Resident #1 because Resident #1 could not sit still during the MRI examination. RN F stated a CT was not ordered during the examination on 4/22/24 because it wasn't the main focus of the examination. RN F stated a CT scan was ordered by [NP B]. RN F stated, [The CT] showed that it had progressive worsening and including a new cerebral infarction and it's hard to tell because they're comparing it to a CT from 2021. And from my understanding [Resident #1] had similar symptoms earlier last year. But then it kind of resolved itself. Like what happened now. By the time we saw her Monday [4/22/24], our main focus wasn't the facial drooping. [The facial drooping] seemed more like edema. And [Physician D] may have noticed some flattening but it wasn't correlating with what the CT showed.From the nurses' standpoint it had gotten better. During an interview on 4/24/24 at 1:07 p.m., LVN A stated she worked with Resident #1 during the weekend from 4/20/24 to 4/21/24. LVN A stated a change in condition was any difference from a resident's baseline. LVN A stated if she saw a resident had a change in condition she would notify [NP B] or the resident's physician as soon as she could. LVN A stated at around 10:00 a.m. on 4/20/24, [CNA C] had come and told me that [Resident #1] didn't look to good as far as-[CNA C] said [Resident #1] was kind of droopy when she was feeding her. So I didn't see when [CNA C] feed her [Resident #1] usually cries, it's a behavior thing. And I was just checking [Resident #1], I had gone in there and I was like ok, [Resident #1] was kind off on the right side her lip was a little down and doing her crying. I just kept an eye on [Resident #1] that day . [Resident #1] seemed ok and I passed it onto the night nurse [RN E.] The next day [4/21/24], [Resident #1] was up again and [Resident #1's RP] came and seemed concerned . I texted [NP B] after that and [NP B] ordered a doppler, which I put in.[Resident #1's RP] was concerned that she had a stroke. I didn't see anything indicating that. And I think that's what kind of threw her off. Like I said, I don't know what [CNA C] told her. When asked why she didn't notify Resident #1's physician or NP B, LVN A stated, At the time I didn't see a need for it. I was keeping an eye on her. When asked if there was anything she could have changed that weekend, from 4/20/24 to 4/21/24, LVN A stated, I felt I should have notified the doctor on Saturday [4/20/24.] During an interview on 4/24/24 at 1:25 p.m., the DON stated a change of condition was, anything from vital signs being abnormal to what [the resident's] normal baseline should be, discoloration, pain. Anything visual that would be different than their normal baselines.If there is an actual observed change in condition, first and foremost, if it's not a 911 issue, they'd contact the doctor . The timeframe [of the notification] would change depending on what's going on. It's time-sensitive, but it would be as quickly and as soon as possible.If there's an actual change in condition, and getting all your stuff together, it would be around 30 minutes. Unless it's more life-threatening and then you'd do it right away. When asked what he knew about what happened to Resident #1 during the weekend of 4/20/24, the DON stated, I know what [Resident #1's family told me, that they felt-they point-blank said she was having a stroke. And speaking with [LVN A] and [RN E], they both had made the comment that during Saturday day shift [4/20/24] and Saturday night to Sunday morning [4/21/24] there was no signs or symptoms of any type of facial disparity or changes. Nothing along that line. And at some point [NP B] was called.[NP B] had asked for a doppler. The doppler was done. [Physician D] was in Monday morning [4/22/24] and at that point he didn't see a sense of emergency or sense of a stroke. He did say that there's some slight swelling in her right hand. The DON stated he assessed Resident #1 and stated, the pulse was there. Very slight swelling. She was warm to touch. I didn't notice any facial changes and this was Monday morning-ish. Monday evening, about 9:30-10:00 at night. I got a call that [Resident #1's] family wanted [Resident #1] taken to the hospital for a stat MRI. [NP B] said there's no way that they're going to do a stat MRI at the hospital but she can have one done the following morning. [RN E] called the family. The family was ok with that. Tuesday morning [4/23/24], [Physician D] again came in just to lay eyes on her prior to her going out to the CT and the CT was done. [Resident #1] came back. No issues with the CT. [NP B] called the family and said maybe it was a transient type incident where it can come and go.[a] TIA absolutely could slightly trigger or resolve itself within moments. When asked if the facility had a quality assurance process to ensure physicians and nurse practitioners were promptly notified of a change in condition, the DON stated the facility had stand-up meetings every morning on Mondays through Fridays where they reviewed the nursing progress notes. When asked what sort of negative effects could occur to the residents if their physicians or nurse practitioners were not notified promptly, the DON stated, the change in condition could get worse. That's an if. During a follow-up interview on 4/24/24 at 2:00 p.m., NP B stated she would like to be notified of a change in condition at the time the change of condition was identified. NP B stated when LVN A called her on Sunday, LVN A did not state when the symptoms started. NP B stated she did not know when Resident #1's symptoms first started. NP B stated, I don't know where I heard this, I can't say, but someone has said [Resident #1's RP] came in Sunday [4/21/24] to see [Resident #1], found the change in condition, went out to notify the nurse, the [CNA] followed her into the room and said, [Resident #1] was like that yesterday [4/20/21] and I told the nurse.' But I heard that as second-hand information. I don't know that for a fact. NP B stated if there actually was a delay in notification, she would not have done anything differently for Resident #1 because Resident #1 had a history of similar symptoms before and because Resident #1's family had been verbal about not wanting aggressive care. During a follow-up interview on 4/24/24 at 3:08 p.m., the DON stated he had not done any education following 4/20/24 because he was awaiting the results of this current investigation. During an interview on 4/24/24 at 3:16 p.m., RN E stated she worked with Resident #1 during the weekend of 4/20/24 to 4/21/24. RN E stated she worked the overnight shift. RN E stated on Saturday LVN A stated CNA C made a complaint that Resident #1 was not normal for her baseline. RN E stated she did not have any facial drooping, swollen hands, or purple hands during her shift beginning on the evening of 4/20/24 to the morning of 4/21/24. RN E stated she did not notify Resident #1's RP on 4/20/24 because she did not see the symptoms CNA C described. RN E stated LVN A made a noted on the 24 hour report that Resident #1 had facial drooping. In a follow-up interview on 4/24/24 at 3:47 p.m., LVN A stated CNA C notified her of Resident #1's symptoms in the morning, around 10:00 a.m. LVN A stated since the weekend of 4/20/24, she did not receive any educational in-service. Observation on 4/25/24 at 11:01 a.m. revealed Resident #1 was sitting in her wheelchair by a table in the day room. Resident #1 was fully-dressed and in no acute distress and making nonsensical mumbling noises. Resident #1 did not have facial drooping. The Administrator was notified of an IJ on 4/24/24 at 5:29 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 4/25/24 at 4:34 p.m. and included the following: To Identify Any Other Residents to Have the Potential: Beginning on 4/24/24, Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be made, the physician will be notified. The evaluation will be documented in the residents clinical record. Education/ System Change: On 4/24/24, the Director of Nursing / designee initiated reeducated with Licensed Nurses on the following topics: - Abuse and Neglect - Notification of Changes : Changes refer to any resident who may need to have their plan of care or altered their treatment significantly. Changes can include but not limited to the use of any medical procedure or therapy that has not been used on the resident before. Direct care will notify Licensed nurse of changes of condition. Licensed nurse will notify provider once assessment is complete if change of condition is noted. Notification of changes training will be completed upon hire and subsequently. - When a licensed nurse is notified of a change in condition, they will evaluate the resident in condition and document their evaluation in the clinical record. Licensed nurses will complete assessment of resident upon on notification of changes and will notify Medical Provider. DON/Designee will monitor this training upon hire and subsequently. - On 4/24/24, the Director of Nursing / designee initiated reeducated with Certified Nurse Aides, Nurse Aides, and Medication Aides on the following topics: - Abuse and Neglect - Notification of Change; Direct care will notify Licensed nurse of changes of condition. Licensed nurse will notify provided as appropriate. How will this notification be reported or tracked? Changes will be reviewed during clinical morning meeting by DON/Designee. - Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. DON will validate 100% training completion using an employee roster Monitoring: Beginning 4/25/24 and going forward, the Director of Nursing / designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 4/25/24 and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 4/25/24 and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. An AdHoc QAPI was conducted on April 24, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct. The surveyor verification of the Plan of Removal on 4/26/24 was as follows: Observation on 4/26/24 at 11:38 a.m. revealed Resident #1 was seen awake, alert, fully-dressed, and in no acute distress. Resident #1 was not interviewable at the time of observation, but facial symmetry was intact at the time of the observation. Record review of a nursing progress note, dated 4/24/24, revealed Resident #1 was assessed with no concerns identified. Record review of daily census, dated 4/24/24, revealed all 134 residents were assessed and documented in nursing progress notes. Record review of nursing progress notes revealed no concerns or recent changes in conditions were identified. Record review of educational in-services, dated from 4/24/24 to 4/25/24, revealed all staff members had been educated on abuse and neglect. Record review of educational in-services, dated from 4/24/24 to 4/25/24, revealed the facility educated all CNAs, NAs, LVNs, RNs and administrative nurses. Record review of CNA Orientation checklist, not dated, revealed Abuse/neglect/exploitation, and change of condition notification will be included in the orientation checklist used for CNAs, NAs, and CMAs. Record review of a charge nurse orientation checklist, not dated, revealed notification of family for resident changes will be included in the skills checkoff. Record review of a document titled, Morning Clinical Meeting, not dated, revealed the DON had a log to note any changes in condition and monitor compliance. The DON stated the results of this log will go to the monthly QAPI meeting. Record review of a document titled, QAPI Meeting Attendance and Agenda, not dated, revealed the facility plans to include the IJ and POR items in future QAPI monthly meetings as well as the morning meeting. Record review of a QAPI meeting, dated 4/24/24, revealed the IJ was discussed in a QAPI meeting. During interviews conducted on 4/26/24, 22 staff members (7 LVNs, 3 RNs, 9 CNAs, 2 CMAs, 1 NA) across both shifts were interviewed. All 22 staff members confirmed they received education on abuse, neglect, and notification of changes. Licensed nurses were able to verbalize they will evaluate a change of condition and notification medical provider promptly. All other nursing staff stated when they identify a change in condition they will notify the licensed nurse promptly. During an interview on 4/26/24 at 2:05 p.m., the DON stated he educated staff on abuse, neglect, and change of condition report. DON stated new staff will have abuse, neglect, and change of condition on their new hire check-off list. The DON confirmed they will review the 24-hour report in the morning clinical meeting to ensure any changes in conditions are documented and communicate to the physician and resident representative. The DON confirmed they had a QAPI meeting wherein they discussed the IJ. During an interview on 4/26/24 at 2:29 p.m., the Administrator stated he will provide oversight to the DON by attending the clinical morning meeting and he will ensure the POR items are discussed. The Administrator confirmed they will review the 24-hour report in the morning clinical meeting to ensure any changes in conditions are documented and communicate to the physician and resident representative. The Administrator confirmed they had a QAPI meeting wherein they discussed the IJ. On 4/26/24 at 5:40 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interview and record review, the facility failed to immediately inform the resident's physician and notify, consistent with his or her authority, notify a resident's representative when there was an accident involving the resident when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes in that: The facility failed to promptly notify Resident #1's physician and Resident #1's responsible party when Resident #1 exhibited right-sided facial drooping and edema and coolness to both hands on 4/20/24. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/24/24 at 5:23 p.m. While the IJ was removed on 4/26/24 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure prompt notification of a resident's physician and responsible party. This deficient practice could place residents at risk of not having their RP or physician informed when there is a change in condition resulting in a delay in medical intervention and decline in health. The findings were: Record review of Resident #1's face sheet, dated 4/23/24, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], late onset, muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites, weakness, and hypertensive heart [heart problems caused by high blood pressure] and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMs score because Resident #1 was rarely/never understood. Record review of Resident #1's nursing progress notes revealed no progress notes for 4/20/24. There were the following nursing progress notes beginning 4/21/24: - Nursing progress note dated 4/21/24 and written by LVN A: Resident noted to having edema to right hand with coldness to touch more than left hand. [R]ight facial side drooping . [NP B] informed. Ordered venous doppler [an imaging test to check for blood flow] to [right upper extremity.] - Nursing progress note dated 4/22/24 and written by LVN A: [Physician D] was in facility doing rounds on residents. Informed him of resident right hand and facial drooping . [Physician D] saw resident, right hand not as swollen or as cold as yesterday and right side facial not as much. He ordered 3 view x-ray to right hand and wrist. - Nursing progress note dated 4/22/24 and written by the DON: [Resident #1's RP] and another individual unknown to this writer in DON office with concerns of [Resident #1.] She stated that [Resident #1] had a stroke and she knows what a stroke looks like, she asked this writer if [Resident #1] had a stroke, I explained that I was not in a position to give DX's [diagnoses] and explained what [NP B] had ordered and that [Physician D] was in not more than 3 hours ago to assess along with [n]ew orders. - Nursing progress note dated 4/23/24 and written by RN E: [Resident #1's RP] called and voiced her want to send [Resident #1] out to the ER for MRI of head . [NP B] notified of request , yet no order given to send pt to ER at this time . [NP B] voiced she tend to schedule MRI in AM. Record review of Resident #1's physician order, dated 4/23/24 revealed the following order by NP B: STAT CT OF THE BRAIN W/OUT IV CONTRAST R/O CVA. Record review of Resident #1's CT of head/brain, dated 4/23/24, revealed the following: Reason for exam: Facial Drooping . FINDINGS . There is an approximately 4 to 5 cm region of relative parenchyma hypodensity [darker portions of an imaging scan that indicate possible open or fluid-filled spots in the brain tissue] . this region of ischemia [inadequate blood supply] is new since 2021 its exact acuity [onset] is indeterminate. Suggest further evaluation with MRI of the brain . IMPRESSION . since comparison, progressive worsening of ischemic disease of cerebrum including a new cerebral infarct [blood flow disruption in the brain] involving the left parieto-occipital region [the back portion of the brain that involves vision and the brain's ability to comprehend input from your five basic sense.] During an interview on 4/23/24 at 9:07 a.m., Resident #1's RP stated she went to the facility on [DATE] at around 2:00 pm to 2:30 pm and found Resident #1 in her room with her (Resident #1's) face drooping on the right side. Resident #1's RP stated she reported the issue to LVN A, who did not go to assess Resident #1 at the time. Resident #1's RP stated while she was returning to Resident #1's room, CNA C stated yesterday, 4/20/24, Resident #1 had facial drooping and while she (CNA C) attempted to feed her breakfast on 4/20/24 food was falling out of Resident #1's mouth. Resident #1's RP stated when CNA C left, she noticed Resident #1's right hand were swollen and purple. Resident #1's RP stated she went out of Resident #1's room to report the findings to LVN A, who looked at Resident #1 and then left. Resident #1's RP stated another unknown nurse entered the room who stated she will report the findings to NP B. Resident #1's RP stated it was not normal for Resident #1 to have facial drooping and swollen, purple hands. Resident #1's RP stated about one year ago the facility called her (Resident #1's RP) stating Resident #1 had a stroke, but Resident #1's RP stated when she (Resident #1's RP) arrived at the facility Resident #1 was fine, but Resident #1's arm was hanging for a couple days. Resident #1's RP stated Resident #1's symptoms on 4/21/24 were worse than the issue about one year ago. Resident #1's RP stated she was not notified when the symptoms occurred on 4/20/24. During an interview and record review on 4/23/24 at 12:49 p.m., NP B stated Resident #1 had been her patient for three years. NP B stated Resident #1 had exhibited right hand weakness before in May 2023. NP B stated on Sunday at 3:33 p.m., she received a call from the nurse stating Resident #1's RP was in the facility, Resident #1's right hand was swollen, and Resident #1 had facial drooping to the right side. NP B stated, I said, well, [Resident #1's] had right-sided weakness on several occasions that have come and gone. But the cold extremities is concerning if she's not getting blood flow. So I said let's get a doppler and we'll see her the next day. NP B stated she did not believe Resident #1's symptoms was an emergent concern because Resident #1's vital signs were table and Resident #1 exhibited similar symptoms before. NP B stated, Then [Physician D] and his RN came to see [Resident #1] yesterday [4/22/24] at around 7:50 a.m. The nurse reported . [Resident #1's RP's concern], the drooping on her face, the right hand swelling and [Physician D] examined [Resident #1] and he said [Resident #1] didn't have facial drooping now, the extremities are the same temperature. But [Physician D] didn't see evidence of a stroke. I chose not to go there that morning [4/22/24] because [Resident #1 had] already been examined . At 9:30 p.m. that night I get a call from the night nurse that [Resident #1's RP] was requesting [Resident #1] to go to the ER and have an MRI of [Resident #1's] brain . NP B stated the local hospital could not do MRIs after 4:00 p.m. and instead she ordered for a CT scan the next morning, 4/23/24. NP B stated she believed it was a TIA and no irreversible brain damage was done. Resident #1's CT results of her head were reviewed with NP B at this time. In a follow-up interview on 4/23/24 at 1:57 p.m., NP B stated she spoke with [Physician D] and they felt nothing needed to be done for Resident #1 because Resident #1's symptoms resolve. During an interview on 4/24/24 at 9:59 p.m., CNA C stated she worked with Resident #1 during the weekend of 4/20/24 - 4/21/24. CNA C stated Resident #1 required total care and requires assistance with transfers. CNA C stated on 4/20/24 at around 7:00 a.m CNA C stated, Something about [Resident #1] didn't look normal.It looked like she had a stroke because her right side, her mouth was drooping on the right side. Her right arm was dangling. Her hand was ice cold. So I went and put her [right] hand over her abdomen and [Resident #1] just like-she mumbles a lot even when she was mumbling, it sounded like she was slurred. And when I fed [Resident #1], some of her food was coming out on the right side of her mouth. I went and reported to the [LVN A at around 7:00 - 7:30 a.m.] I said, 'I think she had a mild stroke or something. Maybe you can go take a look at her.' [LVN A] said, 'ok.' .[LVN A] said, 'that I let the night nurse know to keep an eye on her.' And we got busy so I assumed she went and checked on her. CNA C stated Resident #1's symptoms continued to 4/21/24 and additional on 4/21/24, Resident #1's hands became swollen. CNA C stated she only notified LVN A. During an interview on 4/24/24 at 11:04 a.m., RN F stated she was with Physician D when he examined Resident #1 on 4/22/24. RN F stated she and Physician D examined Resident #1 due to some right arm swelling. RN F stated NP B mostly followed Resident #1. RN F stated, [Physician D and I] examined her arm and [NP B] ordered a doppler. [Physician D] added an x-ray and that was basically our main focus. RN F stated Resident #1's arm was not very swollen and that Resident #1's nurse reported the symptoms started on Saturday, 4/20/24. RN F stated Resident #1 exhibited some facial drooping to the left side, which did not correlate with the swelling on Resident #1's right side. RN F stated an MRI could not be done with Resident #1 because Resident #1 could not sit still during the MRI examination. RN F stated a CT was not ordered during the examination on 4/22/24 because it wasn't the main focus of the examination. RN F stated a CT scan was ordered by [NP B]. RN F stated, [The CT] showed that it had progressive worsening and including a new cerebral infarction and it's hard to tell because they're comparing it to a CT from 2021. And from my understanding [Resident #1] had similar symptoms earlier last year. But then it kind of resolved itself. Like what happened now. By the time we saw her Monday [4/22/24], our main focus wasn't the facial drooping. [The facial drooping] seemed more like edema. And [Physician D] may have noticed some flattening but it wasn't correlating with what the CT showed.From the nurses' standpoint it had gotten better. During an interview on 4/24/24 at 1:07 p.m., LVN A stated she worked with Resident #1 during the weekend from 4/20/24 to 4/21/24. LVN A stated a change in condition was any difference from a resident's baseline. LVN A stated if she saw a resident had a change in condition she would notify [NP B] or the resident's physician as soon as she could. LVN A stated at around 10:00 a.m. on 4/20/24, [CNA C] had come and told me that [Resident #1] didn't look to good as far as-[CNA C] said [Resident #1] was kind of droopy when she was feeding her. So I didn't see when [CNA C] feed her [Resident #1] usually cries, it's a behavior thing. And I was just checking [Resident #1], I had gone in there and I was like ok, [Resident #1] was kind off on the right side her lip was a little down and doing her crying. I just kept an eye on [Resident #1] that day . [Resident #1] seemed ok and I passed it onto the night nurse [RN E.] The next day [4/21/24], [Resident #1] was up again and [Resident #1's RP] came and seemed concerned . I texted [NP B] after that and [NP B] ordered a doppler, which I put in.