Every finding on record at Heritage House at Paris Rehab & Nursing

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 (Resident #3) residents reviewed for quality of care. The facility failed to ensure that the Wound Care Treatment Nurse K notified the physician when Resident #3 was noted to have an open wound to the right side of his scrotum on 02/02/2026. This failure could place residents at risk of complications which include worsening existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 02/04/2026 indicated Resident #3 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included venous insufficiency peripheral (lack of oxygen to the extremities) hypertension (high blood pressure), neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the normal communication between the nervous system and the bladder resulting in urinary incontinence or retention), pressure ulcer of the right heel, non-pressure chronic ulcer of the back, diabetes mellitus due to underlying condition without complications (condition results from insufficient production of insulin, causing high blood sugar due to other conditions), benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 03, indicating his cognition was severely impaired. The MDS assessment indicated Resident #3 had a urinary catheter and was always incontinent of bowel. The MDS assessment indicated Resident #3 was dependent with lower body dressing, taking off footwear and sitting to lying/lying to sitting, and personal hygiene. The MDS indicated Resident #3 was at risk for developing pressure ulcers/injuries and had unhealed pressure ulcers/skin injuries. Record review of Resident #3's comprehensive care plan dated 11/5/2025 and revised on 11/05/2025, indicated Resident #3 was incontinent of bowel/bladder with interventions for weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns. The care plan indicated to report any new skin conditions to the physician. Record review of Resident #3's order summary report dated 02/04/2026, with active orders as of 08/01/2025, indicated Resident #3 had an order to perform head to toe skin assessment, document any changes in skin integrity in the medical record on Friday for wound prevention/early identification with a start date of 08/01/25. The order indicated to notify the physician with any changes in skin integrity. During an interview on 02/03/2026 at 07:30 AM, Resident #3 said he was experiencing some pain in his down there area the last couple of days. Resident #3 said he was not sure what was going on down there but the nurse and aides had looked at him yesterday and assisted him with the situation and offered him pain medication. Resident #3 said the wound care treatment nurse had not been to see him yet today that he could remember. Record review of Resident #3's progress note dated 02/02/2026 at 05:32 PM did indicate a new open area to right posterior lower leg with hospice physician notified and new order received noted by Wound Care Treatment Nurse K. Record review of Resident #3's progress note dated 02/03/2026 at 06:47 AM indicated awaiting a call back from hospice for any new orders. Will refer this area to wound care specialist during rounds on Thursday signed by Wound Care Treatment Nurse K During an interview on 02/03/2026 at 09:10 AM, the Wound Care Treatment Nurse K stated Resident #3 had an area on his penis that looked slightly ulcerated (open painful sore) during wound care on 02/02/2026. The Wound Care Treatment Nurse K stated she called the hospice nurse on 02/02/2026 and did not document it. The Wound Care Treatment Nurse K stated she did not notify the physician because she had notified hospice. During an interview and observation on 02/03/2026 at 09:15 AM, Resident #3 had an open area approximately the size of a nickel on the right side of the scrotum. There was no bandage noted upon removal of Resident #3's disposable brief. The Wound care Treatment Nurse K said the area on Resident #3's scrotum was not as opened yesterday. Attempted telephone call on 02/03/2026 at 09:30 AM to the hospice nurse, left message and requested a call back. Attempted telephone call on 02/03/2026 at 10:00 AM to the hospice nurse, left message and requested a call back. Attempted telephone call on 02/03/2026 at 10:10 AM to the Resident #3's responsible party/family member, left message and requested a call back. During an interview on 02/03/2026 at 10:30 AM, CNA G stated she had assisted the Wound Care Treatment Nurse K on 02/02/2026 for Resident #3. CNA G stated the nickel sized opened area on the right side of Resident #3's scrotum was present at that time. Record Review of hospice progress notes dated 02/04/2026 indicated on Monday, 02/02/2026 SN was notified by Wound Care Treatment Nurse K of redness noted to penis at foley catheter insertion. The hospice progress note did not indicate notification of the new open area to Resident #3's right side of the scrotum. During an interview on 02/04/2026 at 01:06 PM, the physician stated that he had seen Resident #3 on 02/03/2026 after the facility notified him that morning regarding the new development of wound area on the right side of Resident #3's scrotum and diagnosed him with cellulitis (a rare but severe bacterial infection causing rapid swelling, intense pain, warmth and redness) of the penis. The physician stated the area is pus filled abscess that had surfaced and opened. The physician stated that Resident #3 often refused care by the staff, and these types of situations can occur from poor hygiene. The physician stated he did not feel the facility was responsible or had any fault with the development of the abscess. The physician stated he did not feel the resident could endure the treatment needed at bedside to incise the abscess for drainage and had suggested to the family to do the procedure inpatient at the hospital. The physician stated the family had notified him on 02/04/2026 to move forward to transfer the resident for the procedure to the hospital. The physician stated that he was not notified on 02/02/2026 by the facility or hospice of any new wound developments involving Resident #3's penis/scrotum area. The physician stated he expected the facility to notify him so care could be coordinated between entities and advocate for the resident's health and well being as quickly as possible to be proactive in the care. During an interview on 02/04/2026 at 01:40 PM, the DON stated the facility notified the hospice. The DON stated the facility always notifies the hospice if the resident is on hospice because sometimes family members would rather have the hospice physician make the new orders of care and prevent overlapping care. The DON stated she had seen the hospice nurse in the facility that evening on 2/2/2026. The DON said she assumed the Wound Care Treatment Nurse K had notified the hospice nurse that day and was waiting to receive orders. The DON stated she expected all nursing staff to document and report any changes in condition as they are found to prevent any further decline in resident's health and well-being. During an interview on 02/04/2026 at 02:50 PM, the Administrator said he expected the clinical staff to document and report timely to the physician, and family when appropriate - any changes of condition to prevent decline in health status. Record review of the facility's policy titled Notification of Changes with a revised date of 01/10/2020, indicated. To provide guidance on when to communicate acute changes in status to physician/nurse practioner, and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 3. A significant change in the physical, mental or psychosocial status of the resident. assessment of the skin area is documented in the clinical software.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 (Resident #3) residents reviewed for quality of care. The facility failed to ensure that CNA L notified the charge nurse of Resident #3's open wound on the right side of the scrotum on 02/01/2026. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection. Findings included: Record review of a face sheet dated 02/04/2026 indicated Resident #3 was an [AGE] year old male admitted to the facility on [DATE] with diagnoses which included venous insufficiency peripheral (lack of oxygen to the extremities) hypertension (high blood pressure), neuromuscular dysfunction of the bladder (nerve damage to the brain, spinal cord, or peripheral nerves disrupts the normal communication between the nervous system and the bladder resulting in urinary incontinence or retention), pressure ulcer of the right heel, non-pressure chronic ulcer of the back, diabetes mellitus due to underlying condition without complications (condition results from insufficient production of insulin, causing high blood sugar due to other conditions), benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated he was able to make himself understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 03, indicating his cognition was severely impaired. The MDS assessment indicated Resident #3 had a urinary catheter and was always incontinent of bowel. The MDS assessment indicated Resident #3 was dependent with lower body dressing, taking off footwear and sitting to lying/lying to sitting, and personal hygiene. The MDS indicated Resident #3 was at risk for developing pressure ulcers/injuries and had unhealed pressure ulcers/skin injuries. Record review of Resident #3's comprehensive care plan dated 11/5/2025 and revised on 11/05/2025, indicated Resident #3 was incontinent of bowel/bladder with interventions for weekly skin checks to monitor for redness, circulatory problems, breakdown, or other skin concerns. The care plan indicated to report any new skin conditions to the physician. Record review of Resident #3's order summary report dated 02/04/2026, with active orders as of 08/01/2025, indicated Resident #3 had an order to perform head to toe skin assessment, document any changes in skin integrity in the medical record on Friday for wound prevention/early identification with a start date of 08/01/25. The order indicated to notify the physician with any changes in skin integrity. During an interview on 02/03/2026 at 07:30 AM, Resident #3 said he was experiencing some pain in his down there area the last couple of days. Resident #3 said he was not sure what was going on down there but the nurse and aides had looked at him yesterday and assisted him with the situation and offered him pain medication. Resident #3 said the wound care treatment nurse had not been to see him yet today that he could remember. Record review of Resident #3's progress note dated 02/02/2026 at 05:32 PM did indicate a new open area to right posterior lower leg with hospice physician notified and new order received noted by Wound Care Treatment Nurse K. Record review of Resident #3's progress note dated 02/03/2026 at 06:47 AM indicated awaiting a call back from hospice for any new orders. Will refer this area to wound care specialist during rounds on Thursday signed by Wound Care Treatment Nurse K During an interview and observation on 02/03/2026 at 09:15 AM, Resident #3 had an open area approximately the size of a nickel on the right side of the scrotum. There was no bandage noted upon removal of Resident #3's disposable brief. The Wound care Treatment Nurse K said the area on Resident #3's scrotum was not as opened yesterday. During an interview on 02/03/2026 at 10:45 AM, CNA L stated he had worked Sunday, 02/01/2026. CNA L stated that he had noticed the opened skin area on the right side of Resident #3's scrotum. CNA L stated that he had not reported to the nurse because the area had powder and cream on it, and he thought it had already been addressed. CNA L stated he should have reported to the nurse to be sure and to prevent any further decline in Resident #3's condition. During an interview on 02/03/2026, at 11:00 AM, LPN F stated she was not notified of any new areas of concern and had not noticed any opened area to the right side of Resident #3's scrotum over the weekend shift while she worked. LPN F stated Resident #3 was sent out to the hospital on [DATE] at the request of the family and the physician for further treatment of the abscess. Record Review of hospice progress notes dated 02/04/2026 indicated on Monday, 02/02/2026 SN was notified by Wound Care Treatment Nurse K of redness noted to penis at foley catheter insertion. The hospice progress note did not indicate notification of the new open area to Resident #3's right side of the scrotum. During an interview on 02/04/2026 at 01:06 PM, the physician stated that he had seen Resident #3 on 02/03/2026 after the facility notified him that morning regarding the new development of wound area on the right side of Resident #3's scrotum and diagnosed him with cellulitis (a rare but severe bacterial infection causing rapid swelling, intense pain, warmth and redness) of the penis. The physician stated the area is pus filled abscess that had surfaced and opened. The physician stated that Resident #3 often refused care by the staff, and these types of situations can occur from poor hygiene. The physician stated he did not feel the facility was responsible or had any fault with the development of the abscess. The physician stated he did not feel the resident could endure the treatment needed at bedside to incise the abscess for drainage and had suggested to the family to do the procedure inpatient at the hospital. The physician stated the family had notified him on 02/04/2026 to move forward to transfer the resident for the procedure to the hospital. The physician stated that he was not notified on 02/02/2026 by the facility or hospice of any new wound developments involving Resident #3's penis/scrotum area. The physician stated he expected the facility to notify him so care could be coordinated between entities and advocate for the resident's health and well being as quickly as possible to be proactive in the care. During an interview on 02/04/2026 at 01:40 PM, the DON stated the facility notified the hospice. The DON stated the facility always notifies the hospice if the resident is on hospice because sometimes family members would rather have the hospice physician make the new orders of care and prevent overlapping care. The DON stated she had seen the hospice nurse in the facility that evening on 2/2/2026. The DON said she assumed the Wound Care Treatment Nurse K had notified the hospice nurse that day and was waiting to receive orders. The DON stated she expected all nursing staff to document and report any changes in condition as they are found to prevent any further decline in resident's health and well-being. During an interview on 02/04/2026 at 02:50 PM, the Administrator said he expected the clinical staff to document and report timely to the physician, and family when appropriate - any changes of condition to prevent decline in health status. Record review of the facility's policy titled Notification of Changes with a revised date of 01/10/2020, indicated. To provide guidance on when to communicate acute changes in status to physician/nurse practioner, and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 3. A significant change in the physical, mental or psychosocial status of the resident. assessment of the skin area is documented in the clinical software.

Based on observation, interview, and record review the facility failed to keep residents informed, in advance, of the care to be furnished and the type of care giver or professional that would furnish the care for 14 of 18 residents reviewed for laboratory services. (Anonymous Residents #1, AR#2, AR #4, AR#5, AR#7, AR#8, AR#9, AR#10, AR#11, AR#12, AR#14, AR#15, AR#16, and AR#17) 1.The facility failed to protect and promote the rights of Anonymous Residents #1, AR#2, AR #4, AR#5, AR#7, AR#8, AR#9, AR#10, AR#11, AR#12, AR#14, AR#15, AR#16, and AR#17 by failing to keep them informed of medical procedures and results. This failure could place residents at risk of decreased psychosocial wellbeing, decreased privacy and decreased quality of life.The findings included:During a record review on 02/03/2026 at 9:45 a.m. of the forms titled 'Resident Council Minutes', dated September 2025 through December 2025 revealed no documented concerns from the residents about being informed of medical procedures or staff entering their rooms without permission.During a record review on 02/03/2026 at 10:00 a.m. of the facility grievance log dated February 2025 through February 2026 showed no grievances related to informing residents of medical procedures or staff entering their rooms without permission.During a record review on 02/03/2026 at 10:15 a.m. of the facility in-service binder, no in-services were noted related to informing residents of medical procedures such as labs and x-rays, informing residents of medical procedure results, or not entering resident's rooms until they have been given permission to enter by the resident.During a confidential interview at an undisclosed date and time, AR#1 stated they had been to the DON and Administrator with concerns that he and the other residents were not kept informed of medical procedures, such as labs and x-rays prior to them being performed. AR #1 stated it startled them each time someone came in in the middle of the night to take their blood. AR #1 stated the facility was not informing the residents of the results of their medical procedures. AR #1 stated he spoke with the DON on 01/22/2026 regarding the concerns and the Administrator on 01/29/2026 when he had no response for the DON. AR#1, AR#2, AR#4, AR#5, AR#7, AR#8, AR#9, AR#10, AR#11, AR#12, AR#14, AR#15, AR#16, and AR#17, stated they are not being informed of lab draws, x-rays or doppler studies done within the facility prior to the outside individual showing up to perform the procedures and it made them feel scared and uneasy.During an interview on 02/04/2026 at 10:15 a.m., the DON stated she was not informed of the residents having a concern about not being aware of the days the lab technician drew blood. She stated she was also not aware of the resident concern about x ray and dopplers being performed without their prior knowledge. She stated had she been made aware of this concern, she would have filled out a grievance form and followed up with the complaint of the resident or family member. The DON stated the resident's responsible party was informed of all new orders including labs and x-rays. She stated routine labs are done without notification of the residents or family because they were notified when the new order came in. The DON stated she could understand it may be frightening to the residents to see an unfamiliar face when the lab or x-ray technician showed up in the middle of the night.During an interview on 02/04/2026 at 11:00 a.m., LPN F stated she did not inform the residents only the responsible party of new orders for labs and x-rays. She stated she did not go down a list and inform the residents that they were due for labs that day or that they would be getting labs drawn. LPN F stated she was not certain how the residents being uninformed of when their labs would be drawn could negatively impact them. During an interview on 02/04/2026 at 11:30 a.m., the Administrator stated he was informed that one resident had concerns about what labs were being drawn. He stated when he interviewed the resident, the resident explained he was frightened by a stranger entering his room in the middle of the night because no one explained the way the lab worked in a long-term care facility. The Administrator stated he explained the process, and he felt the issue had been resolved. He stated the resident spoke with him around 01/29/2026. He stated his expectation was for nursing staff to explain procedures to residents that would understand and keep them informed on their health status.Review of a facility policy titled Dignity dated 2021 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights.

Based on observation, interviews, and record review, the facility failed to follow the menu to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure the Dietary Manager followed the menu for the lunch meal on 02/02/2026. This failure could place residents at risk of weight loss, not having their nutritional needs met, and a decreased quality of life.Findings included: During record review of a facility menu dated 02/02/2026 indicated the meal menu for the day was roast breast of turkey and gravy, savory bread stuffing, green bean casserole, and buttered dinner roll served with margarine, chocolate pudding cake. (Cycle: Texas 6 Week 4 Regular) During an observation of the lunch meal on 02/02/2026 at 12:15 p.m., the residents were served turkey and gravy, bread stuffing, green bean casserole, chocolate pudding cake. The residents were not served a dinner roll. During an interview on 02/02/2026 at 12:25 p.m., the Dietary Manager said there were no rolls to serve any residents in the facility with the lunch meal. The Dietary Manager said there should have been a substitution made such as a slice of bread to ensure the caloric content was the same value as the menu indicated to prevent nutritional weight loss. During an interview on 02/04/2026 at 2:50 PM., the DON said there were no rolls to be served to the residents because the delivery truck was unable to get into the parking lot due to the ice and snow the previous week. The DON said it was important to follow the menus to prevent weight loss. During an interview on 02/04/2026 at 3:00 PM, the ADM stated he expected dietary staff to follow the menu and the recipes for the facility's meals. The ADM stated he expected the Dietary Manager to ensure menus were printed for each meal. The ADM stated the importance of following the meal plans was to ensure residents had the appropriate nutrients. Record review of the Menus Changes and Substitutions policy, last revised on 08/02/2017 indicated, Any variation from the planned menu will be properly documented by the Dietary Services Manager and reviewed and signed by the Dietitian.Fundamental Information: Substitutions are generally necessary when an item needed to prepare the planned menu item is not available.

Based on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 18 anonymous residents reviewed for resident rights (Anonymous Resident (AR) AR#7, AR#8, AR#10, AR#12, AR#13, AR#16, AR#18). The facility failed to protect and promote the rights of Anonymous Residents #7, AR #8, AR #10, AR#12, AR#13, AR#16, and AR#18 by failing to wait for permission to enter the resident's room after knocking. These failures could place residents at risk for decreased self-esteem, decreased privacy and decreased quality of life. The findings included:During a confidential interview at an undisclosed date and time, AR #7 stated they have in the past requested the staff wait for permission to enter their room after knocking. She stated the day before she was sitting on the toilet and the staff member (LVN C) knocked and came into the room with the lunch tray. She stated she was embarrassed, but she was getting used to the staff just coming in no matter what.During a confidential interview at an undisclosed date and time, AR# 13 stated staff knocked and came into the room in the middle of her getting dressed this morning to open her blinds (ADON D) and bring in daylight. AR#13 stated they were completely capable of opening their own blinds and letting their own sunshine into the room when they were ready for it.During an observation and confidential interview at an undisclosed date and time, AR #8 was being interviewed behind a closed door by this state surveyor. ADON D knocked on the door and opened it without waiting for permission. She advanced into the room and opened the blinds and told AR#8 to have a good day and exited the room leaving the door open. AR#8 stated I am so sorry she did that, it was very disrespectful. All the staff just burst into the room without waiting for me to say come in. I bet they would be really upset if someone did that to them in their bedroom. AR#8 stated staff not waiting for permission to come in happens multiple times daily, especially when they are passing meal trays out.During an observation on 02/02/2026 at 11:40 a.m., LVN C entered 4 rooms (AR#7, #10, #12, and #18) without waiting for the resident's permission while passing lunch trays.During an interview on 02/02/2026 at 12:00 p.m., LVN C stated she knocked on the door and announced she had their lunch tray prior to entering the room. She stated she does not always wait for the residents to respond because sometimes they are asleep, and she needed to wake them to eat lunch while it was hot. She stated it is the resident's choice to eat when they want, and she would not like it if someone delivering food knocked and came on in her house. She stated she would feel disrespected and frightened.During an interview on 02/03/2026 at 2:20 p.m., ADON D stated she had not realized she was walking into the room without permission. She stated she knocks and greets the residents and opens their blinds to bring in light to start their day. She stated she would not like it if someone walked into her bedroom without permission or in the middle of a conversation with someone else. During an interview on 02/04/2026 at 10:15 a.m., the DON stated she was unaware the staff was walking into the residents' rooms without waiting for permission to enter. She stated it was a violation of their dignity to be barged in on. She stated it was her expectation that all staff wait to be welcomed in by any resident capable of welcoming them. The DON stated the resident could feel embarrassed or angry for the intrusion.During an interview on 02/04/2026 at 11:15 a.m., the Administrator stated it was his expectation for all residents to be treated with dignity and respect and for the staff to treat the facility as the resident's home. He stated he expected all doors to be knocked on and no one to enter the rooms of the residents without permission. He stated many staff members would be highly offended if someone just walked into their home with permission.Review of a facility policy titled Dignity dated 2021 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #7, Resident #29, and Resident #67) of 18 residents reviewed for care plans. Resident #7 had no care plan developed for her bilateral lower extremity limited range of motion.The care plan for Resident #29 had interventions for a fall mat at bedside that was not implemented.Resident #67 had no care plan developed for his left lower extremity contracture. These failures could place residents at risk of not having their individualized needs met, falls, decreased range of motion and a decline in their quality of care and life.Findings included:1. Record review of an undated face sheet revealed Resident #7 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Wernicke's Encephalopathy (an acute, life-threatening neurological emergency caused by a severe deficiency of thiamine (vitamin B1) commonly associated with alcohol use disorder or malnutrition), diabetes type II (a chronic metabolic disorder occurring when the body becomes resistant to insulin or fails to produce enough, leading to high blood sugar), and chronic pain (persistent discomfort lasting longer than three to six months, often continuing beyond the expected healing time of an initial injury).Record review of a quarterly MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 99 which indicated the inability of the resident to participate in the assessment and severe cognitive impairment. Resident #7 was dependent for ADLs such as toileting, transfer, and bathing. Resident #7 had limited range of motion to her bilateral (right and left) lower extremities.Record review of a care plan dated 01/06/2026 revealed no care plan for Resident #7's limited range of motion to her bilateral lower extremities.During an observation and interview on 02/03/2026 at 8:45 a.m. Resident #7 was lying in bed and stated she had trouble moving her legs. She stated she could wiggle her toes, but she could not move her ankles or knees well. She stated no one exercised her legs anymore since she was no longer in therapy. She stated her legs were only painful if she sat up in the wheelchair too long.2. Record review of an undated face sheet revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with the diagnoses bipolar disorder (a chronic mental illness characterized by extreme mood swings, ranging from high-energy mania/hypomania to low-energy depression, which impair daily functioning), major depression (a serious, common mood disorder characterized by persistent, severe sadness, loss of interest, and physical symptoms like fatigue, lasting at least two weeks), and anxiety (intense, excessive, and persistent worry that interferes with daily life, causing symptoms like restlessness, rapid heartbeat, sweating, trouble sleeping, and difficulty concentrating).Record review of a quarterly MDS assessment dated [DATE] revealed Resident #29 had a BIMS of 99 which indicated severe cognitive impairment. Resident #29 required dependent assistance for ADLs such as toileting, transfer, and bathing. Resident #29 had two or more falls in the last 90 days with no injury.Record review of a care plan dated 08/13/2025 titled 'High Fall Risk' revealed Resident #29 had an intervention from previous falls to have a fall mat beside bed.Record review of the consolidated physician orders dated 02/03/2026 revealed Resident #29 had an order for a fall mat beside bed when in bed started on 09/05/2025.Record review of an incident report dated 09/05/2025 revealed Resident #29 rolled out of bed and was observed lying beside the bed on the floor.Record review of an incident report dated 11/04/2025 revealed Resident #29 rolled out of bed and was observed lying on the fall mat beside the bed.Record review of an incident report dated 11/05/2025 revealed Resident #29 rolled out of bed and was observed lying on the fall mat beside the bed.During an observation and interview on 02/03/2026 at 9:00 a.m., Resident #29's fall mat was noted to be propped against the wall across the room. Resident #29 stated the staff sometimes forget to put the mat back