[Resident #1's RP] was concerned that she had a stroke. I didn't see anything indicating that. And I think that's what kind of threw her off. Like I said, I don't know what [CNA C] told her. When asked why she didn't notify Resident #1's physician or NP B, LVN A stated, At the time I didn't see a need for it. I was keeping an eye on her. When asked if there was anything she could have changed that weekend, from 4/20/24 to 4/21/24, LVN A stated, I felt I should have notified the doctor on Saturday [4/20/24.] During an interview on 4/24/24 at 1:25 p.m., the DON stated a change of condition was, anything from vital signs being abnormal to what [the resident's] normal baseline should be, discoloration, pain. Anything visual that would be different than their normal baselines.If there is an actual observed change in condition, first and foremost, if it's not a 911 issue, they'd contact the doctor . The timeframe [of the notification] would change depending on what's going on. It's time-sensitive, but it would be as quickly and as soon as possible.If there's an actual change in condition, and getting all your stuff together, it would be around 30 minutes. Unless it's more life-threatening and then you'd do it right away. When asked what he knew about what happened to Resident #1 during the weekend of 4/20/24, the DON stated, I know what [Resident #1's family told me, that they felt-they point-blank said she was having a stroke. And speaking with [LVN A] and [RN E], they both had made the comment that during Saturday day shift [4/20/24] and Saturday night to Sunday morning [4/21/24] there was no signs or symptoms of any type of facial disparity or changes. Nothing along that line. And at some point [NP B] was called.[NP B] had asked for a doppler. The doppler was done. [Physician D] was in Monday morning [4/22/24] and at that point he didn't see a sense of emergency or sense of a stroke. He did say that there's some slight swelling in her right hand. The DON stated he assessed Resident #1 and stated, the pulse was there. Very slight swelling. She was warm to touch. I didn't notice any facial changes and this was Monday morning-ish. Monday evening, about 9:30-10:00 at night. I got a call that [Resident #1's] family wanted [Resident #1] taken to the hospital for a stat MRI. [NP B] said there's no way that they're going to do a stat MRI at the hospital but she can have one done the following morning. [RN E] called the family. The family was ok with that. Tuesday morning [4/23/24], [Physician D] again came in just to lay eyes on her prior to her going out to the CT and the CT was done. [Resident #1] came back. No issues with the CT. [NP B] called the family and said maybe it was a transient type incident where it can come and go.[a] TIA absolutely could slightly trigger or resolve itself within moments. When asked if the facility had a quality assurance process to ensure physicians and nurse practitioners were promptly notified of a change in condition, the DON stated the facility had stand-up meetings every morning on Mondays through Fridays where they reviewed the nursing progress notes. When asked what sort of negative effects could occur to the residents if their physicians or nurse practitioners were not notified promptly, the DON stated, the change in condition could get worse. That's an if. During a follow-up interview on 4/24/24 at 2:00 p.m., NP B stated she would like to be notified of a change in condition at the time the change of condition was identified. NP B stated when LVN A called her on Sunday, LVN A did not state when the symptoms started. NP B stated she did not know when Resident #1's symptoms first started. NP B stated, I don't know where I heard this, I can't say, but someone has said [Resident #1's RP] came in Sunday [4/21/24] to see [Resident #1], found the change in condition, went out to notify the nurse, the [CNA] followed her into the room and said, [Resident #1] was like that yesterday [4/20/21] and I told the nurse.' But I heard that as second-hand information. I don't know that for a fact. NP B stated if there actually was a delay in notification, she would not have done anything differently for Resident #1 because Resident #1 had a history of similar symptoms before and because Resident #1's family had been verbal about not wanting aggressive care. During a follow-up interview on 4/24/24 at 3:08 p.m., the DON stated he had not done any education following 4/20/24 because he was awaiting the results of this current investigation. During an interview on 4/24/24 at 3:16 p.m., RN E stated she worked with Resident #1 during the weekend of 4/20/24 to 4/21/24. RN E stated she worked the overnight shift. RN E stated on Saturday LVN A stated CNA C made a complaint that Resident #1 was not normal for her baseline. RN E stated she did not have any facial drooping, swollen hands, or purple hands during her shift beginning on the evening of 4/20/24 to the morning of 4/21/24. RN E stated she did not notify Resident #1's RP on 4/20/24 because she did not see the symptoms CNA C described. RN E stated LVN A made a noted on the 24 hour report that Resident #1 had facial drooping. In a follow-up interview on 4/24/24 at 3:47 p.m., LVN A stated CNA C notified her of Resident #1's symptoms in the morning, around 10:00 a.m. LVN A stated since the weekend of 4/20/24, she did not receive any educational in-service. The Administrator was notified of an IJ on 4/24/24 at 5:29 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 4/25/24 at 4:34 p.m. and included the following: Issue: F580 Notification of Changes Licensed Nurse performed a head to toe on resident #1 on 4/24/24 with no adverse findings documented in the medical record. To Identify Any Other Residents to Have the Potential: Beginning on 4/24/24, Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be made, the physician will be notified. The evaluation will be documented in the residents clinical record. Education/ System Change: On 4/24/24, the Director of Nursing / designee initiated reeducated with Licensed Nurses on the following topics: - Abuse and Neglect - Notification of Changes : Changes refer to any resident who may need to have their plan of care or altered their treatment significantly. Changes can include but not limited to the use of any medical procedure or therapy that has not been used on the resident before. Direct care will notify Licensed nurse of changes of condition. Licensed nurse will notify provider once assessment is complete if change of condition is noted. Notification of changes training will be completed upon hire and subsequently. - When a licensed nurse is notified of a change in condition, they will evaluate the resident in condition and document their evaluation in the clinical record. Licensed nurses will complete assessment of resident upon on notification of changes and will notify Medical Provider. DON/Designee will monitor this training upon hire and subsequently. - On 4/24/24, the Director of Nursing / designee initiated reeducated with Certified Nurse Aides, Nurse Aides, and Medication Aides on the following topics: - Abuse and Neglect - Notification of Change; Direct care will notify Licensed nurse of changes of condition. Licensed nurse will notify provided as appropriate. How will this notification be reported or tracked? Changes will be reviewed during clinical morning meeting by DON/Designee. - Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. DON will validate 100% training completion using an employee roster Monitoring: Beginning 4/25/24 and going forward, the Director of Nursing / designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 4/25/24 and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 4/25/24 and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. An AdHoc QAPI was conducted on April 24, 2024, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct. The surveyor verification of the Plan of Removal on 4/26/24 was as follows: Observation on 4/26/24 at 11:38 a.m. revealed Resident #1 was seen awake, alert, fully-dressed, and in no acute distress. Resident #1 was not interviewable at the time of observation, but facial symmetry was intact at the time of the observation. Record review of a nursing progress note, dated 4/24/24, revealed Resident #1 was assessed with no concerns identified. Record review of daily census, dated 4/24/24, revealed all 134 residents were assessed and documented in nursing progress notes. Record review of nursing progress notes revealed no concerns or recent changes in conditions were identified. Record review of educational in-services, dated from 4/24/24 to 4/25/24, revealed all staff members had been educated on abuse and neglect. Record review of educational in-services, dated from 4/24/24 to 4/25/24, revealed the facility educated all CNAs, NAs, LVNs, RNs and administrative nurses. Record review of CNA Orientation checklist, not dated, revealed Abuse/neglect/exploitation, and change of condition notification will be included in the orientation checklist used for CNAs, NAs, and CMAs. Record review of a charge nurse orientation checklist, not dated, revealed notification of family for resident changes will be included in the skills checkoff. Record review of a document titled, Morning Clinical Meeting, not dated, revealed the DON had a log to note any changes in condition and monitor compliance. The DON stated the results of this log will go to the monthly QAPI meeting. Record review of a document titled, QAPI Meeting Attendance and Agenda, not dated, revealed the facility plans to include the IJ and POR items in future QAPI monthly meetings as well as the morning meeting. Record review of a QAPI meeting, dated 4/24/24, revealed the IJ was discussed in a QAPI meeting. During interviews conducted on 4/26/24, 22 staff members (7 LVNs, 3 RNs, 9 CNAs, 2 CMAs, 1 NA) across both shifts were interviewed. All 22 staff members confirmed they received education on abuse, neglect, and notification of changes. Licensed nurses were able to verbalize they will evaluate a change of condition and notification medical provider promptly. All other nursing staff stated when they identify a change in condition they will notify the licensed nurse promptly. During an interview on 4/26/24 at 2:05 p.m., the DON stated he educated staff on abuse, neglect, and change of condition report. DON stated new staff will have abuse, neglect, and change of condition on their new hire check-off list. The DON confirmed they will review the 24-hour report in the morning clinical meeting to ensure any changes in conditions are documented and communicate to the physician and resident representative. The DON confirmed they had a QAPI meeting wherein they discussed the IJ. During an interview on 4/26/24 at 2:29 p.m., the Administrator stated he will provide oversight to the DON by attending the clinical morning meeting and he will ensure the POR items are discussed. The Administrator confirmed they will review the 24-hour report in the morning clinical meeting to ensure any changes in conditions are documented and communicate to the physician and resident representative. The Administrator confirmed they had a QAPI meeting wherein they discussed the IJ. On 4/26/24 at 5:40 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Treatment Nurse A used the sit-to-stand mechanical lift, as required on the care plan, which directed two-person assist for transfers with a mechanical lift. This resulted in the resident experiencing pain and sustained a right distal femur fracture (fracture of the upper leg bone above the knee). This deficient practice placed residents at risk of injury due inadequate supervision and assistance. The findings were: Record review of Resident #1's face sheet, dated 08/19/2022, revealed she was admitted to the facility on [DATE] with diagnoses which included delusional disorder (a mental illness in which a person has delusions, but with no accompanying prominent hallucinations, thought disorder, or mood disorder), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), Alzheimer's disease (common cause of dementia, a continuous decline in thinking, behavioral and social skills), unsteadiness on feet, and obesity (abnormal or excessive fat accumulation that presents a risk to health). Record review of Resident #1's MDS, a quarterly qssessment dated 06/2/2022, revealed a BIMS (Brief Interview of Mental Status) score of 7 out of 15, indicating thqt her cognitive skills for daily decision making were moderately impaired. Further review of the MDS revealed Resident #1 required extensive assistance of 2 people with transfer between surfaces which included to or from bed, chair, wheelchair or standing position. Record review of Resident #1's care plan for the problem area of Resident #1 had an ADL self-care performance deficit r/t [related to] poor balance, debility, impaired cognition, with a start date of 02/17/2021 and revised on 5/24/22, revealed under Interventions was Transfer: Resident #1 requires extensive assistance by 2 staff to move between surfaces using Sit to Stand lift (a mechanical lift). Record review of Resident #1's Incident Witness note by Treatment Nurse A, dated 08/15/2022, revealed This nurse transfer patient from bed to wheel chair [sic], assisted by patient. When patient almost on the wheel chair [sic] resident told this nurse that her knee pop. This nurse got patient into wheel chair [sic] and contacted NP B and reported patients [sic] complaints. NP came and assessed patient's knee, order this nurse to ace wrap knee and monitor for any changes. Record review of Resident #1's electronic physician orders, revealed an order with a start date of 08/15/2022 for an ace wrap to right knee daily, on in AM and off in the evening for one week. Record review of Resident #1's electronic physician orders, revealed an order with a start date of 08/15/2022 for Acetaminophen (pain medication) tablet 500 mg, 1 tablet three times a day for right knee pain. Record review of Resident #1's NP B's note, dated 08/16/2022, revealed I was asked to evaluate the patient yesterday by nursing for right knee paint following a 1 person maximum assist transfer from the bed to the WC [wheelchair]. During the transfer the patient reports that she felt a 'pop' in her right knee and experienced significant sudden onset pain in the right knee. She was unable to specify where exactly the pain was, rubbing all over the entire anterior [front] knee surface. She was noted to have tenderness to the superior medial aspect [top portion above the midline surface] of the knee without swelling, discoloration or warmth. She had AROM [active range of motion] in the knee with only mild discomfort noted. Orders were given for scheduled pain medication and compression ace wrap to the knee .She [Resident #1] says that it feels better with the ace wrap on . Record review of Resident #1's Nurses' Progress Note, dated 08/19/2022, written by LVN D revealed Resident c/o [complained of] right knee discomfort. Resident's right knee appears extremely swollen, warm to touch, .tender w/ [with] palpitation. Left voicemail for NP B. Record review of Resident #1's physician's orders revealed a verbal order dated 08/19/2022 for an x-ray of the right knee immediately for pain and swelling. Record review of Resident #1's x-ray of her right knee, dated 08/19/2022, revealed diffuse [CONDITION(S)] (disease that weakens bones where they can easily break) and an acute distal femoral diametaphyseal fracture (fracture of the upper leg bone above the knee). Record review of Resident #1's NP B's note dated 08/19/2022 revealed .nurse reports of increasing right lower extremity/knee pain with significant swelling of the general area .Right knee pain that began on 08/15/2022 during a transfer out of bed. Now with a significant increase in her pain and new swelling around/above the knee .Resident #1 describes the pain as constant, severe, increasing with movement of her leg .moderate swelling in the RLE [Right Lower Extremity], proximal to the knee and extending down into the knee some. Significant tenderness noted to light palpation of the distal femur/superior knee .Assessment: Closed fracture of distal end of right femur, diametaphyseal With pain and swelling, consult completed with orthopedics as evidence by review of the chart, radiographs completed today, nursing interviews, patient interview and exam findings. Record review of HHS 3613A Provider Investigation Report, dated 08/19/2022 and completed by the DON, revealed on 08/15/2022 during the transfer of Resident #1 of a stand and pivot, Treatment Nurse A heard a pop noise with soreness to Resident #1's knee. The NP assessed the resident at the time of the incident and ordered a wrap to the knee and pain medication. Later the knee was more swollen and more tender, and an x-ray was ordered on 08/19/2022 which results showed a fracture. Record review of Investigation Statement from LVN A, dated 08/22/2022, completed by the DON for the incident with Resident #1, revealed on 08/15/2022 around 11:00 a.m., Treatment Nurse A provided wound care and treatments to Resident #1. Treatment Nurse A transferred Resident #1 and the resident stated, she felt a 'pop'. Treatment Nurse A immediately notified the NP on duty of the incident. The Treatment Nurse A did not have anyone assist her when Resident #1 was transferred. Record review of Incident Report #1716 Transfer Related for Resident #1, dated 08/15/2022, revealed during a transfer from bed to wheelchair Resident #1 told Treatment Nurse A her right knee pop. Treatment Nurse assessed Resident #1's knee and called NP B to assess the resident. Record review of incidents from 07/01/2022 to 10/02/2022 revealed there was one incident as the result of a transfer which involved Resident #1 on 08/15/2022. In an interview on 10/02/2022 at 10:32 a.m., Resident #1 stated before she hurt her right leg, she could stand and transfer herself with assistance by standing up and holding on to the overbed table and then pivoting into her wheelchair. Resident #1 stated when Treatment Nurse A transferred the resident, the nurse told Resident #1 to put her arms on the nurse's shoulder with the resident's hands clasped together behind the nurse's neck, had the resident stand, and did the transfer without assistance. In a further interview on 10/03/2022 at 8:51 a.m., Resident #1 stated on 08/15/2022, when Treatment Nurse A transferred her, the nurse had the resident sit at the edge of her bed. Resident #1 stated she asked Treatment Nurse A where the sit-to-stand mechanical lift was and the nurse stated 'What sit-to-stand? We don't' need that.' That's what she said! Resident #1 stated Treatment Nurse A directed the resident to clasp her hands together, place them over the nurse's head behind the nurse's neck. Resident #1 stated And like a dummy I did it like she told me to do and when she put me down, I heard a pop in my knee. Resident #1 stated this was the first time the Treatment Nurse A had transferred the resident. In an interview on 10/03/2022 at 10:43 a.m., Treatment Nurse A stated on 08/15/2022 she sat Resident #1 on the edge of the bed, placed a gait belt on the resident, the resident stood up and pivoted and then placed her arm on the wheelchair and sat down. Treatment Nurse A said she had transferred Resident #1 without assistance of another staff member and stated she did not tell the resident to place her clasped hands behind the nurse's neck. Treatment Nurse A stated, Resident #1 told her she felt a pop and the resident's leg hurt after the resident was in her wheelchair. The Treatment Nurse A stated she went and told NP B, who had an office in the facility, and the NP assessed the resident. Treatment Nurse A stated she had transferred Resident #1 before with a gait belt by herself without any issues, and had never used the sit-to-stand mechanical lift when she transferred Resident #1. Treatment Nurse A stated because she had taken care of Resident #1 before, she did not look at the resident's care plan. Treatment Nurse A stated she had access to resident's care plans in their electronic clinical record, and would look at the resident's care plans when she has a new resident, but not for residents she has taken care of before. In an interview on 10/03/2022 at 2:50 p.m., the DON stated, on 08/15/2022, when Treatment Nurse A transferred Resident #1 by herself, one of the resident's legs did not pivot and the resident stated she felt a pop. Treatment Nurse A went to the NP B's office, informed her what happened; the NP assessed the resident, gave initial orders to monitor the knee and put an ace wrap on it. The DON stated they monitored Resident #1's leg for two to three days. He stated on the third day it was tender, and x-rays were ordered. The DON stated the x-rays showed a fracture just on the femur where it attached to the knee behind the patella (kneecap). The DON reviewed Resident #1's care plan for the problem area of ADL self-care performance deficit and stated the care plan indicated two staff members were required to transfer the resident. The DON stated I believe it was one staff person who transferred Resident #1 on 08/15/2022. The DON stated the nurses had access to residents' care plans in the electronic clinical records and were expected to look at the care plans daily. The DON stated the risk of not following the resident's care plan could result in possible injury to the resident. In an interview on 10/03/2022 at 3:38 p.m., the Administrator stated he did not know why Treatment Nurse A transferred Resident #1 by herself on 08/15/2022 and said, there were staff on the hallway. The Administrator stated the nurses had access to residents' care plans in their electronic clinical records. The Administrator said the risk of not following the care plan for a resident who required a two-person transfer, was a high risk. Record review of the facility's policy Transferring a Resident, bed to Chair/Chair to Bed, revised 07/2015, revealed The purpose of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Under Preparation was Review the resident's care plan to assess for any special needs of the resident. Under Steps in the Procedure .Verify the amount of assistance that the resident requires prior to performing this procedure.