down after they mop. Resident #29 explained she had the fall mat because she had fallen out of bed a few times in the past.During an observation on 02/03/2026 at 11:15 a.m., Resident #29's fall mat remained propped against the wall across the room from the resident.During an observation on 02/03/2026 at 2:40 p.m., Resident #29's fall mat remained propped against the wall across the room from the resident.3. Record review of an undated face sheet revealed Resident #67 was a [AGE] year-old male admitted on [DATE] with the diagnoses CVA ( Cerebrovascular Accident (CVA), commonly known as a stroke, occurs when blood flow to the brain is interrupted, causing brain cells to die), atrial fibrillation (the most common heart arrhythmia, causing the heart's upper chambers to quiver chaotically instead of beating effectively), and dementia (a general term for a progressive decline in memory, thinking, and behavior, severe enough to interfere with daily life, usually caused by neurodegenerative diseases like Alzheimer's).Record review of a quarterly MDS assessment dated [DATE] revealed Resident #67 had a BIMS of 13 which indicated no cognitive impairment. Resident #67 required substantial assistance (helper does more than half of work) for ADLs such as toileting, transfer, and bathing. Record review of Resident #67's consolidated physician orders dated January 2026, revealed the following order dated 05/02/2025:Apply knee brace to left leg daily. Remove only during bathing or patient care. Re apply after treatment to prevent progression of joint contracture due to flexor spasticity (a type of increased muscle stiffness where muscles, often in the arms or legs, involuntarily contract and stay in a bent or flexed position, making it hard to straighten the limb) from old CVA.Record review of the care plan dated 01/20/2026 revealed no care plan for Resident #67's left knee contracture or brace usage.During an interview on 02/03/2026 at 10:15 a.m., Resident #67 stated the staff used to put the brace on everyday but had not done so in the last couple of months. He stated before Christmas was the last time he recalled a nurse putting it on him. He stated he was unsure if the knee contracture had gotten worse because he did not feel much in that knee and never tried to walk on it anymore.During an interview on 02/03/2026 at 3:40 p.m., MDS Coordinator B stated care plans were to include all things that were coded on the MDS. She stated they should be reviewed by the nursing staff to know the individual care instructions for each resident. She stated not care planning an important item like a contracture with the interventions could result in the staff not knowing what is needed for the management of the contracture to prevent it from becoming worse. She stated she felt like leaving the contracture and knee brace off of the care plan was an oversight. She stated Resident #7's limited ROM not being care planned could lead to the staff being unaware she needs passive ROM performed during ADL care.During an interview on 02/04/2026 at 11:00 a.m., the DON stated it was the floor nurse and the administrative nurses' responsibility to ensure that staff was educated about interventions for all aspects of the resident's care. She stated without interventions for contracture management, Resident #67's contracture could worsen causing pain and decreased quality of life.During an interview on 02/04/2026 at 2:00 p.m., the ADM stated he expected the staff to follow the interventions decided on by the MDS coordinator and interdisciplinary team. He stated the interventions were in place to keep everyone safe and prevent accidents. He stated not following the interventions could decrease the resident's quality of life.Record review of a facility policy undated titled 'Comprehensive Care Planning revealed The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

Based on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 18 residents reviewed for MDS accuracy. (Resident #17) The facility failed to accurately code Resident #17's use of high-risk drug class medications (drug classes, including antipsychotics, anticoagulants, benzodiazepines, hypnotics, opioids, antiplatelets, hypoglycemics (including insulin), diuretics, and, newly added, anticonvulsants).This failure could place residents at risk of not receiving needed care and services. Findings included:Record review of an undated face sheet revealed Resident #17 was a 72- year-old- female, admitted on [DATE] with the diagnoses CHF (congestive heart failure- is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), anxiety (intense, excessive, and persistent worry that interferes with daily life, causing symptoms like restlessness, rapid heartbeat, sweating, trouble sleeping, and difficulty concentrating), and dementia (a general term for a progressive decline in memory, thinking, and behavior, severe enough to interfere with daily life, usually caused by neurodegenerative diseases like Alzheimer's).Record review of a quarterly MDS assessment dated [DATE] for Resident #17 revealed a BIMS of 09, which indicated moderate cognitive impairment. The MDS also revealed Resident #17 required dependent level assistance with bed mobility, transfer, and toileting. The MDS revealed Resident #17 had not taken any high-risk drug class medications. Record review of Resident #17's consolidated physician orders dated 11/01/2025 revealed the following orders:Sertraline (antidepressant) 100mg once daily, start date 08/13/2025Torsemide (diuretic) 20mg once daily, start date 08/13/2025Seroquel (antipsychotic) 25 mg twice daily, start date 10/24/2025 Record review of the MAR dated November 2025 revealed Resident #17 received the following medications each day:Sertraline (antidepressant) 100mg once dailyTorsemide (diuretic) 20mg once dailySeroquel (antipsychotic) 25 mg twice daily. Record review of care plan dated 08/13/2025 revealed Resident #17 used psychotropic medications: antidepressants and antipsychotics daily. A care plan also dated 08/13/2025 revealed Resident #17 used diuretic medications daily for congestive heart failure. During an interview on 02/03/2026 at 3:15 p.m., MDS Coordinator B revealed that Resident #17 received sertraline, torsemide and Seroquel each day during the month of November 2025. She stated those medications should have been coded on the MDS to capture the items for a complete representation of the resident's care. She stated not coding them could lead to not including them on the care plan which is the blueprint for individualized resident care. She stated the miscoding was an oversight. During an interview on 02/04/2026 at 11:00 a.m., the Administrator stated it was the responsibility of the MDS Nurse to produce accurate MDSs and care plans. The Administrator stated accuracy is important for revenue as well as to ensure the facility was reporting the correct information to CMS on the quality measures. During a record review of the facility's undated Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 5 residents reviewed for ADLs (Resident #2). The facility failed to provide assistance for Resident #2 with the removal of facial hair on 02/02/2026. These failures could place residents at risk of not receiving services/care and decreased quality of life.Findings Include: 1. Record review of a face sheet dated 01/08/2026 indicated Resident # 2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson disease (progressive neurodegenerative disorder impacts central nervous system), congestive heart failure (heart cannot pump blood well enough to supply your body), stiff-man syndrome (autoimmune disease - severe muscle stiffness), hypertension (high blood pressure). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 usually understand and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 11 which indicated moderate cognitive impairment. The MDS assessment indicated Resident #2 was dependent for all ADLs. Record review of the care plan with target date 02/17/2026 indicated Resident #2 had an activity of daily living (ADL) self-care performance deficit related to Parkinson disease with dyskinesia (involuntary, erratic, and uncontrollable muscle movements). The care plan indicated interventions included Resident #2 was dependent with bathing and required a shower, shave, oral care, hair care, and nail care provided per schedule and when needed. Record review of Resident #2's electronic medical record reflected CNA G gave Resident #2 a shower on Monday, 02/02/2026. Record review of the facility's schedules for resident shower indicated Resident #2 received showers on Monday, Wednesday and Fridays on the 6AM to 6PM shift. During an interview and observation on 02/02/2026 at 08:30 AM, Resident #2 said he was waiting for the aide because it was his shower day. Resident #2 had approximately one half inch facial hair growth and stated, he sure would like to be shaved and showered. A musty odor was noted upon entering Resident #2's room. Resident #2's top linen sheet had several dark brown circular stains. During an interview and observation on 02/03/2026 at 08:40 AM, Resident #2 had a clean-shaven-face, and he smiled when asked about it. Resident #2 stated he had been shaven on the morning of 02/03/2024. Resident #2 said the aide was going to come and get him for his shower in a little while. A musty odor was noted upon entering the room. Resident #2's top linen sheet continued to have the same noted dark brown circular stains. Resident #2 said his sheets had not been changed on 02/02/2026 or 02/03/2026. During an interview on 02/04/2026 at 09:15 AM, Resident #2 said he did not get a shower or his linens changed on yesterday's date. Resident #2 said the aide never came back to get him yesterday. A musty odor was noted upon entering the room. Resident #2's top linen sheet continued to have the same noted dark brown circular stains. During an interview on 02/4/2026 at 09:30 AM, CNA H said she was the shower aide unless the aides were shorthanded on the floor. CNA H said she was responsible for giving the residents showers. CNA H said there was a shower schedule posted at the nurse's station to let the CNAs know who needed a shower on what day. CNA H said it was important for residents to receive their showers so staff could observe their skin and to maintain the residents' cleanliness. CNA H said Resident #2 should have received a bath on Monday, Wednesday and Fridays. CNA H said she worked the halls on Monday therefore Resident #2 would have had a shower by CNA G. CNA H said CNA G had asked her to finish shaving Resident #2 on 02/03/2026, Tuesday morning, but she was not asked to shower Resident #2. CNA H said she was not aware if Resident #2 received a shower on 02/02/2026 or 02/03/2026. During an interview on 02/04/2026 at 02:15 PM, CNA G said she had not given a bath or changed the linens for Resident #2 on Monday or Tuesday. CNA G said she got busy and forgot with surveyors in the building. CNA G said she had documented on Monday that she gave Resident #2 a bath by mistake. CNA G said that she was assigned to Resident #2 but had failed to complete the shower as scheduled. CNA G said it was important to give regular scheduled showers and baths to the residents for their dignity and cleanliness. During an interview on 02/02/2026at 2:50 PM, the DON said it was the CNAs responsibility to give the residents their showers and provide personal hygiene. The DON said there was a shower list that identified what resident received a shower on which day. The DON said the CNAs performed showers on the residents, but any of the nursing staff could and should perform showers when needed. The DON said she expected the CNAs to communicate with the charge nurses daily to ensure resident's needs were being met. The DON said if a resident refused, she expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, she expected staff to report the refusal to the family and document the refusal. The DON said she was responsible to ensure the oversight of resident 's being bathed and showered appropriately according to the resident's Plan of Care. The DON said the importance of the residents receiving their scheduled showers was to maintain dignity, hygiene, skin integrity, skin inspections and prevent skin infections. The DON said ultimately it was her responsibility to ensure the showers and personal hygiene were performed for the residents by the staff. During an interview on 02/04/2026 at 03:50 PM, the Administrator said he expected baths/showers as scheduled or as requested by the resident. The Administrator said clinical staff were responsible for making sure the baths/showers were provided for the residents. The Administrator said if the residents refused ADL care, the staff should educate the residents. The Administrator said if a resident refused, he expected staff to try again a couple times or send a different staff member to ask the resident. The DON said if a resident continued to refuse, he expected staff to report the refusal to the family and document the refusal. The Administrator said it was important for the residents to receive baths/showers for hygiene according to the resident's plan of care to make the residents feel good, infection control and dignity. Record review of undated facility policy and procedure titled, Activities of Daily Living Care Guidelines, reflected a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observations, interviews and record reviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 2 of 5 residents with limited range of motion (Resident #7 and Resident #67) Resident #7 had limited range of motion to bilateral lower extremities with no services to prevent further decrease in range of motion.Resident #67 had an order for a knee brace to prevent further contracture that was not carried out.These failures could place residents at risk of not having their individualized needs met, decreased range of motion and a decline in their quality of care and life.The findings included: 1. Record review of an undated face sheet revealed Resident #7 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Wernicke's Encephalopathy (an acute, life-threatening neurological emergency caused by a severe deficiency of thiamine (vitamin B1) commonly associated with alcohol use disorder or malnutrition), diabetes type II (a chronic metabolic disorder occurring when the body becomes resistant to insulin or fails to produce enough, leading to high blood sugar), and chronic pain (persistent discomfort lasting longer than three to six months, often continuing beyond the expected healing time of an initial injury). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 99 which indicated the inability of the resident to participate in the assessment and severe cognitive impairment. Resident #7 was dependent for ADLs such as toileting, transfer, and bathing. Resident #7 had limited range of motion to her bilateral (right and left) lower extremities. Record review of a care plan dated 01/06/2026 revealed no care plan for Resident #7's limited range of motion to her bilateral lower extremities. Record review of the ADL sheet dated January 2026 for Resident #7 showed no range of motion exercises being performed. Record review of the ADL sheet dated February 2026 for Resident #7 showed no range of motion exercises being performed. During an observation and interview on 02/03/2026 at 8:45 a.m. Resident #7 was lying in bed and stated she had trouble moving her legs. She stated she could wiggle her toes, but she could not move her ankles or knees well. Resident #7 stated therapy used to exercise her legs, and it would help, but they had to stop. She stated no one had exercised her legs since she stopped therapy. She could not recall how long-ago therapy stopped. 2.Record review of an undated face sheet revealed Resident #67 was a [AGE] year-old male admitted on [DATE] with the diagnoses CVA ( Cerebrovascular Accident (CVA), commonly known as a stroke, occurs when blood flow to the brain is interrupted, causing brain cells to die), atrial fibrillation (the most common heart arrhythmia, causing the heart's upper chambers to quiver chaotically instead of beating effectively), and dementia (a general term for a progressive decline in memory, thinking, and behavior, severe enough to interfere with daily life, usually caused by neurodegenerative diseases like Alzheimer's). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #67 had a BIMS of 13 which indicated no cognitive impairment. Resident #67 required substantial assistance (helper does more than half of work) for ADLs such as toileting, transfer, and bathing. Record review of Resident #67's consolidated physician orders dated January 2026, revealed the following order dated 05/02/2025: Apply knee brace to left leg daily. Remove only during bathing or patient care. Re apply after treatment to prevent progression of joint contracture due to flexor spasticity (a type of increased muscle stiffness where muscles, often in the arms or legs, involuntarily contract and stay in a bent or flexed position, making it hard to straighten the limb) from old CVA. Record review of the administration records for Resident #67 revealed no order or documentation for the application or removal of the ordered brace. Record review of the care plan dated 01/20/2026 revealed no care plan for Resident #67's left knee contracture or brace usage. During an observation and interview on 02/02/2026 at 8:40 a.m., Resident #67 stated the staff was supposed to put the leg brace on him everyday because he had a bad knee on his left side that had started to draw up since his stroke. He stated the brace was over in the chair next to his bed. A long-hinged knee brace was noted under towels and a jacket in the chair next to Resident #67's bed. During an observation on 02/02/2026 at 11:30 a.m., Resident #67's knee brace remained in the chair beside his bed under a jacket and towels. During an observation on 02/02/2026 at 2:30 p.m., Resident #67's knee brace remained in the chair beside his bed under a jacket and towels. During an observation on 02/03/2026 at 8:30 a.m., Resident #67's knee brace remained in the chair beside his bed under a jacket and towels. During an interview on 02/03/2026 at 10:15 a.m., Resident #67 stated the staff used to put the brace on everyday but had not done so in the last couple of months. He stated before Christmas was the last time he recalled a nurse putting it on him. He stated he was unsure if the knee contracture had gotten worse because he did not feel much in that knee and never tried to walk on it anymore. During an interview on 02/04/2026 at 11:00 a.m., the DON stated it was the floor nurse and the administrative nurses' responsibility to ensure that staff was educated about interventions for all aspects of the resident's care. She stated without interventions for contracture management, Resident #67's contracture could worsen causing pain and decreased quality of life. She stated he recently started hospice services, and she was unsure if the brace would continue. The DON stated Resident #67 had limited ROM to her lower extremities because she did not like to get out of bed. She stated the facility did not have an official restorative nursing program, but she felt confident her staff did ROM exercises with the residents during ADL care. During an interview on 02/03/2026 at 3:40 p.m., MDS Coordinator B stated she was aware Resident #7 had limited range of motion to her bilateral lower extremities. She stated she was not sure who was doing range of motion exercises with her because the facility did not have a restorative nursing program and unless the resident was on therapy services the resident probably was not getting any range of motion exercises. She stated Resident #67 should have been getting the leg brace applied daily by nursing as ordered by the doctor. She stated she was unsure why he had not been wearing it. She stated no refusals were reported to her. During an interview on 02/04/2026 at 2:00 p.m., the ADM stated he expected the staff to follow the physician and nursing recommendations and perform ROM exercises to decrease the risk for contractures and contracture worsening on anyone with limited ROM. Facility policy requested for limited range of motion on 02/04/2026 at 2:30 p.m. None was provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 out of 5 residents (Resident #35) reviewed for respiratory care. The facility failed to have Resident #35's oxygen sign outside the door on 02/02/2026 and 02/03/2026. This failure could place residents who receive oxygen for respiratory care at risk of safety accidents, including fire hazards and potential harm.Findings included: Record review of Resident #35's face sheet, dated 02/04/2026 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included, myopathies (a group of disorders causing primary dysfunction of skeletal muscle fibers causing progressive weakness), dementia (decline in cognitive abilities related to memory, language, and reasoning), dysphagia (difficulty swallowing), heart disease. Record review of Resident #35's comprehensive care plan, dated 02/04/2026, did not indicate, Resident #35 had oxygen usage. Record review of Resident #35's quarterly MDS assessment, dated 01/13/2026, indicated Resident #35 usually understood and was usually understood by others. Resident #35's BIMS score was 12, which indicated his cognition was moderately impaired. The MDS indicated Resident #35 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated during the 7-day look-back period, he was not receiving oxygen. Record review of Resident #35's Physician order dated 02/01/2026 indicated oxygen at 2-4 liters via nasal cannula as needed for shortness of breath. During an observation on 02/02/2026 at 08:26 a.m., Resident #35 had oxygen on at 2 liters per nasal cannula. No oxygen sign was noted outside his door. During an observation on 02/02/2026 at 4:00 p.m., Resident #35 had oxygen on at 2 liters per nasal cannula. No oxygen sign was noted outside his door. During an observation on 02/03/2026 at 4:00 p.m., Resident #35 did not have on oxygen. The oxygen concentrator was observed at Resident #35's bedside. No oxygen sign was noted outside his door. During an observation and interview on 02/03/2026 at 04:10 p.m., CNA G said she was aware that the resident wore oxygen by the oxygen sign outside the door. She said the charge nurse usually put up the oxygen sign outside the door of the residents that had oxygen. CNA G said she could not recall if Resident #35 wore oxygen as he is a new resident and she just came onto shift. During an interview on 02/04/26 at 1:08 p.m., the ADON said all residents that require oxygen should have an oxygen sign on the door to prevent accidents and for the safety of the residents and staff. The ADON said she was not aware of Resident #35 did not have an oxygen notification sign on his door. She said Resident #35 had declined quickly and that had gone unnoticed. During an interview on 02/05/2026 at 02:50 p.m., the DON said any resident with oxygen use should have a sign on the door to notify the staff and visitors that oxygen was in use to prevent any safety hazards such as flames or fires. During an interview on 02/05/2026 at 03:00 p.m., the Administrator said all residents who require oxygen should have an oxygen sign on the door for the safety of residents and staff. Record review of the facility's policy titled Oxygen Administration, review date of 01/05/2020, indicated, Fundamental Information: During a respiratory emergency it is appropriate for nursing to administer oxygen immediately then notify. Oxygen signs remain on room doorway the entire time the oxygen source is in the patient room.

Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 5 residents (Resident #9) reviewed for trauma-informed care. The facility did not ensure Resident #9 had an accurate trauma screen that identified possible triggers when Resident #9 had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.The findings included: 1. Record review of a face sheet dated 02/04/2026 indicated Resident #9 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive irreversible brain disorder), chronic obstructive pulmonary disease (difficulty breathing), Type 2 diabetes (high sugar in the bloodstream), major depressive disorder, recurrent (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life threatening or violent content - lasting over a month). Record review of the Quarterly MDS dated [DATE] indicated Resident#9 understood others and was able to make herself understood. The MDS assessment indicated Resident #9 was independent for eating, toileting, personal hygiene, and required supervision/touching assistance with showering/bathing. The MDS assessment indicated Resident #9 used the wheelchair for mobility. The MDS assessment indicated Resident #9 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #9 had anxiety, depression and post traumatic Disorder. Record review of Resident #9's care plan revised 12/02/2025 indicated she had alteration in mood related to disease process, diagnosis of depression and anxiety. Resident #9's care plan included interventions to administer medications as ordered, assist the resident to identify strengths, positive coping skills, and reinforce these, monitor/record mood to determine if problems seem to be related to external causes, monitor/record/report to physician any acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills, and the resident needs encouragement/assistance/support to maintain as much independence and control as possible. Resident #46's care plan did not indicate she had a history of sexual trauma. Record review of Resident #9's Comprehensive Trauma Screening with effective date 09/30/2022 completed by the previous social worker did not indicate Resident #9 had a history of trauma on Section C Question B. During an interview on 02/03/2026 at 10:00 AM, Resident #9 said she had a history of trauma, and she preferred not to discuss it with the surveyor because she had already told the facility about those incidents of her past and sometimes it still affects her sleep. During an interview on 02/03/2026 at 11:00 AM, the Social Worker said that she was not aware of Resident #9 having a history of trauma. The Social Worker said trauma assessments were done on admission and occasionally if the resident went to the hospital the system would trigger for a trauma assessment to be completed, and she would re-do it. The Social Worker said she had not completed Resident #9's trauma assessment because she was new at the facility (started in April 2025). The Social Worker said addressing trauma informed care was important because it could affect the resident's well-being and quality of life, and how they interacted with staff and each other and it could affect their sleep. The Social Worker said the trauma assessment for Resident #9 should have been marked yes in Section C Question B based upon the answers reflected in Section 2 according to the assessment instructions. Section 2, question f of the Comprehensive Trauma assessment dated [DATE] was marked yes for have you ever been sexually assaulted. The Social worker said the care plan was updated by several different staff such as herself, MDS Nurse, DON or the ADONS. The Social Worker stated the care plan did not adequately reflect the trauma assessment but that she could update the care plans with the triggers associated with Resident #9's traumas. During an interview on 02/03/2026 at 11:15 AM, the MDS Nurse said the informed trauma assessment was inaccurately filled out, and the care plans should reflect the triggers associated with Resident #9's trauma. The MDS Nurse said it was important for history of trauma and triggers to be identified so that the staff would not trigger Resident #9's anxiety or go in her room and say something that was going to upset her because Resident #9 did have a lot of anxiety. During an interview on 02/04/2026 at 2:50 PM, the DON said she was not aware of Resident #9 having any sexual trauma. The DON said if Resident #9 had sexual trauma it should be on her trauma assessment and in her care plan. The DON said the previous social worker would have identified the trauma and put it in the care plan. The DON said it was important for trauma to be identified because the resident's treatment would be different, and they would have to look for mannerisms, behaviors, triggers, and offer psych services, counselor services. The DON said it was important for it to be included on the resident's care plan, so they knew how to care for them. The DON said the trauma assessments are completed upon admission, and she feels it is impossible to back track before her employment started with the facility to ensure accuracy. During an interview on 02/04/2026 at 5:44 PM, the Administrator said he expected the Social Worker to address trauma on the trauma assessment and for trauma and triggers to be included in the residents' care plans. The Administrator said the Social Worker was responsible for this. The Administrator said it was important for trauma and triggers to be identified so it could be treated, if necessary. The Administrator said if trauma was not identified it could affect the resident's quality of life mentally. The Administrator said triggers needed to be identified so they could treat and evaluate the resident's mental status. Record review of the facility's policy Trauma Informed Care dated 10/24/2022 Reflected, The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to:a. Experiencing a lack of privacy or confinement in a crowded or small space.b. Exposure to loud noises, or bright/flashing lights.c. Certain sights, such as objects that are associated with their abuser.d. Sounds, smells, and physical touch.