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 7 Residents (Resident #1) reviewed for comprehensive care plans, in that: The facility failed to ensure Treatment Nurse A followed Resident #1's care plan by transfering Resident #1 from her bed to wheelchair, without using the sit-to-stand mechanical lift and without assistance of another staff member. This resulted in Resident #1 sustaining a distal femoral diametaphyseal fracture (fracture of the upper leg bone above the knee). This failure could place residents, who required the use of a mechanical lift for transfers, at risk of injury. The findings were: Record review of Resident #1's face sheet, dated 08/19/2022, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan for the problem area of Resident #1 had an ADL self-care performance deficit r/t [related to] poor balance, debility, impaired cognition, with a start date of 02/17/2021 and revised on 05/24/2022, revealed under Interventions was Transfer: Resident #1 requires extensive assistance by 2 staff to move between surfaces using Sit to Stand lift [a mechanical lift]. Record review of Resident #1's MDS, a quarterly assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 7 out of 15, indicating that her cognitive skills for daily decision making were moderately impaired. Further review of the MDS revealed Resident #1 required extensive assistance of 2 people with transfers between surfaces which included to or from bed, chair, wheelchair or standing position. Record review of Resident #1's Incident Witness note by Treatment Nurse A, dated 08/15/2022, revealed This nurse transfer patient from bed to wheel chair [sic], assisted by patient. When patient almost on the wheel chair [sic] resident told this nurse that her knee pop. This nurse got patient into wheel chair [sic] and contacted NP B and reported patients [sic] complaints. NP came and assessed patient's knee, order this nurse to ace wrap knee and monitor for any changes. Record review of Resident #1's electronic physician orders, revealed an order with a start date of 08/15/2022 for an ace wrap to right knee daily on in AM and off in the evening for one week. Record review of Resident #1's electronic physician orders, revealed an order with a start date of 08/15/2022 for Acetaminophen (pain medication) tablet 500 mg, 1 tablet three times a day for right knee pain. Record review of Resident #1's NP B's note dated 08/16/2022 revealed I was asked to evaluate the patient yesterday by nursing for right knee paint following a 1 person maximum assist transfer from the bed to the WC [wheelchair]. During the transfer the patient reports that she felt a 'pop' in her right knee and experienced significant sudden onset pain in the right knee. She was unable to specify where exactly the pain was, rubbing all over the entire anterior [front] knee surface. She was noted to have tenderness to the superior medial aspect [top portion above the midline surface] of the knee without swelling, discoloration or warmth. She had AROM [active range of motion] in the knee with only mild discomfort noted. Orders were given for scheduled pain medication and compression ace wrap to the knee .She [Resident #1] says that it feels better with the ace wrap on . Record review of Resident #1's Nurses' Progress Note, dated 08/19/2022, written by LVN D revealed Resident c/o [complained of] right knee discomfort. Resident's right knee appears extremely swollen, warm to touch, .tender w/ [with] palpitation. Left voicemail for NP B. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's x-ray of her right knee, dated 08/19/2022, revealed diffuse [CONDITION(S)] (disease that weakens bones where they can easily break) and an acute distal femoral diametaphyseal fracture (fracture of the upper leg bone above the knee). Record review of Resident #1's NP B's note, dated 08/19/2022, revealed .nurse reports of increasing right lower extremity/knee pain with significant swelling of the general area .Right knee pain that began on 08/15/2022 during a transfer out of bed. Now with a significant increase in her pain and new swelling around/above the knee .Resident #1 describes the pain as constant, severe, increasing with movement of her leg .moderate swelling in the RLE [Right Lower Extremity], proximal to the knee and extending down into the knee some. Significant tenderness noted to light palpation of the distal femur/superior knee .Assessment: Closed fracture of distal end of right femur, diametaphyseal With pain and swelling, consult completed with orthopedics as evidence by review of the chart, radiographs completed today, nursing interviews, patient interview and exam findings. Record review of Incident Report #1716 Transfer Related for Resident #1, dated 08/15/2022, revealed during a transfer from bed to wheelchair Resident #1 told Treatment Nurse A her right knee pop. Treatment Nurse assessed Resident #1's knee and called NP B to assess the resident. In an interview on 10/02/2022 at 10:32 a.m., Resident #1 stated before she hurt her right leg, she could stand and transfer herself with assistance by standing up and holding on to the overbed table and then pivoting into her wheelchair. Resident #1 stated when Treatment Nurse A transferred the resident, the nurse told Resident #1 to put her arms on the nurse's shoulder with the resident's hands clasped together behind the nurse's neck, had the resident stand, and did the transfer without assistance. In a further interview on 10/03/2022 at 8:51 a.m., Resident #1 stated on 08/15/2022, when Treatment Nurse A transferred her, the nurse had the resident sit at the edge of her bed. Resident #1 stated she asked Treatment Nurse A where the sit-to-stand mechanical lift was and the nurse stated 'What sit-to-stand? We don't' need that.' That's what she said! Resident #1 stated Treatment Nurse A directed the resident to clasp her hands together, place them over the nurse's head behind the nurse's neck. Resident #1 stated And like a dummy I did it like she told me to do and when she put me down, I heard a pop in my knee. Resident #1 stated this was the first time the Treatment Nurse A had transferred the resident. In an interview on 10/03/2022 at 10:43 a.m., Treatment Nurse A stated, on 08/15/2022, she sat Resident #1 on the edge of the bed, placed a gait belt on the resident, the resident stood up and pivoted and then placed her arm on the wheelchair and sat down. Treatment Nurse A said she had transferred Resident #1 without assistance of another staff member and stated she did not tell the resident to place her clasped hands behind the nurse's neck. Treatment Nurse A stated, Resident #1 told her she felt a pop and the resident's leg hurt after the resident was in her wheelchair. The Treatment Nurse A stated she went and told NP B, who had an office in the facility, and the NP assessed the resident. Treatment Nurse A stated she had transferred Resident #1 before with a gait belt by herself without any issues, and had never used the sit-to-stand mechanical lift when she transferred Resident #1. Treatment Nurse A stated because she had taken care of Resident #1 before, she did not look at the resident's care plan. Treatment Nurse A stated she had access to resident's care plans in their electronic clinical record, and would look at the resident's care plans when she has a new resident, but not for residents she has taken care of before. In an interview on 10/03/2022 at 2:50 p.m., the DON stated on 08/15/2022 when Treatment Nurse A transferred Resident #1 by herself, one of the resident's legs did not pivot and the resident stated she felt a pop. Treatment Nurse A went to the NP B's office, informed her what happened; the NP assessed the resident, gave initial orders to monitor the knee and put an ace wrap on it. The DON stated they monitored Resident #1's leg for two to three days. He stated on the third day it was tender, and x-rays were ordered. The DON stated the x-rays showed a fracture just on the femur where it attached to the knee behind the patella (kneecap). The DON reviewed Resident #1's care plan for the problem area of ADL self-care performance and stated the care plan indicated two staff members were required to transfer the resident. The DON stated I believe it was one staff person who transferred Resident #1 on 8/15/22. The DON stated the nurses had access to residents' care plans in the electronic clinical records and were expected to look at the care plans daily. The DON stated the risk of not following the resident's care plan could result in possible injury to the resident. In an interview on 10/03/2022 at 3:38 p.m., the Administrator stated he did not know why Treatment Nurse A transferred Resident #1 by herself on 08/15/2022 and said, there were staff on the hallway. The Administrator stated the nurses had access to residents' care plans in their electronic clinical records. The Administrator said the risk of not following the care plan for a resident who required a two-person transfer, was a high risk. The Administrator stated he ensured residents were free from abuse and neglect through monitoring which involved walking the halls, talking to residents and investigating any allegations of abuse and grievances brought to his attention. In an interview on 10/03/2022 at 3:58 p.m., the Administrator stated the facility did not have a policy for following the resident's care plan. Record review of the facility's policy Transferring a Resident, bed to Chair/Chair to Bed, revised 07/2015, revealed The purpose of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Under Preparation was Review the resident's care plan to assess for any special needs of the resident. Under Steps in the Procedure .Verify the amount of assistance that the resident requires prior to performing this procedure.

Based on observation, interview and record review, the facility failed to ensure Residents received treatment and care in accordance with professional standards of practice that met the physical, mental and psychological needs for 8 of 8 Residents (Resident # 3, 4, 5, 6, 7, 8, 9 and 10) reviewed for quality of care related to COVID-19 in that: 1. Resident #3 in the COVID-19 positive unit was not cared for by a licensed nurse from 4:30 p.m. to 10:00 p.m. on 7/13/20. Resident #3 had a decline in health and transferred to the hospital the following day. Resident #3 was not administered scheduled medications from 6:00 a.m. to 10:00 a.m. on 7/11/20. 2. Resident #4, #5, #6, #7, #8, #9 and #10 in the COVID-19 positive unit were not cared for by a licensed nurse from 4:30 p.m. to 10:00 p.m. on 7/13/20 and were not administered scheduled medications from 6:00 a.m. to 10:00 a.m. on 7/11/20. These failures resulted in identification of an Immediate Jeopardy (IJ) on 7/16/20. While the IJ was removed 7/18/20, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents in the COVID-19 positive unit. Staff were in-serviced and increased nursing supervision was provided. These deficient practices affected residents in the COVID-19 positive unit and placed them at risk for harm, or death. The findings were: 1. a. Record review of Resident #3's face sheet, dated 7/15/20, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #3's most recent Quarterly MDS, dated [DATE], revealed the resident was moderately cognitively impaired for daily decision-making skills. Further review of the Quarterly MDS revealed 1-person physical assist with bed mobility and transfers. Record review of nursing note dated 7/14/20 at 9:03 a.m. by LVN A, revealed Resident #3 was assessed and noted with increased respirations, SpO2 (oxygen saturation) at 65% and O2 (oxygen) was administered at 2 liters. Record review of nursing note dated 7/14/20 at 9:48 a.m. by LVN A revealed orders were received for Resident #3 to be sent to the emergency room by ambulance for further evaluation and treatment. Record review of Resident #3's electronic record revealed no documentation in the nursing notes that the Resident was reported to have had a [MEDICAL CONDITION] or documentation of the Resident's vital signs reported by CNA F on 7/13/20. During an interview on 7/16/20 at 12:27 p.m., LVN B confirmed working on 7/13/20 from 5:20 a.m. to 9:25 p.m. LVN B revealed CNA E approached her at the nurse's station and told her he believed Resident #3, in the COVID-19 positive unit was having a [MEDICAL CONDITION]. LVN B stated, I never went to assess or investigate. LVN B further stated she did not know if a nurse was working in the COVID-19 positive unit at the time CNA E approached her about Resident #3. LVN B revealed I know that if somebody for sure had coded, you cannot go into the COVID unit without PPE and so by the time a nurse would have put on the PPE the resident would have been dead. During an interview on 7/16/20 at 1:04 p.m., CNA E revealed he worked on 7/13/20 from 10:00 a.m. to 6:40 p.m. CNA E revealed he was asked by CNA F at approximately 5:00 p.m. on 7/13/20 to get a nurse because she believed Resident #3 was having a [MEDICAL CONDITION]. CNA E stated he went out of the COVID-19 positive unit to the nurse's station where LVN B and LVN H were sitting. CNA E stated he told LVN B and LVN H that a nurse was needed in the COVID-19 positive unit because CNA F told him she believed Resident #3 was having a [MEDICAL CONDITION]. CNA E revealed that only LVN B acknowledged him. CNA E then asked LVN B to go to the COVID-19 positive unit to assess. CNA E stated LVN B did not go to the COVID-19 positive unit to assess Resident #3 and told him I'm not going, I'm not her nurse. CNA E then asked LVN B what nurse was in the charge of the COVID-19 positive unit, LVN B replied, I don't know. During an interview on 7/16/20 at 2:00 p.m., LVN A revealed she worked on the COVID-19 positive unit on 7/13/20 from 6 a.m. until 4:30 p.m. LVN A stated she informed the DON by phone she was leaving the COVID-19 positive unit and CNA F would be left there by herself. LVN A revealed she was told by the DON to give report to CNA F and told her don't worry, there's plenty of nurses in the building. LVN A confirmed she left the COVID-19 positive unit without being relieved by a licensed nurse. During an interview on 7/16/20 at 2:47 p.m., CNA F confirmed she worked on the COVID-19 positive unit on 7/13/20 from 6:00 a.m. to 10:00 p.m. CNA F stated LVN A was on speaker phone with the DON who instructed LVN A to give her (CNA F) report and then LVN A left the COVID-19 positive unit at 4:30 p.m. CNA F revealed she was passing out food trays between approximately 5:00 p.m. and 5:30 p.m. when she believed Resident #3 had displayed [MEDICAL CONDITION] activity. CNA F called CNA E into the COVID-19 positive unit to notify a nurse to assess. CNA F stated CNA E came back to the COVID-19 positive unit to inform her nobody was coming and LVN B told CNA E she would not go to the COVID-19 positive unit unless somebody was coding ([MEDICAL CONDITION]). CNA F stated she then called the nurse's station and LVN G picked up the phone. CNA F stated she told LVN G she believed Resident #3 was having [MEDICAL CONDITION] activity and had obtained the Resident's blood pressure and oxygen saturation. CNA F revealed she told LVN G Resident #3's blood pressure was high and oxygen level was low. LVN G instructed CNA F to go back and take Resident #3's temperature and to call her back. CNA F stated she obtained Resident #3's temperature and called back LVN G at the nurse's station who informed her she would notify the physician on call. CNA F revealed a licensed nurse did not come into the COVID-19 positive unit until 10:00 p.m. (PUT DOWN WHO THE NIGHT NURSE WAS) During an interview on 7/17/20 at 12:23 p.m. LVN H revealed CNA F was working on the COVID-19 positive unit on 7/13/20 but could not recall if a licensed nurse was working in the unit during the evening shift. LVN H stated the DON left the facility between 5:00 p.m. and 5:30 p.m. leaving LVN B, LVN G and herself in the facility during the evening shift on 7/13/20. LVN H confirmed she worked on 7/13/20 from 6:00 a.m. to 8:25 p.m. and did not go into the COVID-19 positive unit on 7/13/20. During an interview on 7/17/20 at 12:48 p.m., the DON confirmed she worked on 7/13/20 from 7:30 a.m. to 5:45 p.m. The DON revealed LVN A left the COVID-19 positive unit at approximately 5:00 p.m. on 7/13/20 leaving CNA F in the unit by herself. The DON further stated the night nurse was supposed to come in early and if unable had instructed LVN B and LVN H to go into the COVID-19 positive unit if CNA F needed help. The DON further stated she received a text message from LVN B about Resident #3 having had possible [MEDICAL CONDITION] activity and the DON texted back stating Please peek in the door and check on Resident #3. Assess her and see if she needs to be sent out. The DON stated LVN B texted back, CNA F said everything was fine. The DON stated she based the assumption that LVN B had gone into the COVID-19 positive unit to assess Resident #3 by LVN B's text message response. The DON revealed LVN I made the nursing schedule and was under the impression the night nurse would come in early. LVN I never said nobody was coming. The DON further revealed my back up plan was that if something occurred the nurses in the front would be able to help. During an interview on 7/17/20 at 2:22 p.m. LVN G confirmed she worked on 7/13/20 from 2:00 p.m. to 10:00 p.m. LVN G stated she answered a call from the phone in the nurse's station at approximately 6:30 p.m. or 7:30 p.m. from CNA F who was calling from the COVID-19 positive unit to inform her she believed Resident #3 had displayed [MEDICAL CONDITION] activity. LVN G instructed CNA F to take Resident #3's temperature and call her back. LVN G stated CNA F reported back by phone with Resident #3's temperature and informed CNA F she would notify the physician. LVN G confirmed she did not go into the COVID-19 positive unit to assess Resident #3 and did not document Resident #3's vital signs in the electronic record. LVN G further stated she did not document she had called the physician. During an interview on 7/17/20 at 2:48 p.m., LVN I revealed she was in charge of making the nursing schedule. LVN I stated she received a call between 4:00 p.m. and 6:00 p.m. on 7/13/20 from LVN G informing her CNA F reported she believed Resident #3 in the COVID-19 positive unit had a [MEDICAL CONDITION]. LVN I stated LVN B was scheduled to work the COVID-19 positive unit on 7/13/20 with CNA F but LVN B refused. During an interview on 7/17/20 at 4:52 p.m., LVN D confirmed she worked the overnight shift beginning on 7/13/20 at 10:00 p.m. LVN D stated she was scheduled on the COVID-19 positive unit and when she came in at 10:00 p.m. there was nobody in the COVID unit. I did not get report from anybody. Record review of the nursing schedule for the COVID-19 positive unit on 7/13/20 revealed the following: -LVN A 6:00 a.m. to 4:15 p.m. -CNA F 6:00 a.m. to 10:00 p.m. -(Unassigned) Covid Nurse 4:15 p.m. to 10:00 p.m. b. Review of Resident #3's Physician order [REDACTED]. - [MEDICATION NAME] 20 mg give 1 tablet by mouth one time a day, start date 10/12/19 - [MEDICATION NAME] 0.5 mg give 1 tablet by mouth two times a day, start date 4/6/20 - [MEDICATION NAME] 125 mg give 1 capsule by mouth three times a day, start date 5/11/20 - [MEDICATION NAME] Capsule Delayed Release Particles 60 mg give 1 capsule by mouth one time a day, start date 8/5/19 - Potassium Chloride 20 meq give 1 tablet by mouth one time a day, start date 8/4/19 - [MEDICATION NAME] 10 mg give 1 tablet by mouth one time a day, start date 8/5/19 - [MEDICATION NAME] 50 mg give 1 tablet by mouth every 12 hours, start date 9/25/19 - [MEDICATION NAME] 10 mg give 1 tablet by mouth one time a day, start date 8/5/19 Review of Resident #3's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] 20 mg, [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] 125 mg at 8:00 a.m. on 7/11/20, [MEDICATION NAME] 60 mg, Potassium Chloride 20 meq, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 50 mg and [MEDICATION NAME] 10 mg at 9:00 a.m. on 7/11/20. 2. a. Record review of Resident #4's Face Sheet, dated 7/17/20, revealed an admission date of [DATE] and re-admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #4's most recent Quarterly MDS, dated [DATE], revealed a BIMS score of 5 which indicated the Resident was severely cognitively impaired for daily decision-making skills. Further review of the Quarterly MDS revealed Resident #4 required 1-person physical assist with bed mobility and transfers. Review of Resident #4's Physician order [REDACTED]. - [MEDICATION NAME] 50 mg give 1 tablet by mouth two times a day, start date 6/4/20. Review of Resident #4's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] 50 mg at 8:00 a.m. on 7/11/20. b. Record review of Resident #5's Face Sheet, dated 7/17/2020, revealed an admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE], revealed a BIMS of 6 which indicated severe cognitive impairment. Further review of the Quarterly MDS revealed the Resident required 1-person physical assist with bed mobility and transfers. Review of Resident #5's Physician order [REDACTED]. -Aspirin 81 mg give 1 tablet by mouth one time a day, start date 10/1/2018 -[MEDICATION NAME] tablet 1000-unit give 1 tablet by mouth one time a day, start date 10/1/2018 -[MEDICATION NAME] ER 50 mg give 1 tablet by mouth one time a day, start date 10/1/2018 -[MEDICATION NAME] Chloride ER 10 mg give 1 tablet by mouth one time a day, start date 10/1/2018 -[MEDICATION NAME] capsule 100 mg give 1 capsule by mouth two times a day, start date 10/1/2018. Review of Resident #5's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of Aspirin 81 mg, [MEDICATION NAME] 1000-unit, [MEDICATION NAME] ER 50 mg, [MEDICATION NAME] Chloride ER 10 mg, [MEDICATION NAME] 100 mg, on 7/11/2020 at 8:00 a.m. c. Record review of Resident #6's Face Sheet, dated 7/15/20, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #6's most recent Admission MDS, dated [DATE], revealed a BIMS score of 1 which indicated the Resident was severely cognitively impaired for daily decision-making skills. Further review of the Admission MDS revealed the Resident required extensive assistance with bed mobility and transfers. Review of Resident #6's Physician order [REDACTED]. -[MEDICATION NAME] 25 mg give 2 tablets by mouth three times a day, start date 6/15/20 -Losartan 100 mg give 1 tablet by mouth one time a day, start date 6/16/20 -[MEDICATION NAME] 1000 mg give 1 tablet by mouth one time a day, start date 6/16/20 -[MEDICATION NAME]-[MEDICATION NAME] give 2 tablets by mouth three times a day, start date 6/15/20 Review of Resident #6's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] 25 mg, Losartan 100 mg, [MEDICATION NAME] 1000 mg and [MEDICATION NAME]-[MEDICATION NAME] 25 mg-100 mg at 9:00 a.m. on 7/11/20. d. Record review of Resident #7's Face Sheet, dated 7/16/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Admission MDS dated [DATE] revealed a BIMS of 12 which indicated moderately impaired cognition. Further review of the Admission MDS revealed the Resident required 1-person physical assist with bed mobility and transfers. Review of Resident #7's Physician order [REDACTED]. -Bacid tablet give 1 table by mouth one time a day, start date 6/6/2020 -Losartan Potassium 100 mg give 1 tablet by mouth one time a day, start date 6/6/2020 Review of Resident #7's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration [MEDICATION NAME] 40 mg, Losartan Potassium 100 mg on 7/11/2020 at 9:00 a.m. e. Record review of Resident #8's Face Sheet, dated 7/17/20, revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #8's most recent Quarterly MDS, dated [DATE], revealed a BIMS score of 4, which indicated the Resident was severely cognitively impaired for daily decision-making skills. Further review of the Quarterly MDS revealed the Resident required 1-person physical assist with bed mobility and 2-person physical assist with transfers. Review of Resident #8's Physician order [REDACTED]. -[MEDICATION NAME] Nebulization Solution 2.5 mg/3 ml inhale orally via nebulizer every 6 hours, start date 7/10/20. Review of Resident #8's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] Nebulization Solution 2.5 mg/3 ml at 6:00 a.m. on 7/11/20. f. Record review of Resident #9's Face Sheet, dated 7/18/2020 revealed an admission of 11/29/2012 and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Quarterly MDS dated [DATE] revealed a BIMS of 10 which indicated moderately impaired cognition. Further review of the Quarterly MDS revealed the Resident required 1-person physical assist with bed mobility and transfers. Review of Resident #9's Physician order [REDACTED]. -[MEDICATION NAME] 2 mg give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday and Sunday, start date 6/20/2020 -Clean Right heel and left lower extremity with normal saline, apply [MEDICATION NAME] ointment to right heel and left lower extremity, cover right heel, leave left lower extremity open to air one time a day, start date 5/24/2020 Review of Resident #9's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] 2 mg on 7/11/2020 at 8:00 a.m. and [MEDICATION NAME] ointment treatment to right heel on 7/13/2020 and 7/14/2020 at 9:00 a.m. Observation on 7/15/2020 at 3:50 p.m. of Resident #9 's right heel revealed a clean, dry, calloused, unopened area on the bottom of the Resident's right heel with no drainage or redness apparent around the area. Interview with Resident #9 on 7/15/2020 at 3:50 p.m. during observation of the right heel she revealed that a foot doctor attended to her heel and had treatment for [REDACTED]. g. Record review of Resident #10's Face Sheet, dated 7/16/2020 revealed an admission of 9/18/2019 and readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Significant Change MDS, dated [DATE], revealed a BIMS of 13 which indicated cognitively intact. Further review of the MDS revealed the Resident required a 2-person physical assist with bed mobility and transfers. Review of Resident #10's Physician order [REDACTED]. -[MEDICATION NAME] Bisulfate 75 mg give 1 tablet by mouth one time a day, start date 11/11/2019 -[MEDICATION NAME] Powder 3350 give 17gram by mouth one time a day, start date 11/12/2019 -Vitamin B12 500 mcg give 1 tablet by mouth one time a day, start date11/11/2019 -Vitamin D3 1000 unit give 1 tablet by mouth one time a day, start date 11/11/2019 -[MEDICATION NAME] Chloride 5 mg give 1 tablet by mouth two times a day, start date 4/2/2020 Review of Resident #10's July 2020 MAR (Medication Administration Record) revealed no signature of staff indicating administration of [MEDICATION NAME] Bisulfate 75 mg, [MEDICATION NAME] Powder 3350, Vitamin B12 500 mcg, Vitamin D3 1000 unit and [MEDICATION NAME] Chloride 5 mg on 7/11/2020 at 9:00 a.m. During an interview on 7/12/2020 at 10:50 a.m. LVN C stated she was not scheduled to work on the COVID unit on 7/11/2020 but was assigned to the unit by the Administrator from 10:00 a.m. until 10:00 p.m. on 7/11/2020 as LVN H, who was scheduled to work the unit from 6 a.m. - 6 p.m., had called in and would not be working. She confirmed that she had not administered any medications prior to 10:00 a.m. on 7/11/2020 to COVID Residents #3, #4, #5, #6, #7, #8, #9 and #10. During an interview on 7/14/2020 at 1:59 p.m. the Administrator confirmed there had not been a designated nurse on the COVID unit from 6:00 - 10:00 a.m. on 7/11/2020 and that medications scheduled from 6:00 a.m. - 10:00 a.m. were not administered to residents (#3, #4, #5, #6, #7, #8, #9, #10) on the COVID unit. During an interview on 7/15/2020 at 11:13 a.m. with LVN B she confirmed she worked in the facility on 7/11/2020 in the morning but did not work on the COVID unit and did not administer any scheduled medications from 6:00 a.m. - 10:00 a.m. to the COVID unit residents. During an interview on 7/16/2020 at 2:00 p.m. LVN A stated she didn't realize that Resident #9 had a 9:00 a.m. wound treatment order for the right heel. LVN A confirmed she had not done the wound treatment on 7/13/2020 and 7/14/2020 at 9:00 a.m. During an interview on 7/17/2020 at 3:30 p.m. the Interim DON confirmed there were no signatures of staff on Resident #3, 4, 5, 6, 7, 8, 9 and 10''s July MAR indicated [REDACTED] Review of the policy General Dose Preparation and Medication Administration, dated 2017 revealed in part .1. Facility staff should comply with the facility policy, applicable law and the State Operations Manual when administering medications. On 7/16/20 at 6:15 p.m. the Administrator, Assisting Administrator, Clinical Specialist and Assisting DON were notified of an Immediate Jeopardy (IJ) situation for the above failure, a completed IJ template was provided and a Plan of Removal was requested. On 7/17/20 at 6:38 p.m. the facility's Plan of Removal was approved. The facility's Plan of Removal included the following steps to be taken by the facility: 1. Assessments for current COVID-19 residents completed by a licensed nurse 7/16/20. 2. Abuse, Neglect, Exploitation in-service completed 7/16/20 and 7/17/20. 3. 10 Rights of Medication Administration in-service completed 7/16/20-7/17/20. 4. Change of shift expectations which included verbal report, medical record review and staffing concerns in-service completed 7/16/20-7/17/20. 5. Medication and Treatment records were audited by the Interim DON for compliance and the Medical Director notification 7/16/20. 6. Medical Director notified of Immediate Jeopardy 7/16/20 per interview with the Administrator and the Interim DON. 7. Interim DON daily monitoring of staffing coverage on COVID-19 unit 7/16/20. The surveyor verification of the Plan of Removal on 7/18/2020 was as follows: Interview with the Clinical Specialist and records reviewed of 10 COVID-19 positive residents revealed completion of assessments. Review of in-service records revealed Abuse, Neglect and Exploitation training provided and documented for staff. Review of in-service records revealed 10 Rights of Medication Administration training provided and documented for staff. Review of in-service records revealed change of shift expectations training was provided and documented for staff. Review of Medication Administration Audit Report revealed 8 COVID-19 positive resident's medication error/missed medications had been reported to the Medical Director. Interview with the Interim DON revealed daily monitoring for staffing coverage in the COVID-19 unit would be monitored daily. Observation on the COVID-19 unit revealed 1 licensed nurse and 1 CNA scheduled per shift 7/18/20. Record review revealed implementation of new staffing schedule. Medication and Treatment records reviewed for all COVID-19 positive residents revealed medications and treatments administered as scheduled 7/16/20 to 7/18/20. In-service sign-in sheets and material covered by the in-services were reviewed onsite 7/18/20 included Abuse, Neglect, Exploitation Policy, designated licensed nursing coverage in the COVID-19 positive unit, 10 rights of medication administration, change of shift expectations to include verbal report, medical record review, DON/Administration and follow up to address staffing concerns by the Interim DON, medication and treatments records audited for compliance and physician notification if medications are missed, DON/designee daily monitoring of nursing coverage in the COVID-19 positive unit, DON/designee monitoring of the electronic record medication and treatment record audits of COVID-19 positive residents three times a week. Staff interviews were conducted in a private office on 2 different shifts. Interviews occurred on 7/18/20 from 1:21 p.m. - 3:07 p.m. with 9 CNA's, 7 LVN's, 1 RN, 1 Social Worker, 1 Physical Therapist Assistant, the Interim DON and Administrator. All stated they had received in-services regarding Abuse, Neglect and Exploitation, in-service regarding the 10 rights of medication, change of shift expectations to include verbal report, medical record review and staffing concerns, reporting medication errors/missed medications, DON daily monitoring of staffing coverage including the COVID-19 positive unit and use of new scheduling system. On 7/18/20 at 6:41p.m. the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern until all staff were in-serviced.

Based on observations, interviews, and record reviews, the facility failed to develop and implement its written policies and prodecures that prohibited neglect for 5 of 6 residents (Resident #s 3, 4, 5, 6, and 2) reviewed for neglect related to falls in that: 1. Resident #3 sustained 4 falls within a month - 3 of which were in her bathroom and involved hitting her head. Her shoes were identified as a possible cause of her falls and were not removed. Resident #3's last fall resulted in a laceration above her eye requiring emergency room care and bruising. She was wearing the shoes at the time of this fall. Physical therapy was recommended for Resident #3 and was not started for 17 days. By the time physical therapy was started, Resident #3 had 2 more falls and other interventions were not implemented. 2. The facility failed to implement individualized interventions for and adequately supervise Resident #4 to prevent further falls. Resident #4 sustained 8 falls within 2 months. Physical therapy was recommended after the first fall but was not implemented for 19 days. By the time physical therapy was started, Resident #4 had 3 more falls and other interventions were not implemented. Two of Resident #4's falls occurred in the dining room during meal service while staff were passing trays. The cause of Resident #4's last fall in the dining room was not determined within 72 hours as required by facility policy. Consequently, appropriate intervention to prevent further falls (one-to-one supervision) was not implemented. 3. The facility failed to implement individualized interventions timely for Resident #5 to prevent further falls. Resident #5 sustained 5 falls within a month. The causes of Resident #5's last 2 falls were not determined within 72 hours as required by facility policy. She sustained a quarter-size bump to the back of her head at the time of her last fall. 4. Resident #6 sustained 8 falls within 2 months - the last 4 of which were out of her wheelchair in the dining room during meal service while staff were passing trays. The causes of Resident #6's last 2 falls were not determined within 72 hours as required by facility policy. Consequently, appropriate interventions to prevent further falls (autolock brakes and antitippers to her wheelchair and increased supervision) were not implemented. Resident #6 continued to fall. 5. Resident #2 sustained 2 falls within 2 months. Occupational therapy restorative nursing was recommended after the first fall but was still not in place at the time of the second fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 5/12/17. While the IJ was removed on 5/15/17, the facility remained out of compliance at a severity of potential harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 14 residents with recurrent falls at risk for future falls and could result in injury or death. The findings were: Record review of the facility's abuse prohibition policy (effective 10/15/15) revealed Genesis HealthCare Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: . Training of employees . Prevention of occurences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations . Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . The administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Review of the facility's fall management policy (last revised 3/15/16) revealed Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury . Practice Standards: 1. Identify patient's fall risk by reviewing the following. 1.1 Electronic Medical Record Systems - Nursing Assessment 1.2 Non-electronic Medical Records Systems - Fall Risk Evaluation. 2. Communicate patient's fall risk status to caregivers. 3. Develop individualized plan of care. 4. Review and revise care plan regularly. 5. If patient falls: 5.1 Follow guidelines for managing a fall if staff member is present when the fall occurs. 5.2 Utilize the fall response protocol for both witnessed and unwitnessed falls . 5.3 Document accident/incident: 5.3.1. As a new event in the Risk Management System (RMS); 5.3.2 On a Change of Condition Note; 5.3.3 On the 24-Hour Report; 5.3.4. Investigation using the Fall Investigation/QA and other appropriate tools in the RMS. 5.4 Update care plan to reflect new interventions. 5.5 Conduct interdisciplinary team meeting within 72 hours of fall. 5.6 The Center Executive Director and Center Nurse Executive will conduct a post fall review. 1. Record review of Resident #3's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's admission MDS assessment (ARD 3/27/17) revealed that she scored a 9 on the BIMS (indicating moderate cognitive impairment) and had 1 fall without injury since admission. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing and supervision and setup help only with eating. Record review of Resident #3's care plan (printed 4/28/17) revealed that her fall risk was addressed with interventions of on OT, request PT, continue pain monitoring and management and psych services and individual counseling (created 3/30/17); continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she allows, OT treated recently and currently on PT (created 4/21/17); place glasses within reach and encourage use (created 3/17/17); assist resident in getting in and out of bed, as needed (created 3/17/17); place call light within reach while in bed or close proximity to the bed (created 3/17/17); remind resident to use the call light when attempting to transfer (created 3/17/17); maintain a clutter-free environment in the resident's room and consistent furniture arrangement (created 3/17/17); when resident is in bed, place all necessary personal items within reach (created 3/17/17). Record review of Resident #3's nursing progress notes revealed that she had a fall risk score of 18 (indicating high fall risk) upon admission and required a gait belt with transfer assistance. She was admitted with an abrasion to her mid-forehead and 3 steri strips in place. On 3/27/17, Resident #3 was found on the floor at her bedside. On 3/30/17, the IDT met to discuss the 3/27/17 fall. Interventions were continue pain monitoring and management, on OT, requested PT, resident self transfers, continue psych services and individual counseling. Record review of Resident #3's incident/accident reports revealed that she slid to the floor out of her wheelchair on 3/27/17. Corrective actions were on OT, continue pain monitoring and management, continue psych care and ava counseling, request PT orders. The report was not completed by the DON until 3/31/17. Record review of Resident #3's electronic physician orders [REDACTED]. Continued record review of Resident #3's nursing progress notes revealed that, on 4/7/17, she was found on the floor of her bathroom. She was laying on her right side and stated that she thought she hit her head. Noted she had her slip-on black shoes on . urine present on the floor . states she was taking herself to the bathroom and slipped off the toilet, c/o mild pain to her right side of her head . she states her feet slip out of her shoes and she asked this nurse to let her family know that she wants new shoes, this nurse did so . On 4/11/17, Resident #3 was found seated on her bathroom floor. She stated that she was trying to transfer herself to the toilet and that she hit her head on the wall as she was falling down. On 4/21/17, the IDT met to discuss Resident #3's 4/5/17 and 4/11/17 falls. IDT falls 4/7 self toileting, c/o right arm pain with x ray arm and shoulder negative for acute process, does have [MEDICAL CONDITION], had slippers on at that time could have contributed to fall, fall 4/11 with again self transfer to the toilet, no c/o pain or injury noted. Resident had PT orders and now is on PT, OT treated 3/20-4/3/17 continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she will allow . Continued record review of Resident #3's incident/accident reports revealed that she was found laying on her right side with her pants down and urine present on the floor on 4/7/17. She had her black slip-on shoes and stated that they slipped off her feet often. She reported that she may have hit her head. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, x ray right arm/shoulder 4/7 negative for abnormality but has [MEDICAL CONDITION], continue pain monitoring and management, continue care of (Physician A), offer to toilet on rounds when awake as she allows. The report was not completed by the DON until 4/21/17. She fell while transferring herself to the toilet from her wheelchair and hit her head on the bathroom wall on 4/11/17. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, continue pain monitoring and management, continue care of (Physician A). The report was not completed by the DON until 4/21/17. Review of Resident #3's therapy records revealed that she received PT from 4/14/17 to 4/21/17 and OT from 3/20/17 to 4/3/17. Continued record review of Resident #3's nursing progress notes revealed that, on 4/27/17, a nurse found her laying on her left side next to the toilet. There was urine on the ground and her pants were around her ankles. She was bleeding from the left side of her forehead, and her broken glasses were on the floor under her head . noted she was wearing her 'slip-on' shoes, she states she was going to the bathroom and must have slipped off . Resident #3 was transported to the hospital and returned with a 2-centimeter laceration above her left eyebrow and a 6-centimeter hematoma around her left eye. Resident #3's daughter was notified and was supposed to be picking up the slippers that afternoon. On 5/1/17, the IDT met to discuss Resident #3's 4/27/17 fall. IDT - Fall 4/27 in restroom, self transfered (sp), Staff states she had just been toileted. Resident currently on RNA program for PT/OT, Requesting for ST evaluation orders from MD for cognition/memory, Offer to toilet q2hrs as patient allows. Continued record review of Resident #3's incident/accident reports revealed that she was toileting herself and fell off the toilet on 4/27/17. She stated she got hung up and her pants were noted around her ankles with urine on the floor. She did not use her call bell. There was blood present to her left side of head, and it was noted that she had on her slip-on shoes. The report was not completed as of 4/28/17. Observation of Resident #3 self-propelling her wheelchair down the hall at 11:23 a.m. on 4/28/17 revealed that she had a black eye (left side of face) and a laceration above it. When asked what happened, Resident #3 reported that she fell in her room. She had on black, slip-on shoes. Observation of Resident #3 in her room at 2:29 p.m. on 5/12/17 revealed that she was in the bathroom with her wheelchair. She was attempting to sit on the toilet and said she needed help. The surveyor informed her to use her call light, and she did so. Resident #3 was wearing her black, slip-on shoes. During an interview with Resident #3 after she was assisted with toileting on 5/12/17, she reported that the shoes she was wearing were giving her trouble and stated They say these are making me fall. Resident #3 reported that she hurt her eye because she fell and stated I need new shoes. These are no good. I need to call my family. These are the shoes I had on - they are the only ones I got. They slip off my feet. During an interview with MDS Nurse B at 1:46 p.m. on 4/28/17, when asked about the delay in Resident #3's PT (the evaluation was ordered on [DATE] and PT did not start until 4/14/17), she reported that getting a doctor's order and financials took time. During an interview with CNA D at 4:12 p.m. on 4/28/17, she reported that Resident #3 asked for assistance by using her call light or by coming out to the hallway and yelling at staff passing by. When asked if Resident #3 was on a toileting program, CNA D reported that Resident #3 went to the restroom often and stated She puts on her emergency light when she's in the restroom to let us know she's done. We check to see if she needs to go to the restroom every 30 minutes to an hour. CNA D reported no knowledge of Resident #3's shoes contributing to her falls. During an interview with the DON at 8:36 a.m. on 5/12/17, he reported that he did not know why Resident #3 still had her black slip-on shoes. During an interview with the ADON at 11:13 a.m. on 5/12/17, she reviewed Resident #3's record and reported that the facility got the physician's orders [REDACTED]. 2. Record review of Resident #4's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS assessment (ARD 3/30/17) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, and bathing and the limited assistance of 1 staff for walking in the room and in the corridor, locomotion off the unit, and eating. Record review of Resident #4's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain/anxiety monitoring and management, OT d/c 4/4 and PT treating (created 4/26/17); continue pain monitoring and management, new orders labs cbc cmp ua c&s-new order received abt 3/14/17 for UTI-has pt ot orders pending eval and treatment if indicated (created 3/14/17); pain monitoring and management, continue on secure unit for ongoing monitoring, communication to MD if he would like PT OT if he feels she could benefit pending response (created 3/6/17); pain and anxiety monitoring, requested pt ot and lab (created 3/7/17); completed OT 4/4 and PT is treating, has dementia and anxiety and self transfers and self ambulates (created 4/25/17); continue pain and anxiety monitoring and management, recent OT treated d/cd 4/4 and on PT (created 4/26/17); PT RNP program 4/26 (created 5/8/17); pt d/c 4/24 and RNP 4/26 (created 5/8/17); use wheelchair as needed and when resident will allow (created 3/16/17); remind resident to use call light when attempting to ambulate or transfer (created 5/12/17). Record review of Resident #4's nursing progress notes revealed that she fell on her buttocks after losing her balance on 3/2/17. On 3/6/17, the IDT met to discuss Resident #4's 3/2/17 fall. One of the facility's interventions was communication to MD to see if he thinks she would benefit from PT OT. Record review of Resident #4's incident/accident reports revealed that she fell on [DATE]. She was standing, lost her balance, fell on to her buttocks, and then rolled onto her back. Corrective actions included communication out to MD to see if he thinks she would benefit from PT OT. Continued record review of Resident #4's nursing progress notes revealed that, on 3/6/17, she fell while a CNA was walking with her to a chair in the dining room. She began walking with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. On 3/7/17, the IDT met to discuss Resident #4's 3/6/17 fall. A facility intervention was request out for PT OT and labs. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] while being assisted by a CNA with walking to a chair in the dining room. She began to walk with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. Corrective actions included requested PT OT and labs. Continued record review of Resident #4's nursing progress notes revealed that, on 3/8/17, she had a witnessed fall without injuries. Record review of Resident #4's electronic physician orders [REDACTED].>Continued record review of Resident #4's nursing progress notes revealed that, on 3/13/17, she fell on the floor in front of the sink after the CNA sat her down at the foot of the bed and turned to get something out of her closet. On 3/14/17, the IDT met to discuss Resident #4's 3/13/17 fall. A facility intervention was has PT OT orders pending evaluation and treatment if indicated. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] in front of the sink in her room. The CNA walked Resident #4 to her room, and Resident #4 was walking with a shuffling gait. The CNA sat Resident #4 down at the foot of the bed, turned to unlock the closet to get clothes out of it, and heard a bang. Corrective actions included has PT OT orders pending eval and treatment if indicated. Continued record review of Resident #4's nursing progress notes revealed that, on 3/26/17, Resident #4 had to be lowered to the ground after resident-to-resident contact. Continued record review of Resident #4's incident/accident reports revealed that she was pulled onto another resident's lap and had to be lowered to the floor on 3/26/17. Record review of Resident #4's electronic physician orders [REDACTED]. On 3/29/17, there were PT orders. Review of Resident #4's therapy records revealed that therapy screens were done on 11/28/16 and 2/14/17. Resident #4 received PT from 3/29/17 to 4/24/17 and OT from 3/22/17 to 4/4/17. Continued record review of Resident #4's nursing progress notes revealed that, on 4/25/17, Resident #4 kept getting up from her chair to walk around while the CNA was serving dinner trays. The CNA assisted her back to her chair. A couple of minutes later, staff looked over and Resident #4 was laying on her right side against the side table in the dining room area. On 4/26/17, the IDT met to discuss Resident #4's 4/25/17 fall. fall 4/25/17 while ambulating, no c/o pain or injury, continue pain and anxiety monitoring and management, continue on secure unit for ongoing monitoring, remains a fall risk secondary to unsteady gait, poor cognition, and poor safety awareness and continues to self ambulate and transfer. Continued record review of Resident #4's incident/accident reports revealed that she fell in the dining room while staff were serving dinner trays on 4/25/17. Corrective actions were Continue on secure unit, continue on PT as long as indicated, continue pain and anxiety monitoring and management, encourage activities. Continued record review of Resident #4's nursing progress notes revealed that, on 5/10/17, she was walked to a chair in the dining room by a CNA when the CNA noticed her unsteady gait. The CNA turned to pass trays and turned back to see Resident #4 stand, lose her balance, and fall onto her right side. On 5/12/17, the IDT met to discuss Resident #4's 5/10/17 fall. IDT note Fall 5/10/17 - resident stood up lost balance and fell , witnessed, neuros, no c/o pain or injury. PT RNA program initiated 4/28, OT treated in March, on secure unit for ongoing monitoring and management. Under care of (Physician A), psych, and [MEDICATION NAME] d/cd 5/10/17, requested labs 5/12, continue pain and anxiety monitoring and management. Pharmacy review by consultant and orthostatic [MEDICAL CONDITION] checks recommended and out to MD pending reply. Resident self transfers, self ambulates, poor attention span to participate in diversional activities. Continued record review of Resident #4's incident/accident reports revealed that she fell after losing her balance upon standing from a chair in the dining room while the CNA passed trays on 5/10/17. The report had not been completed as of 5/12/17. 3. Record review of Resident #5's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS assessment (ARD 4/21/17) revealed that she scored a 15 on the BIMS (indicating no cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the limited assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene; supervision of 1 staff for walking in the corridor; the extensive assistance of 1 staff for bathing; and supervision and setup help only with eating. Record review of Resident #5's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of under care psych, labs and cxr done, cardio apt 3/27, on PT PT (created 3/23/17); continue pain monitoring and management, labs done 3/15/17, has had change in mental status and is being evaluated by (rehab) hospital today, resident is on PT OT . (created 3/16/17); pt ot orders pending therapy eval and treatment if indicated (created 3/14/17); on pt ot st, multiple labs, cxr, psych and cardio visits, nurse pracitioner visits, med changes, continue pain monitoring and management (created 3/30/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, and monitoring for and assisting with toilet needs. Record review of Resident #5's nursing progress notes revealed that she had a fall risk score of 10 (indicating moderate fall risk) upon readmission (3/6/17). On 3/9/17, Resident #5 had a witnessed fall with no injury. There were no details documented about this fall. Record review of Resident #5's incident/accident reports revealed that she was being assisted to her wheelchair from her bed to go to the restroom on 3/9/17. She was unable to help transfer and was helped to the ground by a nurse aide. The fall was witnessed, and there were no injuries. Corrective actions were Continue pain monitoring and management, pt ot when eval and treated if indicated, ongoing reminders to ask for help, continue antibiotic until completed. The report was completed by the DON on 3/14/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/10/17, she was lowered to the floor by a CNA when she tried to transfer herself to her wheelchair. There were no injuries. On 3/14/17, the IDT met to discuss Resident #5's 3/9/17 fall. IDT fall 3/9/17 attempting to self transfer and assisted to floor by aide, did not hit head, no c/o pain or injury, has pt ot orders pending eval and treatment if indicated, reminders to ask for assist. On 3/15/17, a nurse was called to her room. She was sitting on the floor next to the restroom door with her wheelchair sitting next to her. She was attempting to self transfer and self toilet and fell . On 3/16/17, the IDT met to discuss Resident #5's 3/15/17 fall. fall 3/15/17 no injuries noted, has chronic pain, recent change in cognition with increased confusion noted, labs 3/15/17, bmp cbc, warm springs hospital to evaluate today for transfer if appropriate. Resident is on PT OT. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting next to the restroom door and sitting up against the wall with her wheelchair next to her on 3/15/17. She was attempting to self transfer to toilet and did not use the call light for help. Corrective actions were continue PT OT, continue pain monitoring and management, labs 3/15/17, (rehab) hospital to come and eval, IV antibiotics until complete date. The report was completed by the DON on 3/16/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/19/17, a nurse was called to Resident #5's room by housekeeping. She was found laying on the floor between her bed and her wheelchair. She stated that she was trying to get up into her wheelchair and it just rolled. The wheelchair was not locked. On 3/23/17, the IDT met to discuss Resident #5's 3/19/17 fall. IDT note fall 3/19/17-attempting to self transfer from bed to w/c. Resident did not have brakes locked . continue PT OT, continue pain monitoring and management, IV antibiotic completed and po antibiotic completes today. (Rehab) hospital had evaluated last week and they accepted but family declined. Labs on 3/15 and 3/20/17, chest x ray 3/16/17. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio apt on 3/27/17. (Physician A) ordered [MEDICATION NAME] on 3/22/17 and visited with resident, dx [MEDICAL CONDITION] with [MEDICAL CONDITION] secondary to pneumonia. Resident was readmitted from hospital with pneumonia on 3/6/17 with pneumonia and noted decline. Continued record review of Resident #5's incident/accident reports revealed that, on 3/19/17, she was attempting to self transfer from her bed to her wheelchair. Her wheelchair wasn't locked and it rolled away. Corrective actions were Continue pt ot, continue pain monitoring and management, IV antibiotic complete and po antibiotic completes today. Had warm springs hospital eval done and they accepted but family declined. had labs 3/15 and 3/20/17 cxr 3/16. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio appt. on 3/27/17 and (Physician A) ordered [MEDICATION NAME] on 3/22/17 and saw resident [DIAGNOSES REDACTED]. The report was completed by the DON on 3/23/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/23/17, she was found sitting on the floor near her bathroom. She reported that she was taking herself to the bathroom. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting on the floor near her bathroom door on 3/23/17. She reported that she was taking herself to the bathroom and slipped. Corrective actions were Continue pain monitoring and management, continue therapy PT OT as long as indicated, continue Psych care, labs as ordered, has ST for swallowing, MBSS to be done, cardio apt 3/27/17 and nurse practitioner visit 3/27/17. The report was not completed by the DON until 3/31/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/24/17, a nurse was called to her room and found her laying on the floor in front of her closet/bed. She reported that her head was hurting, and upon assessment, a quarter-size bump to the back of her head was noted. She had her shoes on. Continued record review of Resident #5's incident/accident reports revealed that, on 3/24/17, she was found laying halfway on the fall mat and halfway on the floor. She had her shoes on. She sustained a quarter-size bump to her head. Corrective actions were Continue pain monitoring and management, continue therapy as long as indicated, PT OT, continue psycho care, (Physician A) visited 3/22, labs as ordered, has had multiple labs, cxr, UA C&S, cardio visit 3/27/17, nurse practitioner visited 3/27/17, new orders for ST with MBSS pending. The report was not completed by the DON until 3/24/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/30/17, the IDT met to discuss her 3/23/17 and 3/24/17 falls. IDT note falls 3/23 and 3/24/17-resident has a noted decline since readmit 3/6/17 and weakness and mental status changes, hallucinations, continues to self transfer. (Physician A) visited 3/22/17 and [DIAGNOSES REDACTED]. Continue pain monitoring and management, medications as ordered. Record review of Resident #5's electronic physician orders [REDACTED]. OT and PT were ordered on [DATE]. Resident #5 was recertified for PT on 4/14/17. OT was discontinued on 4/29/17. On 4/29/17, Resident #5 was referred to RNP. Review of Resident #5's therapy records revealed that therapy screens were done on 3/24/16, 11/11/16, 2/20/17, and 3/28/17. Resident #5 received PT from 3/15/17 to 4/26/17 and OT from 3/14/17 to 4/29/17. Record review of Resident #5's 4/21/17 fall risk assessment revealed that she scored an 18 (indicating high fall risk). 4. Record review of Resident #6's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly MDS assessment (ARD 3/16/17) revealed that she scored a 5 on the BIMS (indicating moderate cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, dressing, bathing, and toileting; the extensive assistance of 2 staff for transfers; the limited assistance of 1 staff for locomotion on and off the unit and personal hygiene; and supervision and setup help only with eating. Record review of Resident #6's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain and anxiety monitoring and management, continue psych services (Physician A), family declined therapy and would like to try RNA program (created 3/23/17); low bed with fall mat (created 4/21/17 and revised 5/2/17); enablers x 2 for turning and repositioning (revised on 3/28/17); on RNA nursing program (created 5/8/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, assisting her to get in and out of bed as needed, glasses within reach, non-skid socks when up, and monitoring for and assisting with toilet needs. Record review of Resident #6's nursing progress notes revealed that she scored an 18 (indicating high fall risk) on her 3/16/17 fall risk assessment. On 3/23/17, she was found on the floor by her bed. She was trying to get on her bed. The IDT met that day and moving Resident #6 to the traditions unit was discussed per her family member's request. Record review of Resident #6's incident/accident reports revealed that she was found on the floor by her bed on 3/23/17. She was attempting to get on her bed. There were no injuries. Correctiv(TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 5 of 6 residents (Resident #s 3, 4, 5, 6, and 2) reviewed for falls in that: 1. Resident #3 sustained 4 falls within a month - 3 of which were in her bathroom and involved hitting her head. Her shoes were identified as a possible cause of her falls and were not removed. Resident #3's last fall resulted in a laceration above her eye requiring emergency room care and bruising. She was wearing the shoes at the time of this fall. Physical therapy was recommended for Resident #3 and was not started for 17 days. By the time physical therapy was started, Resident #3 had 2 more falls and other interventions were not implemented. 2. The facility failed to implement individualized interventions for and adequately supervise Resident #4 to prevent further falls. Resident #4 sustained 8 falls within 2 months. Physical therapy was recommended after the first fall but was not implemented for 19 days. By the time physical therapy was started, Resident #4 had 3 more falls and other interventions were not implemented. Two of Resident #4's falls occurred in the dining room during meal service while staff were passing trays. The cause of Resident #4's last fall in the dining room was not determined within 72 hours as required by facility policy. Consequently, appropriate intervention to prevent further falls (one-to-one supervision) was not implemented. 3. The facility failed to implement individualized interventions timely for Resident #5 to prevent further falls. Resident #5 sustained 5 falls within a month. The causes of Resident #5's last 2 falls were not determined within 72 hours as required by facility policy. She sustained a quarter-size bump to the back of her head at the time of her last fall. 4. Resident #6 sustained 8 falls within 2 months - the last 4 of which were out of her wheelchair in the dining room during meal service while staff were passing trays. The causes of Resident #6's last 2 falls were not determined within 72 hours as required by facility policy. Consequently, appropriate interventions to prevent further falls (autolock brakes and antitippers to her wheelchair and increased supervision) were not implemented. Resident #6 continued to fall. 5. Resident #2 sustained 2 falls within 2 months. Occupational therapy restorative nursing was recommended after the first fall but was still not in place at the time of the second fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 5/12/17. While the IJ was removed on 5/15/17, the facility remained out of compliance at a severity of potential harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 14 residents with recurrent falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #3's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's admission MDS assessment (ARD 3/27/17) revealed that she scored a 9 on the BIMS (indicating moderate cognitive impairment) and had 1 fall without injury since admission. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing and supervision and setup help only with eating. Record review of Resident #3's care plan (printed 4/28/17) revealed that her fall risk was addressed with interventions of on OT, request PT, continue pain monitoring and management and psych services and individual counseling (created 3/30/17); continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she allows, OT treated recently and currently on PT (created 4/21/17); place glasses within reach and encourage use (created 3/17/17); assist resident in getting in and out of bed, as needed (created 3/17/17); place call light within reach while in bed or close proximity to the bed (created 3/17/17); remind resident to use the call light when attempting to transfer (created 3/17/17); maintain a clutter-free environment in the resident's room and consistent furniture arrangement (created 3/17/17); when resident is in bed, place all necessary personal items within reach (created 3/17/17). Record review of Resident #3's nursing progress notes revealed that she had a fall risk score of 18 (indicating high fall risk) upon admission and required a gait belt with transfer assistance. She was admitted with an abrasion to her mid-forehead and 3 steri strips in place. On 3/27/17, Resident #3 was found on the floor at her bedside. On 3/30/17, the IDT met to discuss the 3/27/17 fall. Interventions were continue pain monitoring and management, on OT, requested PT, resident self transfers, continue psych services and individual counseling. Record review of Resident #3's incident/accident reports revealed that she slid to the floor out of her wheelchair on 3/27/17. Corrective actions were on OT, continue pain monitoring and management, continue psych care and ava counseling, request PT orders. The report was not completed by the DON until 3/31/17. Record review of Resident #3's electronic physician orders [REDACTED]. Continued record review of Resident #3's nursing progress notes revealed that, on 4/7/17, she was found on the floor of her bathroom. She was laying on her right side and stated that she thought she hit her head. Noted she had her slip-on black shoes on . urine present on the floor . states she was taking herself to the bathroom and slipped off the toilet, c/o mild pain to her right side of her head . she states her feet slip out of her shoes and she asked this nurse to let her family know that she wants new shoes, this nurse did so . On 4/11/17, Resident #3 was found seated on her bathroom floor. She stated that she was trying to transfer herself to the toilet and that she hit her head on the wall as she was falling down. On 4/21/17, the IDT met to discuss Resident #3's 4/5/17 and 4/11/17 falls. IDT falls 4/7 self toileting, c/o right arm pain with x ray arm and shoulder negative for acute process, does have osteoarthritis, had slippers on at that time could have contributed to fall, fall 4/11 with again self transfer to the toilet, no c/o pain or injury noted. Resident had PT orders and now is on PT, OT treated 3/20-4/3/17 continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she will allow . Continued record review of Resident #3's incident/accident reports revealed that she was found laying on her right side with her pants down and urine present on the floor on 4/7/17. She had her black slip-on shoes and stated that they slipped off her feet often. She reported that she may have hit her head. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, x ray right arm/shoulder 4/7 negative for abnormality but has osteoarthritis, continue pain monitoring and management, continue care of (Physician A), offer to toilet on rounds when awake as she allows. The report was not completed by the DON until 4/21/17. She fell while transferring herself to the toilet from her wheelchair and hit her head on the bathroom wall on 4/11/17. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, continue pain monitoring and management, continue care of (Physician A). The report was not completed by the DON until 4/21/17. Review of Resident #3's therapy records revealed that she received PT from 4/14/17 to 4/21/17 and OT from 3/20/17 to 4/3/17. Continued record review of Resident #3's nursing progress notes revealed that, on 4/27/17, a nurse found her laying on her left side next to the toilet. There was urine on the ground and her pants were around her ankles. She was bleeding from the left side of her forehead, and her broken glasses were on the floor under her head . noted she was wearing her 'slip-on' shoes, she states she was going to the bathroom and must have slipped off . Resident #3 was transported to the hospital and returned with a 2-centimeter laceration above her left eyebrow and a 6-centimeter hematoma around her left eye. Resident #3's daughter was notified and was supposed to be picking up the slippers that afternoon. On 5/1/17, the IDT met to discuss Resident #3's 4/27/17 fall. IDT - Fall 4/27 in restroom, self transfered (sp), Staff states she had just been toileted. Resident currently on RNA program for PT/OT, Requesting for ST evaluation orders from MD for cognition/memory, Offer to toilet q2hrs as patient allows. Continued record review of Resident #3's incident/accident reports revealed that she was toileting herself and fell off the toilet on 4/27/17. She stated she got hung up and her pants were noted around her ankles with urine on the floor. She did not use her call bell. There was blood present to her left side of head, and it was noted that she had on her slip-on shoes. The report was not completed as of 4/28/17. Observation of Resident #3 self-propelling her wheelchair down the hall at 11:23 a.m. on 4/28/17 revealed that she had a black eye (left side of face) and a laceration above it. When asked what happened, Resident #3 reported that she fell in her room. She had on black, slip-on shoes. Observation of Resident #3 in her room at 2:29 p.m. on 5/12/17 revealed that she was in the bathroom with her wheelchair. She was attempting to sit on the toilet and said she needed help. The surveyor informed her to use her call light, and she did so. Resident #3 was wearing her black, slip-on shoes. During an interview with Resident #3 after she was assisted with toileting on 5/12/17, she reported that the shoes she was wearing were giving her trouble and stated They say these are making me fall. Resident #3 reported that she hurt her eye because she fell and stated I need new shoes. These are no good. I need to call my family. These are the shoes I had on - they are the only ones I got. They slip off my feet. During an interview with MDS Nurse B at 1:46 p.m. on 4/28/17, when asked about the delay in Resident #3's PT (the evaluation was ordered on [DATE] and PT did not start until 4/14/17), she reported that getting a doctor's order and financials took time. During an interview with CNA D at 4:12 p.m. on 4/28/17, she reported that Resident #3 asked for assistance by using her call light or by coming out to the hallway and yelling at staff passing by. When asked if Resident #3 was on a toileting program, CNA D reported that Resident #3 went to the restroom often and stated She puts on her emergency light when she's in the restroom to let us know she's done. We check to see if she needs to go to the restroom every 30 minutes to an hour. CNA D reported no knowledge of Resident #3's shoes contributing to her falls. During an interview with the DON at 8:36 a.m. on 5/12/17, he reported that he did not know why Resident #3 still had her black slip-on shoes. During an interview with the ADON at 11:13 a.m. on 5/12/17, she reviewed Resident #3's record and reported that the facility got the physician's orders [REDACTED]. 2. Record review of Resident #4's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS assessment (ARD 3/30/17) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, and bathing and the limited assistance of 1 staff for walking in the room and in the corridor, locomotion off the unit, and eating. Record review of Resident #4's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain/anxiety monitoring and management, OT d/c 4/4 and PT treating (created 4/26/17); continue pain monitoring and management, new orders labs cbc cmp ua c&s-new order received abt 3/14/17 for UTI-has pt ot orders pending eval and treatment if indicated (created 3/14/17); pain monitoring and management, continue on secure unit for ongoing monitoring, communication to MD if he would like PT OT if he feels she could benefit pending response (created 3/6/17); pain and anxiety monitoring, requested pt ot and lab (created 3/7/17); completed OT 4/4 and PT is treating, has dementia and anxiety and self transfers and self ambulates (created 4/25/17); continue pain and anxiety monitoring and management, recent OT treated d/cd 4/4 and on PT (created 4/26/17); PT RNP program 4/26 (created 5/8/17); pt d/c 4/24 and RNP 4/26 (created 5/8/17); use wheelchair as needed and when resident will allow (created 3/16/17); remind resident to use call light when attempting to ambulate or transfer (created 5/12/17). Record review of Resident #4's nursing progress notes revealed that she fell on her buttocks after losing her balance on 3/2/17. On 3/6/17, the IDT met to discuss Resident #4's 3/2/17 fall. One of the facility's interventions was communication to MD to see if he thinks she would benefit from PT OT. Record review of Resident #4's incident/accident reports revealed that she fell on [DATE]. She was standing, lost her balance, fell on to her buttocks, and then rolled onto her back. Corrective actions included communication out to MD to see if he thinks she would benefit from PT OT. Continued record review of Resident #4's nursing progress notes revealed that, on 3/6/17, she fell while a CNA was walking with her to a chair in the dining room. She began walking with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. On 3/7/17, the IDT met to discuss Resident #4's 3/6/17 fall. A facility intervention was request out for PT OT and labs. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] while being assisted by a CNA with walking to a chair in the dining room. She began to walk with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. Corrective actions included requested PT OT and labs. Continued record review of Resident #4's nursing progress notes revealed that, on 3/8/17, she had a witnessed fall without injuries. Record review of Resident #4's electronic physician orders [REDACTED]. Continued record review of Resident #4's nursing progress notes revealed that, on 3/13/17, she fell on the floor in front of the sink after the CNA sat her down at the foot of the bed and turned to get something out of her closet. On 3/14/17, the IDT met to discuss Resident #4's 3/13/17 fall. A facility intervention was has PT OT orders pending evaluation and treatment if indicated. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] in front of the sink in her room. The CNA walked Resident #4 to her room, and Resident #4 was walking with a shuffling gait. The CNA sat Resident #4 down at the foot of the bed, turned to unlock the closet to get clothes out of it, and heard a bang. Corrective actions included has PT OT orders pending eval and treatment if indicated. Continued record review of Resident #4's nursing progress notes revealed that, on 3/26/17, Resident #4 had to be lowered to the ground after resident-to-resident contact. Continued record review of Resident #4's incident/accident reports revealed that she was pulled onto another resident's lap and had to be lowered to the floor on 3/26/17. Record review of Resident #4's electronic physician orders [REDACTED]. On 3/29/17, there were PT orders. Review of Resident #4's therapy records revealed that therapy screens were done on 11/28/16 and 2/14/17. Resident #4 received PT from 3/29/17 to 4/24/17 and OT from 3/22/17 to 4/4/17. Continued record review of Resident #4's nursing progress notes revealed that, on 4/25/17, Resident #4 kept getting up from her chair to walk around while the CNA was serving dinner trays. The CNA assisted her back to her chair. A couple of minutes later, staff looked over and Resident #4 was laying on her right side against the side table in the dining room area. On 4/26/17, the IDT met to discuss Resident #4's 4/25/17 fall. fall 4/25/17 while ambulating, no c/o pain or injury, continue pain and anxiety monitoring and management, continue on secure unit for ongoing monitoring, remains a fall risk secondary to unsteady gait, poor cognition, and poor safety awareness and continues to self ambulate and transfer. Continued record review of Resident #4's incident/accident reports revealed that she fell in the dining room while staff were serving dinner trays on 4/25/17. Corrective actions were Continue on secure unit, continue on PT as long as indicated, continue pain and anxiety monitoring and management, encourage activities. Continued record review of Resident #4's nursing progress notes revealed that, on 5/10/17, she was walked to a chair in the dining room by a CNA when the CNA noticed her unsteady gait. The CNA turned to pass trays and turned back to see Resident #4 stand, lose her balance, and fall onto her right side. On 5/12/17, the IDT met to discuss Resident #4's 5/10/17 fall. IDT note Fall 5/10/17 - resident stood up lost balance and fell , witnessed, neuros, no c/o pain or injury. PT RNA program initiated 4/28, OT treated in March, on secure unit for ongoing monitoring and management. Under care of (Physician A), psych, and zyprexa d/cd 5/10/17, requested labs 5/12, continue pain and anxiety monitoring and management. Pharmacy review by consultant and orthostatic hypotension checks recommended and out to MD pending reply. Resident self transfers, self ambulates, poor attention span to participate in diversional activities. Continued record review of Resident #4's incident/accident reports revealed that she fell after losing her balance upon standing from a chair in the dining room while the CNA passed trays on 5/10/17. The report had not been completed as of 5/12/17. 3. Record review of Resident #5's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS assessment (ARD 4/21/17) revealed that she scored a 15 on the BIMS (indicating no cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the limited assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene; supervision of 1 staff for walking in the corridor; the extensive assistance of 1 staff for bathing; and supervision and setup help only with eating. Record review of Resident #5's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of under care psych, labs and cxr done, cardio apt 3/27, on PT PT (created 3/23/17); continue pain monitoring and management, labs done 3/15/17, has had change in mental status and is being evaluated by (rehab) hospital today, resident is on PT OT . (created 3/16/17); pt ot orders pending therapy eval and treatment if indicated (created 3/14/17); on pt ot st, multiple labs, cxr, psych and cardio visits, nurse pracitioner visits, med changes, continue pain monitoring and management (created 3/30/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, and monitoring for and assisting with toilet needs. Record review of Resident #5's nursing progress notes revealed that she had a fall risk score of 10 (indicating moderate fall risk) upon readmission (3/6/17). On 3/9/17, Resident #5 had a witnessed fall with no injury. There were no details documented about this fall. Record review of Resident #5's incident/accident reports revealed that she was being assisted to her wheelchair from her bed to go to the restroom on 3/9/17. She was unable to help transfer and was helped to the ground by a nurse aide. The fall was witnessed, and there were no injuries. Corrective actions were Continue pain monitoring and management, pt ot when eval and treated if indicated, ongoing reminders to ask for help, continue antibiotic until completed. The report was completed by the DON on 3/14/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/10/17, she was lowered to the floor by a CNA when she tried to transfer herself to her wheelchair. There were no injuries. On 3/14/17, the IDT met to discuss Resident #5's 3/9/17 fall. IDT fall 3/9/17 attempting to self transfer and assisted to floor by aide, did not hit head, no c/o pain or injury, has pt ot orders pending eval and treatment if indicated, reminders to ask for assist. On 3/15/17, a nurse was called to her room. She was sitting on the floor next to the restroom door with her wheelchair sitting next to her. She was attempting to self transfer and self toilet and fell . On 3/16/17, the IDT met to discuss Resident #5's 3/15/17 fall. fall 3/15/17 no injuries noted, has chronic pain, recent change in cognition with increased confusion noted, labs 3/15/17, bmp cbc, warm springs hospital to evaluate today for transfer if appropriate. Resident is on PT OT. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting next to the restroom door and sitting up against the wall with her wheelchair next to her on 3/15/17. She was attempting to self transfer to toilet and did not use the call light for help. Corrective actions were continue PT OT, continue pain monitoring and management, labs 3/15/17, (rehab) hospital to come and eval, IV antibiotics until complete date. The report was completed by the DON on 3/16/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/19/17, a nurse was called to Resident #5's room by housekeeping. She was found laying on the floor between her bed and her wheelchair. She stated that she was trying to get up into her wheelchair and it just rolled. The wheelchair was not locked. On 3/23/17, the IDT met to discuss Resident #5's 3/19/17 fall. IDT note fall 3/19/17-attempting to self transfer from bed to w/c. Resident did not have brakes locked . continue PT OT, continue pain monitoring and management, IV antibiotic completed and po antibiotic completes today. (Rehab) hospital had evaluated last week and they accepted but family declined. Labs on 3/15 and 3/20/17, chest x ray 3/16/17. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio apt on 3/27/17. (Physician A) ordered melatonin on 3/22/17 and visited with resident, dx delirium with psychosis secondary to pneumonia. Resident was readmitted from hospital with pneumonia on 3/6/17 with pneumonia and noted decline. Continued record review of Resident #5's incident/accident reports revealed that, on 3/19/17, she was attempting to self transfer from her bed to her wheelchair. Her wheelchair wasn't locked and it rolled away. Corrective actions were Continue pt ot, continue pain monitoring and management, IV antibiotic complete and po antibiotic completes today. Had warm springs hospital eval done and they accepted but family declined. had labs 3/15 and 3/20/17 cxr 3/16. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio appt. on 3/27/17 and (Physician A) ordered melatonin on 3/22/17 and saw resident [DIAGNOSES REDACTED]. The report was completed by the DON on 3/23/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/23/17, she was found sitting on the floor near her bathroom. She reported that she was taking herself to the bathroom. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting on the floor near her bathroom door on 3/23/17. She reported that she was taking herself to the bathroom and slipped. Corrective actions were Continue pain monitoring and management, continue therapy PT OT as long as indicated, continue Psych care, labs as ordered, has ST for swallowing, MBSS to be done, cardio apt 3/27/17 and nurse practitioner visit 3/27/17. The report was not completed by the DON until 3/31/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/24/17, a nurse was called to her room and found her laying on the floor in front of her closet/bed. She reported that her head was hurting, and upon assessment, a quarter-size bump to the back of her head was noted. She had her shoes on. Continued record review of Resident #5's incident/accident reports revealed that, on 3/24/17, she was found laying halfway on the fall mat and halfway on the floor. She had her shoes on. She sustained a quarter-size bump to her head. Corrective actions were Continue pain monitoring and management, continue therapy as long as indicated, PT OT, continue psycho care, (Physician A) visited 3/22, labs as ordered, has had multiple labs, cxr, UA C&S, cardio visit 3/27/17, nurse practitioner visited 3/27/17, new orders for ST with MBSS pending. The report was not completed by the DON until 3/24/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/30/17, the IDT met to discuss her 3/23/17 and 3/24/17 falls. IDT note falls 3/23 and 3/24/17-resident has a noted decline since readmit 3/6/17 and weakness and mental status changes, hallucinations, continues to self transfer. (Physician A) visited 3/22/17 and [DIAGNOSES REDACTED]. Continue pain monitoring and management, medications as ordered. Record review of Resident #5's electronic physician orders [REDACTED]. OT and PT were ordered on [DATE]. Resident #5 was recertified for PT on 4/14/17. OT was discontinued on 4/29/17. On 4/29/17, Resident #5 was referred to RNP. Review of Resident #5's therapy records revealed that therapy screens were done on 3/24/16, 11/11/16, 2/20/17, and 3/28/17. Resident #5 received PT from 3/15/17 to 4/26/17 and OT from 3/14/17 to 4/29/17. Record review of Resident #5's 4/21/17 fall risk assessment revealed that she scored an 18 (indicating high fall risk). 4. Record review of Resident #6's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly MDS assessment (ARD 3/16/17) revealed that she scored a 5 on the BIMS (indicating moderate cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, dressing, bathing, and toileting; the extensive assistance of 2 staff for transfers; the limited assistance of 1 staff for locomotion on and off the unit and personal hygiene; and supervision and setup help only with eating. Record review of Resident #6's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain and anxiety monitoring and management, continue psych services (Physician A), family declined therapy and would like to try RNA program (created 3/23/17); low bed with fall mat (created 4/21/17 and revised 5/2/17); enablers x 2 for turning and repositioning (revised on 3/28/17); on RNA nursing program (created 5/8/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, assisting her to get in and out of bed as needed, glasses within reach, non-skid socks when up, and monitoring for and assisting with toilet needs. Record review of Resident #6's nursing progress notes revealed that she scored an 18 (indicating high fall risk) on her 3/16/17 fall risk assessment. On 3/23/17, she was found on the floor by her bed. She was trying to get on her bed. The IDT met that day and moving Resident #6 to the traditions unit was discussed per her family member's request. Record review of Resident #6's incident/accident reports revealed that she was found on the floor by her bed on 3/23/17. She was attempting to get on her bed. There were no injuries. Corrective actions were continue and (Physician A) (psych) services, continue pain and anxiety monitoring and management, continue low bed with mat, spoke with (family member) regarding therapy and declined but would like to try RNA program, RNA program written and to be initiated 3/24/17. The report was completed by the DON on 3/24/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/6/17, she was found laying on the floor in her restroom. She had non-skid socks on and reported she was trying to take some stuff to that man. Continued record review of Resident #6's incident/accident reports revealed that she was found laying on the floor in her restroom on 4/7/17 and said she was bringing some stuff to that man. She was wearing non-skid socks. Corrective actions were continue pain/anxiety monitoring and management, continue care with (Physician A), continue low bed with mat, request labs. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/14/17, she scooted from her low bed to the floor mat. Continued record review of Resident #6's incident/accident reports revealed that she was found on the floor mat next to her low bed on 4/14/17. There were no injuries. Corrective actions were continue pain and anxiety monitoring and management, continue low bed with mat, continue (Physician A) psych, continue non slip socks, request labs, Seroquel began 4/12. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/17/17, she was found laying on the floor in her room. She was wearing non-skid socks and could not report what happened. Continued record review of Resident #6's incident/accident reports revealed that she was found laying on the fall mat next to her low bed on 4/17/17. She couldn't explain what happened. She was

Based on observation, interview, and record review, the facility failed to ensure that the resident had the right to be free from neglect for 5 of 6 residents (Resident #s 3, 4, 5, 6, and 2) reviewed for neglect related to falls in that: 1. Resident #3 sustained 4 falls within a month - 3 of which were in her bathroom and involved hitting her head. Her shoes were identified as a possible cause of her falls and were not removed. Resident #3's last fall resulted in a laceration above her eye requiring emergency room care and bruising. She was wearing the shoes at the time of this fall. Physical therapy was recommended for Resident #3 and was not started for 17 days. By the time physical therapy was started, Resident #3 had 2 more falls and other interventions were not implemented. 2. The facility failed to implement individualized interventions for and adequately supervise Resident #4 to prevent further falls. Resident #4 sustained 8 falls within 2 months. Physical therapy was recommended after the first fall but was not implemented for 19 days. By the time physical therapy was started, Resident #4 had 3 more falls and other interventions were not implemented. Two of Resident #4's falls occurred in the dining room during meal service while staff were passing trays. The cause of Resident #4's last fall in the dining room was not determined within 72 hours as required by facility policy. Consequently, appropriate intervention to prevent further falls (one-to-one supervision) was not implemented. 3. The facility failed to implement individualized interventions timely for Resident #5 to prevent further falls. Resident #5 sustained 5 falls within a month. The causes of Resident #5's last 2 falls were not determined within 72 hours as required by facility policy. She sustained a quarter-size bump to the back of her head at the time of her last fall. 4. Resident #6 sustained 8 falls within 2 months - the last 4 of which were out of her wheelchair in the dining room during meal service while staff were passing trays. The causes of Resident #6's last 2 falls were not determined within 72 hours as required by facility policy. Consequently, appropriate interventions to prevent further falls (autolock brakes and antitippers to her wheelchair and increased supervision) were not implemented. Resident #6 continued to fall. 5. Resident #2 sustained 2 falls within 2 months. Occupational therapy restorative nursing was recommended after the first fall but was still not in place at the time of the second fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 5/12/17. While the IJ was removed on 5/15/17, the facility remained out of compliance at a severity of potential harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 14 residents with recurrent falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #3's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's admission MDS assessment (ARD 3/27/17) revealed that she scored a 9 on the BIMS (indicating moderate cognitive impairment) and had 1 fall without injury since admission. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing and supervision and setup help only with eating. Record review of Resident #3's care plan (printed 4/28/17) revealed that her fall risk was addressed with interventions of on OT, request PT, continue pain monitoring and management and psych services and individual counseling (created 3/30/17); continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she allows, OT treated recently and currently on PT (created 4/21/17); place glasses within reach and encourage use (created 3/17/17); assist resident in getting in and out of bed, as needed (created 3/17/17); place call light within reach while in bed or close proximity to the bed (created 3/17/17); remind resident to use the call light when attempting to transfer (created 3/17/17); maintain a clutter-free environment in the resident's room and consistent furniture arrangement (created 3/17/17); when resident is in bed, place all necessary personal items within reach (created 3/17/17). Record review of Resident #3's nursing progress notes revealed that she had a fall risk score of 18 (indicating high fall risk) upon admission and required a gait belt with transfer assistance. She was admitted with an abrasion to her mid-forehead and 3 steri strips in place. On 3/27/17, Resident #3 was found on the floor at her bedside. On 3/30/17, the IDT met to discuss the 3/27/17 fall. Interventions were continue pain monitoring and management, on OT, requested PT, resident self transfers, continue psych services and individual counseling. Record review of Resident #3's incident/accident reports revealed that she slid to the floor out of her wheelchair on 3/27/17. Corrective actions were on OT, continue pain monitoring and management, continue psych care and ava counseling, request PT orders. The report was not completed by the DON until 3/31/17. Record review of Resident #3's electronic physician orders [REDACTED]. Continued record review of Resident #3's nursing progress notes revealed that, on 4/7/17, she was found on the floor of her bathroom. She was laying on her right side and stated that she thought she hit her head. Noted she had her slip-on black shoes on . urine present on the floor . states she was taking herself to the bathroom and slipped off the toilet, c/o mild pain to her right side of her head . she states her feet slip out of her shoes and she asked this nurse to let her family know that she wants new shoes, this nurse did so . On 4/11/17, Resident #3 was found seated on her bathroom floor. She stated that she was trying to transfer herself to the toilet and that she hit her head on the wall as she was falling down. On 4/21/17, the IDT met to discuss Resident #3's 4/5/17 and 4/11/17 falls. IDT falls 4/7 self toileting, c/o right arm pain with x ray arm and shoulder negative for acute process, does have [MEDICAL CONDITION], had slippers on at that time could have contributed to fall, fall 4/11 with again self transfer to the toilet, no c/o pain or injury noted. Resident had PT orders and now is on PT, OT treated 3/20-4/3/17 continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she will allow . Continued record review of Resident #3's incident/accident reports revealed that she was found laying on her right side with her pants down and urine present on the floor on 4/7/17. She had her black slip-on shoes and stated that they slipped off her feet often. She reported that she may have hit her head. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, x ray right arm/shoulder 4/7 negative for abnormality but has [MEDICAL CONDITION], continue pain monitoring and management, continue care of (Physician A), offer to toilet on rounds when awake as she allows. The report was not completed by the DON until 4/21/17. She fell while transferring herself to the toilet from her wheelchair and hit her head on the bathroom wall on 4/11/17. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, continue pain monitoring and management, continue care of (Physician A). The report was not completed by the DON until 4/21/17. Review of Resident #3's therapy records revealed that she received PT from 4/14/17 to 4/21/17 and OT from 3/20/17 to 4/3/17. Continued record review of Resident #3's nursing progress notes revealed that, on 4/27/17, a nurse found her laying on her left side next to the toilet. There was urine on the ground and her pants were around her ankles. She was bleeding from the left side of her forehead, and her broken glasses were on the floor under her head . noted she was wearing her 'slip-on' shoes, she states she was going to the bathroom and must have slipped off . Resident #3 was transported to the hospital and returned with a 2-centimeter laceration above her left eyebrow and a 6-centimeter hematoma around her left eye. Resident #3's daughter was notified and was supposed to be picking up the slippers that afternoon. On 5/1/17, the IDT met to discuss Resident #3's 4/27/17 fall. IDT - Fall 4/27 in restroom, self transfered (sp), Staff states she had just been toileted. Resident currently on RNA program for PT/OT, Requesting for ST evaluation orders from MD for cognition/memory, Offer to toilet q2hrs as patient allows. Continued record review of Resident #3's incident/accident reports revealed that she was toileting herself and fell off the toilet on 4/27/17. She stated she got hung up and her pants were noted around her ankles with urine on the floor. She did not use her call bell. There was blood present to her left side of head, and it was noted that she had on her slip-on shoes. The report was not completed as of 4/28/17. Observation of Resident #3 self-propelling her wheelchair down the hall at 11:23 a.m. on 4/28/17 revealed that she had a black eye (left side of face) and a laceration above it. When asked what happened, Resident #3 reported that she fell in her room. She had on black, slip-on shoes. Observation of Resident #3 in her room at 2:29 p.m. on 5/12/17 revealed that she was in the bathroom with her wheelchair. She was attempting to sit on the toilet and said she needed help. The surveyor informed her to use her call light, and she did so. Resident #3 was wearing her black, slip-on shoes. During an interview with Resident #3 after she was assisted with toileting on 5/12/17, she reported that the shoes she was wearing were giving her trouble and stated They say these are making me fall. Resident #3 reported that she hurt her eye because she fell and stated I need new shoes. These are no good. I need to call my family. These are the shoes I had on - they are the only ones I got. They slip off my feet. During an interview with MDS Nurse B at 1:46 p.m. on 4/28/17, when asked about the delay in Resident #3's PT (the evaluation was ordered on [DATE] and PT did not start until 4/14/17), she reported that getting a doctor's order and financials took time. During an interview with CNA D at 4:12 p.m. on 4/28/17, she reported that Resident #3 asked for assistance by using her call light or by coming out to the hallway and yelling at staff passing by. When asked if Resident #3 was on a toileting program, CNA D reported that Resident #3 went to the restroom often and stated She puts on her emergency light when she's in the restroom to let us know she's done. We check to see if she needs to go to the restroom every 30 minutes to an hour. CNA D reported no knowledge of Resident #3's shoes contributing to her falls. During an interview with the DON at 8:36 a.m. on 5/12/17, he reported that he did not know why Resident #3 still had her black slip-on shoes. During an interview with the ADON at 11:13 a.m. on 5/12/17, she reviewed Resident #3's record and reported that the facility got the physician's orders [REDACTED]. 