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 21 residents reviewed. (Resident #50)The facility failed to securely store wound care treatment chemicals (Povidone-Iodine 10% Solution and .9% Sodium Chloride Irrigation Solution) for Resident #50.This failure could place residents at risk for adverse reactions.Findings included:Record review of Resident #50's face sheet dated 12/15/25 indicated Resident #50 was [AGE] years old and was admitted on [DATE] with diagnoses including Aphasia (a language disorder caused by brain damage), Hypertension (high blood pressure), Amputation of the right foot.Record review of the MDS dated [DATE]indicated Resident #50 could understand and was understood by others. The MDS indicated a BIMS score of 09 indicating Resident #50 had moderately impaired cognition.Record review of a care plan revised on 12/30/25 indicated Resident #50 has impaired cognition and was at risk of a further decline in cognitive and functional abilities related to: Dementia.During an observation on 2/2/26 at 8:51 a.m. Resident #50's room was observed with Povidone-Iodine 10% Solution and .9% Sodium Chloride Irrigation Solution in his room unsecured. Chemicals were in plain view and readily accessible to any individual in the building. Resident was not in room for interview. During an observation on 2/3/26 at 9:15 a.m. Resident #50's room was observed with Povidone-Iodine 10% Solution and .9% Sodium Chloride Irrigation Solution in his room unsecured. Chemicals were in plain view and readily accessible to any individual in the building. Resident was not in room for interview. During an interview on 2/3/26 at 9:20 a.m. LVN A said that residents are not allowed to keep medications inside their room. She said that there is a risk that a resident could get ahold of the medication or chemical and misuse it. She said the main risk is if a resident drank the Povidone-Iodine 10% Solution or .9% Sodium Chloride Irrigation Solution. She said all these items should be kept on either a medication cart or the treatment cart and not left in a resident's room. She said that the treatment medications, Povidone-Iodine 10% Solution or .9% Sodium Chloride Irrigation Solution, should have been kept on the medication cart. She stated that she would remove the chemicals from resident's rooms.During an interview on 2/4/26 at 10:45 a.m. the Director of Nurses said that chemicals used for wound care or treatments should be kept in the treatment cart. She said that there was a risk that any resident could get the medication and harm themselves if they misused the chemicals. It is the responsibility of all staff to ensure that residents do not have access to potentially harmful chemicals.During an interview on 2/4/26 at 10:50 a.m. the Administrator said that wound care treatment chemicals should not be left in plain sight in residents' rooms. He said that there was a risk that a resident could get ahold of the chemicals and improperly use them. Record review of a facility policy dated 01/20/2021 titled Medication Storage revealed that the purpose of this policy was to, It is the policy of this facility to ensure all medications housed on our premises will be stored, dated, and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security All drugs and biologicals will be stored in locked compartments under proper temperature controls.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #2) reviewed for activities. The facility failed to ensure Resident #2's Activities Evaluation was accurately completed on 09/09/2024. The facility failed to ensure Resident #2 was provided in-room activities in August 2024, September 2024, and October 2024. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated it was not very important for Resident #2 to have books, newspapers, and magazines to read. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for bathing/showering. Record review of Resident #2's care plan indicated she was dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and was at risk for isolation. Resident #2's care plan indicated she would attend/participate in activities of choice 1-3 times weekly through the next review date. Resident #2's care plan indicated interventions to assist/escort the resident to activity functions, converse with resident while providing care, provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, provide the resident with assistance as needed during the activity, and the resident's preferred activities are: TV, music, adult coloring, perk word search and family/friend visits. Record review of Resident #2's Activity Evaluation dated 09/09/2024 completed by the Activities Director indicated it was not very important for her to have books, newspapers, and magazines to read. The Activity Evaluation indicated Resident #2 was not interested in reading/audio books. The Activity Evaluation indicated Resident #2 preferred activities in her own room. The Activity Evaluation indicated Resident #2 had poor vision. Record review of the In Room Activity Visit Logs for August 2024, September 2024, and October 2024 indicated: 08/19 Resident #2 with no activity description, no start or end time, and no signature to indicate it was completed. No in-room activities for Resident #2 in September 2024. No in-room activities for Resident #2 in October 2024. During an observation and interview on 11/04/2024 at 9:37 AM, Resident #2 said the staff told her they would read to her, but they had not. Resident #2 said she loved for them to read to her because she was not able to see the books anymore. Resident #2 had books on her overbed table. During an interview on 11/05/2024 at 4:35 PM, the Activities Director said she started in August of 2024. The Activities Director said Resident #2 read her own books, looked at her own pictures, and liked to visit with her family. The Activities Director said Resident #2 was supposed to have in-room activities, and she thought she had been doing these. The Activities Director said she had not tried to read to Resident #2, and she completed activities on her own. The Activities Director said she guessed she had had filled out Resident #2's Activity Evaluation wrong because Resident #2 liked to read. During an interview on 11/06/2024 at 5:48 PM, the Administrator said if Resident #2 liked to be read to, he expected for this to be done for her. The Administrator said the Activities Director was responsible for doing activities and the activities assessments. The Administrator said Resident #2's activities preferences should be included on her care plan as well. The Administrator said this was important to maximize the resident's quality of life. Record review of the facility's policy, Recreational Services, revised 02/2022, indicated, Recreation becomes extremely significant in meeting each resident's needs for quality of life. Well planned programs must be designed to enhance residents' abilities to function at their highest practicable level as well as to allow them to realize their own abilities and their own potential for fulfillment. The process must include assessing the residents' functional abilities, interests and needs, developing mutual agreed upon goals and the use of specialized recreation services as approaches to meet the individualized goals .

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 81 residents residents (Residents #68, #79, #3, #11, #62, #48, #45, and #13) and 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for lunch meal observed on 11/5/24. Resident's #68, #79, #3, #11, #62, #48, #45, and #13 complained that food tasted bad, was not cooked properly and was served cold. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the menu indicated the lunch meal items on 11/5/24 included (A) fried chicken, mash potatoes, spinach, dinner roll and ice cream; (B) steak, egg noodles, green peas, dinner roll and ice cream. During an interview on 11/04/24 9:17 a.m., Resident #68 stated the food was bad every day. During an interview on 11/4/24 at 9:53a.m., Resident #79 stated the food was bad and he did not like his food grinded up. During an interview on 11/04/2024 at 9:58 a.m., Resident #3 stated the food could be better; Resident # 3 stated I feel like I eat a lot of sandwiches all the time. Resident # 3 stated she wanted more of a variety of other foods. During an interview on 11/04/24 10:14 a.m., Resident #11 stated she can't eat rice, corn, berries and gets it on her tray. Resident #11 stated, I had burnt toast this morning and I sent it back. Resident #11 stated the green beans were stringy and felt like she was eating hair. Resident #11 stated her dinner roll was not done yesterday (11/05/24). Resident #11 stated the inside of her dinner roll raw. Resident #11 stated she got cold coffee. During an interview on 11/04/2024 at 10:49 a.m., Resident #62 stated he would not feed the food to a hog. Resident #62 stated most of time the food was not done or was overdone. Resident #62 stated most of the time the pasta noodles were not eatable. During an interview on 11/4/24 at 10:06 a.m., Resident #48 stated he hated getting cold eggs unless the eggs were boiled. Resident #48 stated he liked his eggs over easy and the kitchen fried his eggs too hard. During an interview on 11/04/24 11:23 a.m., Resident #45 food stated the food was horrible, and her family brought her food, or she would starve. During an interview on 11/5/24 at 10:37 a.m., Resident #13 stated the food was not good and meat was tough. During observation and tasting of lunch meal (A) on 11/5/24 at 12:22 p.m., the Dietary Manager stated the steak needed more seasoning, egg noodles tasted like egg noodles and the peas was warm. The frozen ice cream was not sampled during tasting. During observation and tasting of lunch meal (B) on 11/5/24 at 12:30 p.m., the Dietary Manager stated the fried chicken did not look burnt, but the fried chicken did have a dark color to it. During the tasting, surveyors stated the fried chicken skin tasted burnt and was dark in color. The Dietary Manager stated the mash potatoes was warm but needed a little more seasoning. The Dietary Manager stated the spinach tasted like spinach but could use more seasoning. The frozen ice cream was not sampled during tasting. During an interview on 11/06/24 at 9:15 a.m., The Dietary Manager stated she had been employed at the facility for [AGE] years. The Dietary Manager stated the administrator oversaw her at the facility. The Dietary Manager stated she tasted the foods served at every meal and every meal serving. The Dietary Manager stated she did not test taste the foods on 11/5/24 for lunch because she was cooking and was trying to make sure her staff was on point with everything in the kitchen. The Dietary Manager stated the cooks and aide also tasted the foods prior to serving meals that they prepared. The Dietary Manager stated her cooks and aides have completed in-services on following the recipe recently this year (2024). The Dietary Manager stated she did not exact on the actual month the aides and cooks completed in-services on following the recipe. The Dietary Manager stated she handled food complaints from the residents by communicating with the resident personally. The Dietary Manager stated, For the targeted complainers that she would print the menus for the residents, and she would let the family make their choices on the food's preferences for the resident. The Dietary Manager stated by letting the family make the food choices for the resident that it had had helped her targeted complainers calmed down on the food complaints. The Dietary Manager stated for residents complaining about food, that she would adjust the resident's meal choices based on the notes the resident left for her to read. The Dietary Manager stated it was important to ensure the food was palatable, attractive, and appetizing to the residents to make the residents happy and for the resident nutrition. During an interview on 11/6/24 at 12:04 p.m., the Administrator stated he had been the administrator for 14 months. The Administrator stated he oversaw the Dietary Manager. The Administrator stated he ordered test trays from the kitchen. The Administrator stated he was having lunch from the kitchen today. The Administrator stated the results from his last test tray was good. The Administrator stated the Dietary manager would go and talk to each resident who complain of food when he received food complaints to try to resolve the food complaints. The Administrator stated he handled food complaints by writing grievance on the food complaints from the residents. The Administrator stated he had one resident that always had something to say about everything prepared from the kitchen. Stated he recently talked to one resident who complained about the food and was told from that resident that the food was better and had been good lately. The Administrator stated he did not remember off the top of his head of when the last in-service on following the menu was completed by the dietary staff. The Administrator stated it was important to ensure the food was palatable, attractive, and appetizing for the resident for quality of life, weight loss prevention and for enjoyment. Record review of the facility Policy, titled, Menus and Nutritional Adequacy, revised Dated on 5/30/2012, indicated, Menus are planned to meet the average resident nutritional needs.