2. Record review of Resident #4's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS assessment (ARD 3/30/17) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, and bathing and the limited assistance of 1 staff for walking in the room and in the corridor, locomotion off the unit, and eating. Record review of Resident #4's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain/anxiety monitoring and management, OT d/c 4/4 and PT treating (created 4/26/17); continue pain monitoring and management, new orders labs cbc cmp ua c&s-new order received abt 3/14/17 for UTI-has pt ot orders pending eval and treatment if indicated (created 3/14/17); pain monitoring and management, continue on secure unit for ongoing monitoring, communication to MD if he would like PT OT if he feels she could benefit pending response (created 3/6/17); pain and anxiety monitoring, requested pt ot and lab (created 3/7/17); completed OT 4/4 and PT is treating, has dementia and anxiety and self transfers and self ambulates (created 4/25/17); continue pain and anxiety monitoring and management, recent OT treated d/cd 4/4 and on PT (created 4/26/17); PT RNP program 4/26 (created 5/8/17); pt d/c 4/24 and RNP 4/26 (created 5/8/17); use wheelchair as needed and when resident will allow (created 3/16/17); remind resident to use call light when attempting to ambulate or transfer (created 5/12/17). Record review of Resident #4's nursing progress notes revealed that she fell on her buttocks after losing her balance on 3/2/17. On 3/6/17, the IDT met to discuss Resident #4's 3/2/17 fall. One of the facility's interventions was communication to MD to see if he thinks she would benefit from PT OT. Record review of Resident #4's incident/accident reports revealed that she fell on [DATE]. She was standing, lost her balance, fell on to her buttocks, and then rolled onto her back. Corrective actions included communication out to MD to see if he thinks she would benefit from PT OT. Continued record review of Resident #4's nursing progress notes revealed that, on 3/6/17, she fell while a CNA was walking with her to a chair in the dining room. She began walking with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. On 3/7/17, the IDT met to discuss Resident #4's 3/6/17 fall. A facility intervention was request out for PT OT and labs. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] while being assisted by a CNA with walking to a chair in the dining room. She began to walk with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. Corrective actions included requested PT OT and labs. Continued record review of Resident #4's nursing progress notes revealed that, on 3/8/17, she had a witnessed fall without injuries. Record review of Resident #4's electronic physician orders [REDACTED].>Continued record review of Resident #4's nursing progress notes revealed that, on 3/13/17, she fell on the floor in front of the sink after the CNA sat her down at the foot of the bed and turned to get something out of her closet. On 3/14/17, the IDT met to discuss Resident #4's 3/13/17 fall. A facility intervention was has PT OT orders pending evaluation and treatment if indicated. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] in front of the sink in her room. The CNA walked Resident #4 to her room, and Resident #4 was walking with a shuffling gait. The CNA sat Resident #4 down at the foot of the bed, turned to unlock the closet to get clothes out of it, and heard a bang. Corrective actions included has PT OT orders pending eval and treatment if indicated. Continued record review of Resident #4's nursing progress notes revealed that, on 3/26/17, Resident #4 had to be lowered to the ground after resident-to-resident contact. Continued record review of Resident #4's incident/accident reports revealed that she was pulled onto another resident's lap and had to be lowered to the floor on 3/26/17. Record review of Resident #4's electronic physician orders [REDACTED]. On 3/29/17, there were PT orders. Review of Resident #4's therapy records revealed that therapy screens were done on 11/28/16 and 2/14/17. Resident #4 received PT from 3/29/17 to 4/24/17 and OT from 3/22/17 to 4/4/17. Continued record review of Resident #4's nursing progress notes revealed that, on 4/25/17, Resident #4 kept getting up from her chair to walk around while the CNA was serving dinner trays. The CNA assisted her back to her chair. A couple of minutes later, staff looked over and Resident #4 was laying on her right side against the side table in the dining room area. On 4/26/17, the IDT met to discuss Resident #4's 4/25/17 fall. fall 4/25/17 while ambulating, no c/o pain or injury, continue pain and anxiety monitoring and management, continue on secure unit for ongoing monitoring, remains a fall risk secondary to unsteady gait, poor cognition, and poor safety awareness and continues to self ambulate and transfer. Continued record review of Resident #4's incident/accident reports revealed that she fell in the dining room while staff were serving dinner trays on 4/25/17. Corrective actions were Continue on secure unit, continue on PT as long as indicated, continue pain and anxiety monitoring and management, encourage activities. Continued record review of Resident #4's nursing progress notes revealed that, on 5/10/17, she was walked to a chair in the dining room by a CNA when the CNA noticed her unsteady gait. The CNA turned to pass trays and turned back to see Resident #4 stand, lose her balance, and fall onto her right side. On 5/12/17, the IDT met to discuss Resident #4's 5/10/17 fall. IDT note Fall 5/10/17 - resident stood up lost balance and fell , witnessed, neuros, no c/o pain or injury. PT RNA program initiated 4/28, OT treated in March, on secure unit for ongoing monitoring and management. Under care of (Physician A), psych, and [MEDICATION NAME] d/cd 5/10/17, requested labs 5/12, continue pain and anxiety monitoring and management. Pharmacy review by consultant and orthostatic [MEDICAL CONDITION] checks recommended and out to MD pending reply. Resident self transfers, self ambulates, poor attention span to participate in diversional activities. Continued record review of Resident #4's incident/accident reports revealed that she fell after losing her balance upon standing from a chair in the dining room while the CNA passed trays on 5/10/17. The report had not been completed as of 5/12/17. 3. Record review of Resident #5's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS assessment (ARD 4/21/17) revealed that she scored a 15 on the BIMS (indicating no cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the limited assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene; supervision of 1 staff for walking in the corridor; the extensive assistance of 1 staff for bathing; and supervision and setup help only with eating. Record review of Resident #5's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of under care psych, labs and cxr done, cardio apt 3/27, on PT PT (created 3/23/17); continue pain monitoring and management, labs done 3/15/17, has had change in mental status and is being evaluated by (rehab) hospital today, resident is on PT OT . (created 3/16/17); pt ot orders pending therapy eval and treatment if indicated (created 3/14/17); on pt ot st, multiple labs, cxr, psych and cardio visits, nurse pracitioner visits, med changes, continue pain monitoring and management (created 3/30/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, and monitoring for and assisting with toilet needs. Record review of Resident #5's nursing progress notes revealed that she had a fall risk score of 10 (indicating moderate fall risk) upon readmission (3/6/17). On 3/9/17, Resident #5 had a witnessed fall with no injury. There were no details documented about this fall. Record review of Resident #5's incident/accident reports revealed that she was being assisted to her wheelchair from her bed to go to the restroom on 3/9/17. She was unable to help transfer and was helped to the ground by a nurse aide. The fall was witnessed, and there were no injuries. Corrective actions were Continue pain monitoring and management, pt ot when eval and treated if indicated, ongoing reminders to ask for help, continue antibiotic until completed. The report was completed by the DON on 3/14/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/10/17, she was lowered to the floor by a CNA when she tried to transfer herself to her wheelchair. There were no injuries. On 3/14/17, the IDT met to discuss Resident #5's 3/9/17 fall. IDT fall 3/9/17 attempting to self transfer and assisted to floor by aide, did not hit head, no c/o pain or injury, has pt ot orders pending eval and treatment if indicated, reminders to ask for assist. On 3/15/17, a nurse was called to her room. She was sitting on the floor next to the restroom door with her wheelchair sitting next to her. She was attempting to self transfer and self toilet and fell . On 3/16/17, the IDT met to discuss Resident #5's 3/15/17 fall. fall 3/15/17 no injuries noted, has chronic pain, recent change in cognition with increased confusion noted, labs 3/15/17, bmp cbc, warm springs hospital to evaluate today for transfer if appropriate. Resident is on PT OT. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting next to the restroom door and sitting up against the wall with her wheelchair next to her on 3/15/17. She was attempting to self transfer to toilet and did not use the call light for help. Corrective actions were continue PT OT, continue pain monitoring and management, labs 3/15/17, (rehab) hospital to come and eval, IV antibiotics until complete date. The report was completed by the DON on 3/16/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/19/17, a nurse was called to Resident #5's room by housekeeping. She was found laying on the floor between her bed and her wheelchair. She stated that she was trying to get up into her wheelchair and it just rolled. The wheelchair was not locked. On 3/23/17, the IDT met to discuss Resident #5's 3/19/17 fall. IDT note fall 3/19/17-attempting to self transfer from bed to w/c. Resident did not have brakes locked . continue PT OT, continue pain monitoring and management, IV antibiotic completed and po antibiotic completes today. (Rehab) hospital had evaluated last week and they accepted but family declined. Labs on 3/15 and 3/20/17, chest x ray 3/16/17. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio apt on 3/27/17. (Physician A) ordered [MEDICATION NAME] on 3/22/17 and visited with resident, dx [MEDICAL CONDITION] with [MEDICAL CONDITION] secondary to pneumonia. Resident was readmitted from hospital with pneumonia on 3/6/17 with pneumonia and noted decline. Continued record review of Resident #5's incident/accident reports revealed that, on 3/19/17, she was attempting to self transfer from her bed to her wheelchair. Her wheelchair wasn't locked and it rolled away. Corrective actions were Continue pt ot, continue pain monitoring and management, IV antibiotic complete and po antibiotic completes today. Had warm springs hospital eval done and they accepted but family declined. had labs 3/15 and 3/20/17 cxr 3/16. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio appt. on 3/27/17 and (Physician A) ordered [MEDICATION NAME] on 3/22/17 and saw resident [DIAGNOSES REDACTED]. The report was completed by the DON on 3/23/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/23/17, she was found sitting on the floor near her bathroom. She reported that she was taking herself to the bathroom. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting on the floor near her bathroom door on 3/23/17. She reported that she was taking herself to the bathroom and slipped. Corrective actions were Continue pain monitoring and management, continue therapy PT OT as long as indicated, continue Psych care, labs as ordered, has ST for swallowing, MBSS to be done, cardio apt 3/27/17 and nurse practitioner visit 3/27/17. The report was not completed by the DON until 3/31/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/24/17, a nurse was called to her room and found her laying on the floor in front of her closet/bed. She reported that her head was hurting, and upon assessment, a quarter-size bump to the back of her head was noted. She had her shoes on. Continued record review of Resident #5's incident/accident reports revealed that, on 3/24/17, she was found laying halfway on the fall mat and halfway on the floor. She had her shoes on. She sustained a quarter-size bump to her head. Corrective actions were Continue pain monitoring and management, continue therapy as long as indicated, PT OT, continue psycho care, (Physician A) visited 3/22, labs as ordered, has had multiple labs, cxr, UA C&S, cardio visit 3/27/17, nurse practitioner visited 3/27/17, new orders for ST with MBSS pending. The report was not completed by the DON until 3/24/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/30/17, the IDT met to discuss her 3/23/17 and 3/24/17 falls. IDT note falls 3/23 and 3/24/17-resident has a noted decline since readmit 3/6/17 and weakness and mental status changes, hallucinations, continues to self transfer. (Physician A) visited 3/22/17 and [DIAGNOSES REDACTED]. Continue pain monitoring and management, medications as ordered. Record review of Resident #5's electronic physician orders [REDACTED]. OT and PT were ordered on [DATE]. Resident #5 was recertified for PT on 4/14/17. OT was discontinued on 4/29/17. On 4/29/17, Resident #5 was referred to RNP. Review of Resident #5's therapy records revealed that therapy screens were done on 3/24/16, 11/11/16, 2/20/17, and 3/28/17. Resident #5 received PT from 3/15/17 to 4/26/17 and OT from 3/14/17 to 4/29/17. Record review of Resident #5's 4/21/17 fall risk assessment revealed that she scored an 18 (indicating high fall risk). 4. Record review of Resident #6's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly MDS assessment (ARD 3/16/17) revealed that she scored a 5 on the BIMS (indicating moderate cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, dressing, bathing, and toileting; the extensive assistance of 2 staff for transfers; the limited assistance of 1 staff for locomotion on and off the unit and personal hygiene; and supervision and setup help only with eating. Record review of Resident #6's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain and anxiety monitoring and management, continue psych services (Physician A), family declined therapy and would like to try RNA program (created 3/23/17); low bed with fall mat (created 4/21/17 and revised 5/2/17); enablers x 2 for turning and repositioning (revised on 3/28/17); on RNA nursing program (created 5/8/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, assisting her to get in and out of bed as needed, glasses within reach, non-skid socks when up, and monitoring for and assisting with toilet needs. Record review of Resident #6's nursing progress notes revealed that she scored an 18 (indicating high fall risk) on her 3/16/17 fall risk assessment. On 3/23/17, she was found on the floor by her bed. She was trying to get on her bed. The IDT met that day and moving Resident #6 to the traditions unit was discussed per her family member's request. Record review of Resident #6's incident/accident reports revealed that she was found on the floor by her bed on 3/23/17. She was attempting to get on her bed. There were no injuries. Corrective actions were continue and (Physician A) (psych) services, continue pain and anxiety monitoring and management, continue low bed with mat, spoke with (family member) regarding therapy and declined but would like to try RNA program, RNA program written and to be initiated 3/24/17. The report was completed by the DON on 3/24/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/6/17, she was found laying on the floor in her restroom. She had non-skid socks on and reported she was trying to take some stuff to that man. Continued record review of Resident #6's incident/accident reports revealed that she was found laying on the floor in her restroom on 4/7/17 and said she was bringing some stuff to that man. She was wearing non-skid socks. Corrective actions were continue pain/anxiety monitoring and management, continue care with (Physician A), continue low bed with mat, request labs. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/14/17, she scooted from her low bed to the floor mat. Continued record review of Resident #6's incident/accident reports revealed that she was found on the floor mat next to her low bed on 4/14/17. There were no injuries. Corrective actions were continue pain and anxiety monitoring and management, continue low bed with mat, continue (Physician A) psych, continue non slip socks, request labs, [MEDICATION NAME] began 4/12. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/17/17, she was found laying on the floor in her room. She was wearing non-skid socks and could not report what happened. Continued record review of Resident #6's incident/accident reports revealed that she was found laying on the fall mat next to her low bed on 4/17/17. She couldn't explain what happened. She was wearing non-skid socks. Corrective actions were continue pain and anxiety monitoring and mana(TRUNCATED)

Based on observations, interviews, and record reviews, the facility DON failed to provide oversight in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of 5 of 14 residents (Resident #s 3, 4, 5, 6, and 2) identified with recurrent falls in that: The DON failed to follow facility policies and procedures for fall management. He failed to investigate the cause of falls within 72 hours and, therefore, did not implement interventions to prevent further falls. 1. Resident #3 sustained 4 falls within a month - 3 of which were in her bathroom and involved hitting her head. Her shoes were identified as a possible cause of her falls and were not removed. Resident #3's last fall resulted in a laceration above her eye requiring emergency room care and bruising. She was wearing the shoes at the time of this fall. Physical therapy was recommended for Resident #3 and was not started for 17 days. By the time physical therapy was started, Resident #3 had 2 more falls and other interventions were not implemented. 2. The facility failed to implement individualized interventions for and adequately supervise Resident #4 to prevent further falls. Resident #4 sustained 8 falls within 2 months. Physical therapy was recommended after the first fall but was not implemented for 19 days. By the time physical therapy was started, Resident #4 had 3 more falls and other interventions were not implemented. Two of Resident #4's falls occurred in the dining room during meal service while staff were passing trays. The cause of Resident #4's last fall in the dining room was not determined within 72 hours as required by facility policy. Consequently, appropriate intervention to prevent further falls (one-to-one supervision) was not implemented. 3. The facility failed to implement individualized interventions timely for Resident #5 to prevent further falls. Resident #5 sustained 5 falls within a month. The causes of Resident #5's last 2 falls were not determined within 72 hours as required by facility policy. She sustained a quarter-size bump to the back of her head at the time of her last fall. 4. Resident #6 sustained 8 falls within 2 months - the last 4 of which were out of her wheelchair in the dining room during meal service while staff were passing trays. The causes of Resident #6's last 2 falls were not determined within 72 hours as required by facility policy. Consequently, appropriate interventions to prevent further falls (autolock brakes and antitippers to her wheelchair and increased supervision) were not implemented. Resident #6 continued to fall. 5. Resident #2 sustained 2 falls within 2 months. Occupational therapy restorative nursing was recommended after the first fall but was still not in place at the time of the second fall. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 5/12/17. While the IJ was removed on 5/15/17, the facility remained out of compliance at a severity of potential harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. This deficient practice placed 14 residents with recurrent falls at risk for future falls and could result in injury or death. The findings were: 1. Record review of Resident #3's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's admission MDS assessment (ARD 3/27/17) revealed that she scored a 9 on the BIMS (indicating moderate cognitive impairment) and had 1 fall without injury since admission. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing and supervision and setup help only with eating. Record review of Resident #3's care plan (printed 4/28/17) revealed that her fall risk was addressed with interventions of on OT, request PT, continue pain monitoring and management and psych services and individual counseling (created 3/30/17); continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she allows, OT treated recently and currently on PT (created 4/21/17); place glasses within reach and encourage use (created 3/17/17); assist resident in getting in and out of bed, as needed (created 3/17/17); place call light within reach while in bed or close proximity to the bed (created 3/17/17); remind resident to use the call light when attempting to transfer (created 3/17/17); maintain a clutter-free environment in the resident's room and consistent furniture arrangement (created 3/17/17); when resident is in bed, place all necessary personal items within reach (created 3/17/17). Record review of Resident #3's nursing progress notes revealed that she had a fall risk score of 18 (indicating high fall risk) upon admission and required a gait belt with transfer assistance. She was admitted with an abrasion to her mid-forehead and 3 steri strips in place. On 3/27/17, Resident #3 was found on the floor at her bedside. On 3/30/17, the IDT met to discuss the 3/27/17 fall. Interventions were continue pain monitoring and management, on OT, requested PT, resident self transfers, continue psych services and individual counseling. Record review of Resident #3's incident/accident reports revealed that she slid to the floor out of her wheelchair on 3/27/17. Corrective actions were on OT, continue pain monitoring and management, continue psych care and ava counseling, request PT orders. The report was not completed by the DON until 3/31/17. Record review of Resident #3's electronic physician orders [REDACTED]. Continued record review of Resident #3's nursing progress notes revealed that, on 4/7/17, she was found on the floor of her bathroom. She was laying on her right side and stated that she thought she hit her head. Noted she had her slip-on black shoes on . urine present on the floor . states she was taking herself to the bathroom and slipped off the toilet, c/o mild pain to her right side of her head . she states her feet slip out of her shoes and she asked this nurse to let her family know that she wants new shoes, this nurse did so . On 4/11/17, Resident #3 was found seated on her bathroom floor. She stated that she was trying to transfer herself to the toilet and that she hit her head on the wall as she was falling down. On 4/21/17, the IDT met to discuss Resident #3's 4/5/17 and 4/11/17 falls. IDT falls 4/7 self toileting, c/o right arm pain with x ray arm and shoulder negative for acute process, does have [MEDICAL CONDITION], had slippers on at that time could have contributed to fall, fall 4/11 with again self transfer to the toilet, no c/o pain or injury noted. Resident had PT orders and now is on PT, OT treated 3/20-4/3/17 continue pain monitoring and management, continue psych care with (Physician A), offer to toilet q 2 hours while awake as she will allow . Continued record review of Resident #3's incident/accident reports revealed that she was found laying on her right side with her pants down and urine present on the floor on 4/7/17. She had her black slip-on shoes and stated that they slipped off her feet often. She reported that she may have hit her head. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, x ray right arm/shoulder 4/7 negative for abnormality but has [MEDICAL CONDITION], continue pain monitoring and management, continue care of (Physician A), offer to toilet on rounds when awake as she allows. The report was not completed by the DON until 4/21/17. She fell while transferring herself to the toilet from her wheelchair and hit her head on the bathroom wall on 4/11/17. Corrective actions were Resident had PT orders and since fall has been picked up, resident was on OT 3/20-4/3/17, continue pain monitoring and management, continue care of (Physician A). The report was not completed by the DON until 4/21/17. Review of Resident #3's therapy records revealed that she received PT from 4/14/17 to 4/21/17 and OT from 3/20/17 to 4/3/17. Continued record review of Resident #3's nursing progress notes revealed that, on 4/27/17, a nurse found her laying on her left side next to the toilet. There was urine on the ground and her pants were around her ankles. She was bleeding from the left side of her forehead, and her broken glasses were on the floor under her head . noted she was wearing her 'slip-on' shoes, she states she was going to the bathroom and must have slipped off . Resident #3 was transported to the hospital and returned with a 2-centimeter laceration above her left eyebrow and a 6-centimeter hematoma around her left eye. Resident #3's daughter was notified and was supposed to be picking up the slippers that afternoon. On 5/1/17, the IDT met to discuss Resident #3's 4/27/17 fall. IDT - Fall 4/27 in restroom, self transfered (sp), Staff states she had just been toileted. Resident currently on RNA program for PT/OT, Requesting for ST evaluation orders from MD for cognition/memory, Offer to toilet q2hrs as patient allows. Continued record review of Resident #3's incident/accident reports revealed that she was toileting herself and fell off the toilet on 4/27/17. She stated she got hung up and her pants were noted around her ankles with urine on the floor. She did not use her call bell. There was blood present to her left side of head, and it was noted that she had on her slip-on shoes. The report was not completed as of 4/28/17. Observation of Resident #3 self-propelling her wheelchair down the hall at 11:23 a.m. on 4/28/17 revealed that she had a black eye (left side of face) and a laceration above it. When asked what happened, Resident #3 reported that she fell in her room. She had on black, slip-on shoes. Observation of Resident #3 in her room at 2:29 p.m. on 5/12/17 revealed that she was in the bathroom with her wheelchair. She was attempting to sit on the toilet and said she needed help. The surveyor informed her to use her call light, and she did so. Resident #3 was wearing her black, slip-on shoes. During an interview with Resident #3 after she was assisted with toileting on 5/12/17, she reported that the shoes she was wearing were giving her trouble and stated They say these are making me fall. Resident #3 reported that she hurt her eye because she fell and stated I need new shoes. These are no good. I need to call my family. These are the shoes I had on - they are the only ones I got. They slip off my feet. During an interview with MDS Nurse B at 1:46 p.m. on 4/28/17, when asked about the delay in Resident #3's PT (the evaluation was ordered on [DATE] and PT did not start until 4/14/17), she reported that getting a doctor's order and financials took time. During an interview with CNA D at 4:12 p.m. on 4/28/17, she reported that Resident #3 asked for assistance by using her call light or by coming out to the hallway and yelling at staff passing by. When asked if Resident #3 was on a toileting program, CNA D reported that Resident #3 went to the restroom often and stated She puts on her emergency light when she's in the restroom to let us know she's done. We check to see if she needs to go to the restroom every 30 minutes to an hour. CNA D reported no knowledge of Resident #3's shoes contributing to her falls. During an interview with the DON at 8:36 a.m. on 5/12/17, he reported that he did not know why Resident #3 still had her black slip-on shoes. During an interview with the ADON at 11:13 a.m. on 5/12/17, she reviewed Resident #3's record and reported that the facility got the physician's orders [REDACTED]. 2. Record review of Resident #4's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS assessment (ARD 3/30/17) revealed that she scored a 3 on the BIMS (indicating severe cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, personal hygiene, and bathing and the limited assistance of 1 staff for walking in the room and in the corridor, locomotion off the unit, and eating. Record review of Resident #4's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain/anxiety monitoring and management, OT d/c 4/4 and PT treating (created 4/26/17); continue pain monitoring and management, new orders labs cbc cmp ua c&s-new order received abt 3/14/17 for UTI-has pt ot orders pending eval and treatment if indicated (created 3/14/17); pain monitoring and management, continue on secure unit for ongoing monitoring, communication to MD if he would like PT OT if he feels she could benefit pending response (created 3/6/17); pain and anxiety monitoring, requested pt ot and lab (created 3/7/17); completed OT 4/4 and PT is treating, has dementia and anxiety and self transfers and self ambulates (created 4/25/17); continue pain and anxiety monitoring and management, recent OT treated d/cd 4/4 and on PT (created 4/26/17); PT RNP program 4/26 (created 5/8/17); pt d/c 4/24 and RNP 4/26 (created 5/8/17); use wheelchair as needed and when resident will allow (created 3/16/17); remind resident to use call light when attempting to ambulate or transfer (created 5/12/17). Record review of Resident #4's nursing progress notes revealed that she fell on her buttocks after losing her balance on 3/2/17. On 3/6/17, the IDT met to discuss Resident #4's 3/2/17 fall. One of the facility's interventions was communication to MD to see if he thinks she would benefit from PT OT. Record review of Resident #4's incident/accident reports revealed that she fell on [DATE]. She was standing, lost her balance, fell on to her buttocks, and then rolled onto her back. Corrective actions included communication out to MD to see if he thinks she would benefit from PT OT. Continued record review of Resident #4's nursing progress notes revealed that, on 3/6/17, she fell while a CNA was walking with her to a chair in the dining room. She began walking with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. On 3/7/17, the IDT met to discuss Resident #4's 3/6/17 fall. A facility intervention was request out for PT OT and labs. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] while being assisted by a CNA with walking to a chair in the dining room. She began to walk with a shuffling gait, her shoe stuck to the floor, and she fell on to her knees. Corrective actions included requested PT OT and labs. Continued record review of Resident #4's nursing progress notes revealed that, on 3/8/17, she had a witnessed fall without injuries. Record review of Resident #4's electronic physician orders [REDACTED].>Continued record review of Resident #4's nursing progress notes revealed that, on 3/13/17, she fell on the floor in front of the sink after the CNA sat her down at the foot of the bed and turned to get something out of her closet. On 3/14/17, the IDT met to discuss Resident #4's 3/13/17 fall. A facility intervention was has PT OT orders pending evaluation and treatment if indicated. Continued record review of Resident #4's incident/accident reports revealed that she fell on [DATE] in front of the sink in her room. The CNA walked Resident #4 to her room, and Resident #4 was walking with a shuffling gait. The CNA sat Resident #4 down at the foot of the bed, turned to unlock the closet to get clothes out of it, and heard a bang. Corrective actions included has PT OT orders pending eval and treatment if indicated. Continued record review of Resident #4's nursing progress notes revealed that, on 3/26/17, Resident #4 had to be lowered to the ground after resident-to-resident contact. Continued record review of Resident #4's incident/accident reports revealed that she was pulled onto another resident's lap and had to be lowered to the floor on 3/26/17. Record review of Resident #4's electronic physician orders [REDACTED]. On 3/29/17, there were PT orders. Review of Resident #4's therapy records revealed that therapy screens were done on 11/28/16 and 2/14/17. Resident #4 received PT from 3/29/17 to 4/24/17 and OT from 3/22/17 to 4/4/17. Continued record review of Resident #4's nursing progress notes revealed that, on 4/25/17, Resident #4 kept getting up from her chair to walk around while the CNA was serving dinner trays. The CNA assisted her back to her chair. A couple of minutes later, staff looked over and Resident #4 was laying on her right side against the side table in the dining room area. On 4/26/17, the IDT met to discuss Resident #4's 4/25/17 fall. fall 4/25/17 while ambulating, no c/o pain or injury, continue pain and anxiety monitoring and management, continue on secure unit for ongoing monitoring, remains a fall risk secondary to unsteady gait, poor cognition, and poor safety awareness and continues to self ambulate and transfer. Continued record review of Resident #4's incident/accident reports revealed that she fell in the dining room while staff were serving dinner trays on 4/25/17. Corrective actions were Continue on secure unit, continue on PT as long as indicated, continue pain and anxiety monitoring and management, encourage activities. Continued record review of Resident #4's nursing progress notes revealed that, on 5/10/17, she was walked to a chair in the dining room by a CNA when the CNA noticed her unsteady gait. The CNA turned to pass trays and turned back to see Resident #4 stand, lose her balance, and fall onto her right side. On 5/12/17, the IDT met to discuss Resident #4's 5/10/17 fall. IDT note Fall 5/10/17 - resident stood up lost balance and fell , witnessed, neuros, no c/o pain or injury. PT RNA program initiated 4/28, OT treated in March, on secure unit for ongoing monitoring and management. Under care of (Physician A), psych, and [MEDICATION NAME] d/cd 5/10/17, requested labs 5/12, continue pain and anxiety monitoring and management. Pharmacy review by consultant and orthostatic [MEDICAL CONDITION] checks recommended and out to MD pending reply. Resident self transfers, self ambulates, poor attention span to participate in diversional activities. Continued record review of Resident #4's incident/accident reports revealed that she fell after losing her balance upon standing from a chair in the dining room while the CNA passed trays on 5/10/17. The report had not been completed as of 5/12/17. 3. Record review of Resident #5's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS assessment (ARD 4/21/17) revealed that she scored a 15 on the BIMS (indicating no cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the limited assistance of 1 staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene; supervision of 1 staff for walking in the corridor; the extensive assistance of 1 staff for bathing; and supervision and setup help only with eating. Record review of Resident #5's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of under care psych, labs and cxr done, cardio apt 3/27, on PT PT (created 3/23/17); continue pain monitoring and management, labs done 3/15/17, has had change in mental status and is being evaluated by (rehab) hospital today, resident is on PT OT . (created 3/16/17); pt ot orders pending therapy eval and treatment if indicated (created 3/14/17); on pt ot st, multiple labs, cxr, psych and cardio visits, nurse pracitioner visits, med changes, continue pain monitoring and management (created 3/30/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, and monitoring for and assisting with toilet needs. Record review of Resident #5's nursing progress notes revealed that she had a fall risk score of 10 (indicating moderate fall risk) upon readmission (3/6/17). On 3/9/17, Resident #5 had a witnessed fall with no injury. There were no details documented about this fall. Record review of Resident #5's incident/accident reports revealed that she was being assisted to her wheelchair from her bed to go to the restroom on 3/9/17. She was unable to help transfer and was helped to the ground by a nurse aide. The fall was witnessed, and there were no injuries. Corrective actions were Continue pain monitoring and management, pt ot when eval and treated if indicated, ongoing reminders to ask for help, continue antibiotic until completed. The report was completed by the DON on 3/14/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/10/17, she was lowered to the floor by a CNA when she tried to transfer herself to her wheelchair. There were no injuries. On 3/14/17, the IDT met to discuss Resident #5's 3/9/17 fall. IDT fall 3/9/17 attempting to self transfer and assisted to floor by aide, did not hit head, no c/o pain or injury, has pt ot orders pending eval and treatment if indicated, reminders to ask for assist. On 3/15/17, a nurse was called to her room. She was sitting on the floor next to the restroom door with her wheelchair sitting next to her. She was attempting to self transfer and self toilet and fell . On 3/16/17, the IDT met to discuss Resident #5's 3/15/17 fall. fall 3/15/17 no injuries noted, has chronic pain, recent change in cognition with increased confusion noted, labs 3/15/17, bmp cbc, warm springs hospital to evaluate today for transfer if appropriate. Resident is on PT OT. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting next to the restroom door and sitting up against the wall with her wheelchair next to her on 3/15/17. She was attempting to self transfer to toilet and did not use the call light for help. Corrective actions were continue PT OT, continue pain monitoring and management, labs 3/15/17, (rehab) hospital to come and eval, IV antibiotics until complete date. The report was completed by the DON on 3/16/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/19/17, a nurse was called to Resident #5's room by housekeeping. She was found laying on the floor between her bed and her wheelchair. She stated that she was trying to get up into her wheelchair and it just rolled. The wheelchair was not locked. On 3/23/17, the IDT met to discuss Resident #5's 3/19/17 fall. IDT note fall 3/19/17-attempting to self transfer from bed to w/c. Resident did not have brakes locked . continue PT OT, continue pain monitoring and management, IV antibiotic completed and po antibiotic completes today. (Rehab) hospital had evaluated last week and they accepted but family declined. Labs on 3/15 and 3/20/17, chest x ray 3/16/17. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio apt on 3/27/17. (Physician A) ordered [MEDICATION NAME] on 3/22/17 and visited with resident, dx [MEDICAL CONDITION] with [MEDICAL CONDITION] secondary to pneumonia. Resident was readmitted from hospital with pneumonia on 3/6/17 with pneumonia and noted decline. Continued record review of Resident #5's incident/accident reports revealed that, on 3/19/17, she was attempting to self transfer from her bed to her wheelchair. Her wheelchair wasn't locked and it rolled away. Corrective actions were Continue pt ot, continue pain monitoring and management, IV antibiotic complete and po antibiotic completes today. Had warm springs hospital eval done and they accepted but family declined. had labs 3/15 and 3/20/17 cxr 3/16. Mental status continues to fluctuate with vivid hallucinations and she remains a fall risk. Has a cardio appt. on 3/27/17 and (Physician A) ordered [MEDICATION NAME] on 3/22/17 and saw resident [DIAGNOSES REDACTED]. The report was completed by the DON on 3/23/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/23/17, she was found sitting on the floor near her bathroom. She reported that she was taking herself to the bathroom. Continued record review of Resident #5's incident/accident reports revealed that she was found sitting on the floor near her bathroom door on 3/23/17. She reported that she was taking herself to the bathroom and slipped. Corrective actions were Continue pain monitoring and management, continue therapy PT OT as long as indicated, continue Psych care, labs as ordered, has ST for swallowing, MBSS to be done, cardio apt 3/27/17 and nurse practitioner visit 3/27/17. The report was not completed by the DON until 3/31/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/24/17, a nurse was called to her room and found her laying on the floor in front of her closet/bed. She reported that her head was hurting, and upon assessment, a quarter-size bump to the back of her head was noted. She had her shoes on. Continued record review of Resident #5's incident/accident reports revealed that, on 3/24/17, she was found laying halfway on the fall mat and halfway on the floor. She had her shoes on. She sustained a quarter-size bump to her head. Corrective actions were Continue pain monitoring and management, continue therapy as long as indicated, PT OT, continue psycho care, (Physician A) visited 3/22, labs as ordered, has had multiple labs, cxr, UA C&S, cardio visit 3/27/17, nurse practitioner visited 3/27/17, new orders for ST with MBSS pending. The report was not completed by the DON until 3/24/17. Continued record review of Resident #5's nursing progress notes revealed that, on 3/30/17, the IDT met to discuss her 3/23/17 and 3/24/17 falls. IDT note falls 3/23 and 3/24/17-resident has a noted decline since readmit 3/6/17 and weakness and mental status changes, hallucinations, continues to self transfer. (Physician A) visited 3/22/17 and [DIAGNOSES REDACTED]. Continue pain monitoring and management, medications as ordered. Record review of Resident #5's electronic physician orders [REDACTED]. OT and PT were ordered on [DATE]. Resident #5 was recertified for PT on 4/14/17. OT was discontinued on 4/29/17. On 4/29/17, Resident #5 was referred to RNP. Review of Resident #5's therapy records revealed that therapy screens were done on 3/24/16, 11/11/16, 2/20/17, and 3/28/17. Resident #5 received PT from 3/15/17 to 4/26/17 and OT from 3/14/17 to 4/29/17. Record review of Resident #5's 4/21/17 fall risk assessment revealed that she scored an 18 (indicating high fall risk). 4. Record review of Resident #6's face sheet (dated 5/12/17) revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly MDS assessment (ARD 3/16/17) revealed that she scored a 5 on the BIMS (indicating moderate cognitive impairment) and had 2 falls without injury since the prior assessment. She was assessed to need the extensive assistance of 1 staff for bed mobility, dressing, bathing, and toileting; the extensive assistance of 2 staff for transfers; the limited assistance of 1 staff for locomotion on and off the unit and personal hygiene; and supervision and setup help only with eating. Record review of Resident #6's care plan (printed 5/12/17) revealed that her fall risk was addressed with interventions of continue pain and anxiety monitoring and management, continue psych services (Physician A), family declined therapy and would like to try RNA program (created 3/23/17); low bed with fall mat (created 4/21/17 and revised 5/2/17); enablers x 2 for turning and repositioning (revised on 3/28/17); on RNA nursing program (created 5/8/17). Interventions in place prior to recent falls were call light within reach, reminders to use it, assisting her to get in and out of bed as needed, glasses within reach, non-skid socks when up, and monitoring for and assisting with toilet needs. Record review of Resident #6's nursing progress notes revealed that she scored an 18 (indicating high fall risk) on her 3/16/17 fall risk assessment. On 3/23/17, she was found on the floor by her bed. She was trying to get on her bed. The IDT met that day and moving Resident #6 to the traditions unit was discussed per her family member's request. Record review of Resident #6's incident/accident reports revealed that she was found on the floor by her bed on 3/23/17. She was attempting to get on her bed. There were no injuries. Corrective actions were continue and (Physician A) (psych) services, continue pain and anxiety monitoring and management, continue low bed with mat, spoke with (family member) regarding therapy and declined but would like to try RNA program, RNA program written and to be initiated 3/24/17. The report was completed by the DON on 3/24/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/6/17, she was found laying on the floor in her restroom. She had non-skid socks on and reported she was trying to take some stuff to that man. Continued record review of Resident #6's incident/accident reports revealed that she was found laying on the floor in her restroom on 4/7/17 and said she was bringing some stuff to that man. She was wearing non-skid socks. Corrective actions were continue pain/anxiety monitoring and management, continue care with (Physician A), continue low bed with mat, request labs. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/14/17, she scooted from her low bed to the floor mat. Continued record review of Resident #6's incident/accident reports revealed that she was found on the floor mat next to her low bed on 4/14/17. There were no injuries. Corrective actions were continue pain and anxiety monitoring and management, continue low bed with mat, continue (Physician A) psych, continue non slip socks, request labs, [MEDICATION NAME] began 4/12. The report was not completed by the DON until 4/21/17. Continued record review of Resident #6's nursing progress notes revealed that, on 4/17/17, she was found laying on the floor in her room. She was wearing non-skid socks and co(TRUNCATED)