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 3 of 6 residents (Resident #2, Resident #53, and Resident #72) reviewed for infection control. 1. The facility failed to ensure LVN E and CNA F provided proper incontinent care to Resident #2. 2. The facility failed to ensure Resident #53's bagged, dirty briefs were taken out of her bathroom. 3. The facility failed to ensure CNA H provided proper catheter care to Resident #72, and the facility failed to ensure CNA H followed enhanced barrier precautions when she failed to wear gloves as she repositioned and touched Resident #72's sheets. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for toileting and bathing/showering. Record review of Resident #2's care plan revised 09/17/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Resident #2's care plan indicated substantial assistance with toileting. Resident #2's care plan indicated she was incontinent of bowel and bladder to check her frequently for wetness and soiling and change her as needed. During an observation of incontinent care on 11/04/2024 at 9:46 AM, LVN E and CNA F provided incontinent care to Resident #2. LVN E and CNA F put on gloves, unfastened Resident #2's dirty brief, cleaned her front peri area, Resident #2 was turned on her side. LVN E removed the dirty brief, LVN E cleaned resident back peri area, wiped from front to back but used the same wipe to wipe multiple times, she did this several times while cleaning the back peri area, changed gloves, did not perform hand hygiene in between glove changes, applied clean gloves, tucked in the dirty sheets, changed gloves, did not perform hand hygiene in between glove changes and applied the clean sheets and brief. Resident #2 was rolled to the other side CNA F removed the dirty linens and unrolled the clean sheets from underneath resident. CNA F did not change gloves and perform hand hygiene after removing the dirty linens and before touching the clean sheets. CNA F with her dirty gloves repositioned the resident in the bed. After repositioning Resident #2, CNA F removed the dirty gloves and performed hand hygiene and LVN E removed her gloves and performed hand hygiene. During an interview on 11/04/2024 at 2:29 PM, LVN E said when performed incontinent care, she should only wipe once and discard. LVN E said this was important for infection control. LVN E said wiping more than once could result in urinary tract infections. LVN E said hand hygiene should be performed before and after care and in between glove changes. LVN E said she had not realized she failed to perform hand hygiene in between gloves changes. LVN E said gloves should be changed after cleaning the front, after cleaning the back, and when gloves were soiled, and when moving from dirty to clean. LVN E said CNA F should have changed her gloves after removing the dirty linens, before applying the clean linens. LVN E said ADON O was responsible for ensuring the CNAs were performing proper incontinent care. LVN E said hand hygiene was important to be done when required for infection control. During an interview on 11/05/2024 at 3:12 PM, CNA F said gloves should be changed and hand hygiene performed after touching anything contaminated. CNA F said gloves should be changed after removing the dirty linens, before applying the clean linens. CNA F said she had not changed her gloves because she did not think about it. CNA F said it was important to change gloves to prevent contamination. 2. Record review of Resident #53's face sheet dated 11/06/2024 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #53's Quarterly MDS assessment indicated she was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #53 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #53 was independent for toileting and personal hygiene. The MDS assessment indicated Resident #53 did not exhibit rejection of care or behaviors. Record review of Resident #53's care plan with a target date of 01/27/2025 indicated she had an ADL self-care performance deficit related to cognitive decline, episodes of incontinence, unsteady gait, and was at risk for not having her needs met in a timely manner. Resident #53's care plan indicated she was independent for toileting. During an observation and interview of Resident #53's bathroom, there were 2 bags on the floor under the sink each bag contained dirty briefs. There was a strong urine odor in Resident #53's bathroom. Resident #53 said she tried to stay out of the bathroom because of the strong urine odor. Resident #53 said she told the nurses about the dirty briefs in the bathroom and they laugh and they do not take them out. Resident #53 said it was like talking to the air. Resident #53 was unable to say how long the bags with the dirty briefs had been in the bathroom, but she said they had been there a while. During an observation and interview on 11/04/2024 3:58 PM with CNA F, Resident #53 had bags with dirty briefs in her bathroom under the sink. CNA F said the CNAs were responsible for taking out the dirty briefs. CNA F said, I haven't gone in there today, I have been busy and did not have time. CNA F said Resident #53's bathroom smelled like urine. CNA F said it was important for the trash bags with briefs to not be left in the bathroom for sanitizing and to prevent contamination. CNA F said the bathroom smelling like urine could make Resident #53 feel like she was not being cared for. 3. Record review of a face sheet dated 11/06/2024 indicated Resident #72 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and urinary retention. Record review of a Comprehensive MDS assessment dated [DATE] indicated Resident #72 was sometimes able to make herself understood and was sometimes able to understand others. The MDS assessment indicated Resident #72 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #72 was dependent on staff for all ADLs. The MDS assessment indicated Resident #72 had an indwelling catheter. Record review of Resident #72's care plan revised 10/30/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner and required substantial/maximum assistance with toileting. Resident #72's care plan indicated she had a urinary catheter and was at risk for urinary tract infections and injury. Resident #72's care plan indicated catheter care every shift. The care plan indicated Resident #72 required enhanced barrier precautions to wear gown and gloves during high-contact resident care activities. Record review of Resident #72's Order Summary Report indicated to provide catheter care every shift with a start date of 09/26/2024. During an observation and interview on 11/06/2024 starting at 2:12 PM, CNA G and CNA H provided incontinent care to Resident #72. CNA G and CNA H put on PPE and gloves. CNA H cleaned Resident #72's left peri area and wiped down the middle. CNA H did not wipe Resident #72's right peri area and she did not clean the catheter tubing. Resident #72 was turned on her side. When she was turned on her side Resident #72 got a hold of her catheter tubing. CNA G cleaned Resident #72's back peri area. CNA G changed gloves and Resident #72 was turned back onto her back. Resident #72 was still holding her catheter tubing. CNA H removed her gloves and covered Resident #72 up, CNA H touched Resident #72's sheets and blankets without gloves. Resident #72 was still holding her catheter tubing when they covered her up. After this, CNA H and CNA G decided Resident #72 needed to be pulled up in the bed. When CNA H and CNA G pulled up Resident #72 in the bed she started pulling at the catheter. CNA H intervened and stopped Resident #72 from pulling the catheter further, and they finished repositioning her in the bed. CNA H said she thought she had cleaned both sides of Resident #72's front peri area. CNA H said when cleaning a resident with a catheter she should hold the tubing and wipe down it to clean it. CNA H said she should clean the peri area properly and the catheter tubing properly because they could have bacteria and germs and so the resident would not get an infection. CNA H said Resident #72 was on enhanced barrier precautions. CNA H said she was able to touch Resident #72's sheets and reposition her without gloves. CNA H said when providing care to Resident #72 she should be looking at the foley catheter tubing. CNA H said it was important to pay attention to where the foley catheter tubing was so it would not get pulled out and rupture something. During an interview on 11/06/2024 at 4:38 PM, ADON O said when providing incontinent care, the staff should wipe and toss, wipe and toss. ADON O said the same wipe should not be used to wipe multiple times because this could cause urinary tract infections. ADON O said anytime they went from dirty to clean, gloves should be changed. ADON O said hand hygiene should be performed in between glove changes. ADON O said if the staff were still cleaning the dirty, they could skip the hand hygiene in between. ADON O said hand hygiene should be performed at the required times to prevent the spread of infection. ADON O said for enhanced barrier precautions the staff did not have to wear glove if they were not touching the resident's skin. ADON O said the staff was able to touch the residents' surroundings with no gloves. ADON O said it was okay for CNA H to reposition and touch Resident #72's sheets without gloves. ADON O said when performing incontinent care, the CNAs should clean from inside/out, clean the foley from top to bottom. ADON O said they should clean the tube, but make sure they do not pull it. ADON O said the CNAs should be aware of where the catheter tubing was at all times, and they should be aware of where the residents' hands and limbs were. ADON O said it was important for them to be aware of where the foley catheter tube was because it could cause trauma, pain, injury, and it was a risk for infection. ADON O said when providing incontinent care, the CNAs should be trying to clean the residents completely. ADON O said it was important to keep the skin clean and to prevent infections. ADON O said the CNAs and any of the staff should have attempted to take out Resident #53's bagged, dirty briefs out of her bathroom. ADON O said the bagged, dirty briefs should not be left on the floor for cleanliness and hygiene, and they were a breeding ground of infection and bugs. During an interview on 11/06/2024 at 5:22 PM, the DON said gloves should be changed when going from dirty to clean. The DON said if the staff was cleaning the dirty, they removed their gloves, applied new ones, and kept cleaning the dirty, they did not have to perform hand hygiene. The DON said the staff should change gloves and hand sanitize after removing dirty linens. The DON said during incontinent care the CNAs were supposed to clean both sides on the front peri area, and they should be cleaning the foley catheter tubing when providing incontinent care on someone with a foley catheter. The DON said it was important to completely clean the residents and clean the catheter tubing to prevent urinary tract infections, infections, and skin breakdown. The DON said the CNAs should be paying attention to where the residents foley catheter tubing was located while providing incontinent care. The DON said it was important to prevent trauma and risk for infection. The DON said the CNAs practiced incontinent care on the mannequins, and she randomly observed the CNAs perform incontinent care. The DON said she had not noticed any issues with incontinent care. The DON said for enhanced barrier protections PPE and gloves should be worn when touching the residents' sheets and covering them up. The DON said it was important to follow the enhanced barrier precautions for infection control and to protect themselves from the quantity of infections going around. During an interview on 11/06/2024 at 5:50 PM, the Administrator said he expected for the staff to use hand hygiene and glove changes as necessary when needed. The Administrator said nursing administration was responsible for ensuring the staff perform proper hand hygiene and glove changes. The Administrator said he expected for the CNAs to provide proper incontinent care and fully clean the residents. The Administrator said he expected the CNAs to keep the residents from pulling the catheter tubing because this could cause trauma to the urethra (tube connected to the bladder for removal of urine). The Administrator said he expected for the staff to follow the enhanced barrier precautions. The Administrator said nursing administration was responsible for overseeing this. The Administrator said not following the enhanced barrier precautions could be a risk for contamination. Record review of the facility's policy titled, Urinary Catheter Management, review date 08/20/2021 indicated, Residents with indwelling catheters (urethral or suprapubic) shall receive appropriate care and services to prevent and manage catheter-related complications .Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination . Record review of the facility's policy titled, Incontinence Care, review date 02/14/2020 indicated, .put on non-sterile, latex-free gloves .cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, if needed or per incontinent product manufacturer's instructions . remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, brief or other incontinent products, as needed . Record review of the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, accessed on 11/13/2024 indicated, .5a. Hand Hygiene .use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately after glove removal . Record review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), accessed on 11/13/2024 indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: 1. Wounds or indwelling medical devices .

Based on observations, record review, and interviews, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 23 residents (Resident #76) reviewed for accommodation of needs. The facility treatment nurse failed to ensure Resident #76's lunch meal was fully accessible for her to eat on 11/04/2024 at the lunch meal, when the Treatment Nurse served Resident #76 her lunch meal and did not remove it off the tray and kept her plate on the warmer and covered with a lid. This failure could have placed resident at risk of having nutritional needs gone unmet. Findings included: Record review of Resident #76's face sheet dated 11/06/2024 indicated she was a [AGE] year-old female who readmitted to the facility on [DATE] with the diagnoses vascular dementia(disease in which it causes memory loss in older adults), glaucoma of left eye severe stage(eye condition that causes blindness), high blood pressure, depression(condition associated with lowering of a person's mood), anxiety(intense worry or fear), and need for assistance with personal care. Record review of Resident #76's quarterly MDS dated [DATE] indicated she was able to make herself understood, she could understand others, and she had impaired vision. The MDS also indicated she had a BIMS score of 8 which meant she had moderately impaired cognition. Record review of Resident #76's care plan revised 08/20/24 indicated Resident #76 had an ADL self-care performance deficit with interventions for supervision and setup for eating. During an observation of lunch in the dining room on 11/04/2024 starting at 12:15 PM, the Treatment Nurse served Resident #76 her lunch meal and did not remove it off the tray and kept her plate on the warmer and covered with a lid. The Treatment Nurse then walked away. Resident #76 said she could not see what was on her plate because she was blind in one eye. The resident next to Resident #76 assisted her by removing the lid off her plate, turning the plate towards and closer to Resident #76, so she could eat. During an interview on 11/04/2024 at 2:27 PM, the Treatment Nurse said she was familiar with Resident #76, but she was not in the dining room a whole lot. The Treatment Nurse said Resident #76 did not have any vision issues. The Treatment Nurse said she was new, and she did not know if she was supposed to uncover the residents' meals, but she was under the impression not to uncover the plates. The Treatment Nurse said she did not know if it was okay to leave the plates on the tray or not. The Treatment Nurse said from her observations at mealtimes sometimes the plates were left on the trays and sometimes they were not. The Treatment Nurse said to her it was not a big deal whether the plate was left on the tray or not. The Treatment Nurse said it was important to uncover the plate for the residents and ask them if they needed assistance. The Treatment Nurse said she had not asked Resident #76 because she knew Resident #76 did not require assistance and she could set up her own tray. The Treatment Nurse said it was important to assist the residents with their meals so they could have the same quality as those who can set up their meals themselves and it would not be fair to them to not have the assistance they require. During an interview on 11/06/24 at 5:46 PM the DON said she expected all of staff in the dining room assisting with meals to set the plates up for the residents and provide salt and pepper, or whatever else the resident may need during that meal. She said the failure placed a risk for residents not eating what they need. The DON said the failure could also cause a decline or weight loss in the residents. The DON said everyone who passed trays in the dining room were responsible. During an interview on 11/06/24 at 6:05 PM the Administrator said whoever passed the trays in the dining room for meal services was responsible for setting up the trays for each resident and ensuring the resident had what they needed. The Administrator said the failure placed a risk for malnutrition and weight loos for the residents. Record review of the policy Resident Rights dated 2/20/2021 indicated: Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights. The resident [NAME] the right lo a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States . 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including .c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 2 residents (Resident #40) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #40 was appropriately apprised of progress toward resolution when Resident #40's pink pants were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #40 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included sequelae of unspecified cerebrovascular disease (medical conditions that affect the blood vessels of the brain and circulation of blood to the brain). Record review of the MDS assessment indicated Resident #40 was understood by others and was able to understand others. The MDS assessment indicated Resident #40 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #40 was dependent for dressing, toileting, personal hygiene, and bathing/showering. During an interview on 11/04/2024 at 2:52 PM, Resident #40 said she had told the laundry aide she was missing a pair of pink capri pants. Resident #40 said the laundry aide told her she did not remember washing that color capri for her, but she would keep her eye out for them. Resident #40 said it had been about a month and the laundry aide had not let her know anything. During an interview on 11/06/2024 at 11:39 AM, Laundry Aide B said Resident #40 had reported to her she was missing a pair of pink pants. Laundry Aide B said it had been a while since Resident #40 reported the missing pants. Laundry Aide B said when the residents were missing clothing, they would look through the clothes, the lost and found, and if she was unable to find the missing item, tell the resident she was still looking for the clothes. Laundry Aide B said she had notified her supervisor, the Environmental Services Manager, that Resident #40 was missing a pair of pink pants. Laundry Aide B said the Environmental Services Manager was responsible for filing a grievance when a resident's clothing was not found. Laundry Aide B said she did not think a grievance had been filed yet. Laundry Aide B said it was important for the residents' clothing to be returned to them because they did not have much, and everybody needed their clothes. Laundry Aide B said it was important for a grievance to be filed in case the clothes were not found, so they could be in the process of replacing them. During an interview on 11/06/2024 at 11:49 AM, the Environmental Services Manager said if the resident was missing something they would let the Social Worker know for her to file a grievance. The Environmental Services Manager said she did not know anything about Resident #40 missing a pair of pink pants. the Environmental Services Manager said Laundry Aide B usually notified her if something was missing, but she was not aware of Resident #40 missing a pair of pink pants. Therefore, she had not notified the Social Worker for a grievance to be filed. The Environmental Services Manager said it was important for the residents to get their clothing back because they needed them, and it was their personal property. The Environmental Services Manager said it was important for a grievance to be filed so they could work together as a team to recover the lost items, and everyone was aware of it. During an interview on 11/06/2024 at 5:57 PM, the Administrator said if clothes were missing, they would look for them and then write a grievance. The Administrator said if the missing clothes were not found they would replace them. The Administrator said a grievance should have been filed for Resident #40's missing pink pants, and anybody could have filed the grievance. The Administrator said whoever took the residents grievance should write it up and give it to the Social Worker. The Administrator said it was important for the residents to have their clothing returned so they had something to wear. Record review of the facility's, Grievance Policy, revised 07/22/2023, indicated, .Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents .The right to file grievances orally, or in writing in the language he/she understands .

Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 23 residents (Resident #63) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #63 on 11/04/2024,11/05/2024, and 11/06/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 11/06/2024, revealed Resident #63 was a [AGE] year old female with diagnoses which included malignant neoplasm of unspecified part of the right bronchus or lung (cancer that forms in tissues of the lungs, usually in the cell lining air passages), chronic respiratory failure with hypoxia (chronic respiratory failure with hypoxia), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side ( caused by damage to the right side of the brain). Record view of the MDS, dated [DATE], revealed Resident # 63 had a BIMS of 04 indicating severe cognitive impairment. Resident #63 required assistance of two person for dressing, bathing, and personal hygiene ADLs. Record view of the MDS, dated [DATE], revealed Resident # 63 had a BIMS of 04 indicating severe cognitive impairment. Resident #63 required assistance of two person for dressing, bathing, and personal hygiene ADLs. The MDS revealed Resident #63 did not reject care. Record review of care plan, with a revision date of 07/24/2024, indicated Resident # 63 has an ADL self-care performance deficit. Goal: Resident # 63 will maintain a sense of dignity be being clean, dry, odor free and well groomed. Interventions: Resident #63 prefers to have long fingernails. Bathing total care dependent times two person assist, provide shower, shave oral care, hair care, and nail care per schedule when needed. During an observation on 11/04/2024 at 9:48 a.m. Resident # 63 was observed black material under fingernails. During an observation on 11/05/2024 at 9:32 a.m. Resident # 63 was observed black material under fingernails. During an observation on 11/06/2024 at 9:35 a.m. Resident # 63 was observed black material under fingernails. During an interview on 11/06/2024 at 8:58 a.m., CNA K stated it was the CNAs responsibility to ensure the residents fingernails were clean during showers or when needed. CNA K stated it was important to keep resident fingernails clean to keep bacteria down. CNA K stated Resident # 63 could put her hand in her mouth and the bacteria cause sores in her mouth or infection. During an interview on 11/06/2024 at 2:58 p.m., the DON stated it was the CNAs usual cleaned the resident's fingernails on bath days. The DON stated it was important to keep Resident #63 fingernails clean for infection control and dignity purposes. The DON stated she would monitor by making frequent rounds. During an interview on 11/06/2024 at 4:48 p.m., the Administrator stated he expected the CNAs to keep residents clean and dry. The Administrator stated Resident #63 requires long fingernails and digs in her brief. The Administrator stated there could be a risk to Resident #63 putting dirty fingernails in her mouth. The Administrator stated he would monitor by making rounds. Record review of the facility's policy titled Activities of Daily Living Care Guideline dated 2/11/2021, A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 2 residents (Resident #72) reviewed for urinary catheters. The facility failed to ensure CNA H provided proper catheter care to Resident #72 on 11/06/2024. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #72 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and urinary retention. Record review of a Comprehensive MDS assessment dated [DATE] indicated Resident #72 was sometimes able to make herself understood and was sometimes able to understand others. The MDS assessment indicated Resident #72 had a BIMS score of 3, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #72 was dependent on staff for all ADLs. The MDS assessment indicated Resident #72 had an indwelling catheter. Record review of Resident #72's care plan revised 10/30/2024 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner and required substantial/maximum assistance with toileting. Resident #72's care plan indicated she had a urinary catheter and was at risk for urinary tract infections and injury. Resident #72's care plan indicated catheter care every shift. The care plan indicated Resident #72 required enhanced barrier precautions to wear gown and gloves during high-contact resident care activities. Record review of Resident #72's Order Summary Report indicated to provide catheter care every shift with a start date of 09/26/2024. During an observation and interview on 11/06/2024 starting at 2:12 PM, CNA G and CNA H provided incontinent care to Resident #72. CNA G and CNA H put on PPE and gloves. CNA H cleaned Resident #72's left peri area and wiped down the middle. CNA H did not wipe Resident #72's right peri area and she did not clean the foley catheter tubing (thin, flexible tube used to drain urine out of your body from your bladder). Resident #72 was turned on her side. When she was turned on her side Resident #72 got a hold of her catheter tubing. CNA G cleaned Resident #72's back peri area. CNA G changed gloves and Resident #72 was turned back onto her back. Resident #72 was still holding her catheter tubing. CNA H removed her gloves. Resident #72 was still holding her catheter tubing when they covered her up. After this, CNA H and CNA G decided Resident #72 needed to be pulled up in the bed. When CNA H and CNA G pulled up Resident #72 in the bed she started pulling at the catheter. CNA H intervened and stopped Resident #72 from pulling the catheter further, and they finished repositioning her in the bed. CNA H said she thought she had cleaned both sides of Resident #72's front peri area. CNA H said when cleaning a resident with a catheter she should hold the tubing and wipe down it to clean it. CNA H said she should clean the peri area properly and the catheter tubing properly because they could have bacteria and germs and so the resident would not get an infection. CNA H said when providing care to Resident #72 she should be looking at the foley catheter tubing. CNA H said it was important to pay attention to where the foley catheter tubing was so it would not get pulled out and rupture something. During an interview on 11/06/2024 at 4:38 PM, ADON O said when performing incontinent care, the CNAs should clean from inside/out, clean the foley from top to bottom. ADON O said they should clean the tube, but make sure they do not pull it. ADON O said the CNAs should be aware of where the catheter tubing was at all times, and they should be aware of where the residents' hands and limbs were. ADON O said it was important for them to be aware of where the foley catheter tube was because it could cause trauma, pain, injury, and it was a risk for infection. ADON O said when providing incontinent care, the CNAs should be trying to clean the residents completely. ADON O said it was important to keep the skin clean and to prevent infections. During an interview on 11/06/2024 at 5:22 PM, the DON said during incontinent care the CNAs were supposed to clean both sides on the front peri area, and they should be cleaning the foley catheter tubing when providing incontinent care on someone with a foley catheter. The DON said it was important to completely clean the residents and clean the catheter tubing to prevent urinary tract infections, infections, and skin breakdown. The DON said the CNAs should be paying attention to where the residents foley catheter tubing was located while providing incontinent care. The DON said it was important to prevent trauma and risk for infection. The DON said the CNAs practiced incontinent care on the mannequins, and she randomly observed the CNAs perform incontinent care. The DON said she had not noticed any issues with incontinent care. During an interview on 11/06/2024 at 5:50 PM, the Administrator said he expected for the CNAs to provide proper incontinent care and fully clean the residents. The Administrator said he expected the CNAs to keep the residents from pulling the catheter tubing because this could cause trauma to the urethra (tube connected to the bladder for removal of urine). Record review of the facility's policy titled, Urinary Catheter Management, review date 08/20/2021 indicated, Residents with indwelling catheters (urethral or suprapubic) shall receive appropriate care and services to prevent and manage catheter-related complications . Properly position drainage bag and tubing below the level of the bladder and in a dependent position to facilitate flow of urine. Avoid allowing the drainage bag or tubing to touch the floor. Avoid positioning resident on tubing. Do not coil drainage tubing on bed or chair. Avoid loops in tubing: when in bed, hang drainage bag on bed frame (not side rail) towards the foot of the bed; when up in wheelchair or geri-chair, use a leg bag instead of a bedside drainage bag unless contraindicated by resident's condition .Provide perineal/catheter care with a perineal cleanser or mild soap and water at least once daily and promptly after fecal soiling to reduce the potential for bacterial contamination .

Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 2 residents (Residents #2) reviewed for respiratory care. The facility failed to ensure Resident #2 had an order for oxygen. This failure could place residents requiring respiratory care at risk for respiratory complications. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term and long-term memory problem. The MDS assessment indicated Resident #2 required partial/moderate assistance with eating, oral hygiene, substantial/maximal assistance with personal hygiene, and dependent for bathing/showering. The MDS assessment did not indicate Resident #2 used oxygen. Record review of Resident #2's care plan revised 09/17/2024 did not indicate the use of oxygen. Resident #2's care plan indicated she had hospice/terminal prognosis with interventions to coordinate with the hospice to ensure the resident's spiritual, emotional, physical, intellectual, and social needs were met. Record review of Resident #2's Order Summary Report dated 11/04/2024 indicated oxygen at 2-4 liters via nasal canula for shortness of breath or saturation less than 90% as needed with an order date of 10/28/2024 and a start date of 11/04/2024. Record review of Resident #2's progress notes indicated 10/28/2024 hospice here stated oxygen saturation 78 placed on oxygen at 2 liters via nasal canula, signed by RN C. During an observation on 11/04/2024 starting at 9:23 AM, Resident #2 was in bed, an oxygen concentrator with a nasal cannula attached was at Resident #2's bedside, but not in use. LVN E entered the room, checked Resident #2's oxygen saturation and applied the oxygen via nasal cannula at 2 liters. During an interview on 11/04/2024 at 2:29 PM, LVN E said she had noticed Resident #2 had oxygen in her room, but when she checked Resident #2's physician's orders she had not seen an order for oxygen. LVN E said she read a note in Resident #2's progress note that indicated she was started on oxygen on 10/28/2024. LVN E said she asked the hospice nurse about the oxygen order, and they said Resident #2 should have had an order from 10/28/2024. LVN E said it was important for Resident #2 to have an order for oxygen, so everyone knew she was supposed to receive oxygen and to ensure she was receiving the amount of oxygen she needed per the doctor's order. During an interview on 11/04/2024 at 3:27 PM, Hospice RN D said she had visited Resident #2 on 10/28/2024 and her oxygen saturation was low, so she placed oxygen on her at 2 liters via nasal cannula. Hospice RN D said she had given RN C a verbal order for oxygen 2-4 liters per min as needed. Hospice RN D said the facility did not have written orders for them to write down physicians' orders, so the hospice nurse went back to the hospice office put in the order and took kit back to the facility the same day. Hospice RN D said she was not able to remember if she had sent an order over to the facility. Hospice RN said it was important for the orders to be communicated so that everybody was aware of what was going on and the resident was given the care they needed. Hospice RN D said Resident #2 not having an order for oxygen could result in her oxygen getting too low. During an interview on 11/06/2024 at 11:18 AM, RN C said the hospice nurse visited Resident #2, and told her that her oxygen saturation was 70 something and she had put oxygen on Resident #2. RN C said since Resident #2 was a hospice patient and the hospice nurse had put oxygen on her, RN C said she had assumed that Resident #2 had an order for oxygen. RN C said the hospice nurse had not given her a new order for oxygen. RN C said she should have checked for an oxygen order and not just assumed Resident #2 had an order for oxygen. RN C said it was important for there to be an oxygen order for the residents to be more oxygenated and to help them stay alive. During an interview on 11/06/2024 at 5:17 PM, the DON said the nurse had taken the verbal order from the hospice company for Resident #2's oxygen, and normally the hospice faxed over the order, and it was placed in the resident's electronic health record. The DON said if the nurses noticed there was not order for oxygen, they should contact the hospice for an order. The DON said the hospice should have provided the order for the oxygen. The DON said it was important for Resident #2 to have an order for oxygen because she could decline and could pass away if her oxygen was too low or have respiratory distress, and so they could practice within their scope of practice. Record review of the facility's policy titled, Respiratory: Oxygen Administration, review date 02/10/2020, indicated, To describe method for delivering oxygen in order to improve tissue oxygenation, prevent hypoxia, decrease work of breathing and prevent shortness of breath with activity . Verify Physician's order . Hook cannula tubing behind ears and under chin .Set flow rate .

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 3 residents (Resident #32) reviewed for quality of care. Resident #32 was sent to the local hospital on [DATE] for [CONDITION(S)]. Resident #32 was diagnosed with acute kidney failure and septic shock. Resident #32 died on [DATE] from complications related to kidney failure. The facility failed to implement interventions of Resident #32's care plan by failing to monitor the resident for cracked lips, poor skin turgor, thirst, decreased output, lethargy, elevated temperature, low blood pressure with increased pulse, and weight loss and notifying the MD of changes. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 3:05 PM. While the IJ was removed on [DATE] at 2:37 PM, the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need evaluate the effectiveness of the corrective systems. The failure could place residents at risk for infections, hospitalization , or death. Findings include: Record review of Resident #32's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of Resident #32's quarterly MDS, dated [DATE], reflected he had a BIMS score of 13, which indicated minimal impaired cognitive status. His functional status reflected he required extensive assistance with bed mobility, toilet use and personal hygiene. His bowel and bladder function were recorded as always incontinent of bladder and frequently incontinent of bowel. His weight was recorded as 159 pounds with a loss of 5% in 30 days and not on a physician's prescribed weight loss. Record review of Resident #32's care plans in the EHR reflected the following care plans on [DATE]: - Resident #32 had an ADL selfcare performing deficit and is at risk for not having needs met in a timely manner. The interventions for selfcare performing deficits were for staff to provide assistance as needed and therapy to evaluate and treat as indicated. - Resident #32 had a freedom from dehydration related to diuretic usage care plan. Interventions for dehydration included monitoring the resident for cracked lips, poor skin turgor, thirst, decreased output, lethargy, elevated temperature, low blood pressure with increased pulse, and weight loss and notifying the MD of changes. - No care plan was noted to weight loss. Record review of Resident #32's progress notes from [DATE] until [DATE] in the EHR on [DATE] reflected the following: -[DATE] at 5:26 PM, RN A wrote: complains of lower abdomen pain, order received for UA with C&S. Daughter in room aware. Medicated with [MEDICATION(S)] 100mg for pain. -[DATE] at 1:04 AM, LVN B wrote: Resident complaining of abdomen pain new order for urine C & S unable to get at this time, will try later -[DATE] at 1:58 AM, LVN C wrote .Resident denies abdominal pain at present. Urine picked up for C & S -[DATE] at 1:45 PM, LVN D wrote: UA results reported to Dr. [E ]with new orders for [MEDICATION(S)] 1gm intramuscularly for 7 days. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Will give initial dose out of e-kit (emergency kit). 'Daughter' notified. -[DATE] at 8:17 AM, RN A wrote: T97.9 continue on [MEDICATION(S)] 1 gm IM for [CONDITION(S)] with no adverse reaction noted. Fluids encouraged and taken well. Continue to complain of pain in lower abdomen. -[DATE] at 11:39 AM, RN A wrote: T 97.1 in bed no distress. No adverse reaction to [MEDICATION(S)] 1 gm IM for [CONDITION(S)]. Taking oral fluids still has discomfort to lower abdominal area. -[DATE] at 8:25 AM, RN A wrote: T 98.1. Continues [MEDICATION(S)] 1 gm IM daily for [CONDITION(S)]. No adverse reaction noted. Oral fluids given. Often states still has some discomfort in lower abdomen but it is better. -[DATE] at 11:30 AM, LVN D wrote: Final urine culture results with new orders to start [MEDICATION(S)] 100mg on orally once daily for 5 days for yeast infection .12pm initial dose given out of e-kit. -[DATE] at 8:38 AM, LVN D wrote: 96.[DATE]-,d+[DATE] oxygen saturation 93% on O2 at 2 liters per minute via nasal cannula .no adverse reaction noted to [MEDICATION(S)] 1 gram IM daily x 7 days or [MEDICATION(S)] 100mg orally daily x 5 days for yeast infection. -[DATE] at 9:48 AM, RN A wrote: No adverse reaction noted to completed [MEDICATION(S)] or [MEDICATION(S)] for yeast. -[DATE] at 11:48 AM, RN A wrote- ,d+[DATE]-,d+[DATE].,d+[DATE]. O2 sat 90. Lethargic blowing respiration difficulty swallowing. 911 notified. Daughter notified. 1150 transferred to local hospital via EMS. Record review of Resident #32's lab results for a urinalysis on [DATE] in the EHR on [DATE] reflected the following: - + Glucose (indicative of high blood glucose or kidney damage) - + Blood (Urinary tract infections, kidney stones and prostate problems are common reasons for this symptom) - + Leukocyte Esterase (sign that you have an infection or an obstruction in the urinary tract or bladder.) Record review of Resident #32's lab result, final culture of urinalysis on [DATE] in the EHR on [DATE] reflected the following: - [MEDICATION(S)] glabrata (fungus/yeast) was detected - No gram-negative bacteria were detected - No gram-positive bacteria were detected Record review of Resident #32's [DATE] MARS in the EHR on [DATE] reflected the following: -an order for [MEDICAL RECORD OR PHYSICIAN ORDER] < ,d+[DATE] or Pulse is < 60 and notify MD [MEDICATION(S)] held on: -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]-B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] The MD was not notified of these blood pressures. -[MEDICATION(S)] 20mg once daily; hold if B/P <,d+[DATE] or Pulse is < 60 and notify MD. [MEDICATION(S)] held on: -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] The MD was not notified of these blood pressures. -[MEDICATION(S)] 50mg twice daily; hold if B/P <,d+[DATE] or Pulse is < 60 and notify MD. -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P ,d+[DATE] -[DATE]- B/P (am) ,d+[DATE]-P-100; B/P (pm),d+[DATE] -[DATE]- B/P ,d+[DATE]- P-103 -[DATE]- B/P ,d+[DATE]- P 111 -[DATE]- B/P ,d+[DATE]- P-99 -[DATE]- B/P (am) ,d+[DATE]-P-100; B/P (pm) ,d+[DATE] -[DATE]-B/P (am) ,d+[DATE]-P-108; B/P (pm) ,d+[DATE] The MD was not notified Record review of Resident #32's hospital records, dated [DATE], reflected he had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The most common symptom is severe pain, usually in the side of the abdomen.) He was diagnosed with [CONDITION(S)] related to prerenal azotemia (an abnormally high level of nitrogen waste products in the blood) and [CONDITION(S)] related to dehydration and urinary tract infection(A life-threatening complication of an infection. Symptoms include low blood pressure, fast heart rate, and mental confusion). On admission to the ER his labs were: -[MEDICATION(S)] 10.86 mg/dL (normal range 0.7 to 1.3 mg/dL) (High levels of creatinine in the blood or urine can be a sign that the kidneys are not filtering the blood effectively), -Potassium 5.9 mmol/L (normal range 3.,d+[DATE].0 mmol/L) -Anion gap 26 mmol/L (normal range ,d+[DATE] mmol/L)( high anion gap test result may mean that you may have acidosis. Acidosis may be caused by: Dehydration). - BUN 137mg/dL (normal range ,d+[DATE] mg/dL) (a high BUN level means your kidneys aren't working well. But elevated BUN can also be due to: Dehydration, resulting from not drinking enough fluids or for other reasons. Urinary tract obstruction) -gFR 4.63 mL/min (normal range ,d+[DATE] mL/min) (gFR number is an estimate of how well the kidneys are working and keeping you healthy. If a gFR number is low, it signifies the kidneys are not working as well as they should). During a telephone interview on [DATE] at 9:45 AM, MD F stated he was the MD for Resident #32 and was familiar with his case. MD F stated Resident# 32 was sent to theER on [DATE] for [CONDITION(S)] and change in mental status. MD F stated a few days later, on [DATE] Resident #32 expired at the hospital from kidney failure due to [CONDITION(S)] and dehydration. MD F stated Resident #32 had to get several liters of fluids (5 liters) while in the ER to reverse the [CONDITION(S)] and he was in acute renal failure. MD F stated being born with one kidney did not affect Resident #32. MD F explained one kidney could function as two kidneys once they body got acclimated to having only one kidney. MD F explained his choice of IM [MEDICATION(S)] as part of attempting to treat a urinary tract infection while still trying to abide by antibiotic stewardship. MD F stated he started the [MEDICATION(S)] as soon as the culture came back to show it was a yeast. MD F stated he could only rely on the information that the nurses conveyed to him on the resident's condition because he was not there daily. MD F stated he was not given any information to suggest that Resident #32 was not recovering from the urinary tract infection and not drinking. MD F stated he encouraged the staff to open blinds and put fresh water in reach of the residents when he made rounds at the facility. MD F stated the last time he saw Resident #32 he placed fresh iced water in reach of the resident. MD F stated he was not informed of Resident #32's low blood pressure, high pulse, not drinking well, or that his blood pressure medication was being held so frequently. MD F stated all of these signs point to [CONDITION(S)] or dehydration. MD F stated he expected the nurses to call him for low blood pressure and changes in cognitive status. MD F stated he would have sent Resident #32 to the hospital for IV fluids and medication. MD F stated IV hydration in a LTC facility is a difficult task because residents will pull the IV out or they will become occluded. During an interview on [DATE] at 1:00 PM, Med Aide E stated she noticed something wrong with Resident #32 around [DATE]. Med Aide E stated he was sleeping more, harder to arouse to take his medications, started to have lower blood pressures, and seemed slower mentally. Med Aide E stated she reported all the changes she noted in Resident #32 to RN A and she said she would go check on him. Med Aide E stated when she came back to her next scheduled shift to work, Resident #32 was worse, and she called Resident #32's daughter. Resident #32's daughter requested a urinalysis be done and Med Aide E stated she informed RN A on [DATE] of the daughter's request. Med Aide E stated a few days later the MD started Resident #32 on [MEDICATION(S)] injection for a [CONDITION(S)]. Med Aide E stated she was never instructed by the nurse to increase fluids. Med Aide E stated in the past an order was added to the MAR to instruct the nurses and medication aides to encourage water. Med Aide E stated she reported each held dose of blood pressure medication to RN A so that she could assess the resident and inform the MD as ordered. Med Aide E stated it was the nurses responsiblity to notify the MD of all changes. Med Aide E stated she never saw RN A assess Resident #32. Med Aide E stated she did not see an improvement in Resident #32 from the IM antibiotic. During an interview on [DATE] at 2:45 PM, CNA F stated he was not normally on the hall Resident #32 resided on, but he assisted in changing him several times. CNA F stated the week of [DATE] he went to visit Resident #32 and noticed he was completely different than he normally was. He stated Resident #32 was not able to feed himself and was very lethargic. CNA F stated he did incontinent care on Resident #32 because he smelled a foul odor. CNA F stated his brief had a foul-smelling pus like substance in it and coming out of the end of Resident #32's penis. CNA F stated each time he wiped the pus substance away more oozed out of his penis. CNA F stated he immediately went and informed RN A of the findings. CNA F stated RN A never left the desk and he waited over 15 minutes at the nurses' station for RN A to come with him to view the diaper and drainage. There was no documentation in Resident #32's chart of the drainage. CNA F stated that ice and water was passed at the beginning of each shift and in the middle of each shift. CNA F stated Resident #32 could not have given himself a drink of water in his condition. During an interview on [DATE] at 1:45 AM, RN A stated Resident #32 had a change on [DATE] that required he be sent to the ER. RN A stated Resident #32 became hypotensive and was having trouble breathing. RN A stated Resident #32 had recently been on [MEDICATION(S)] for a [CONDITION(S)] and was on [MEDICATION(S)] for a yeast infection in his urine. RN A stated the CNAs were encouraging fluids and Resident #32 was taking them well. RN A stated she was unaware of hypertensive medications being held for low blood pressures. RN A stated she did not audit the MARS unless the Medication Aide told her she had to hold a medication. RN A stated she would have retaken the vital signs and informed the MD if she had been made aware of the low blood pressure and increased pulse rates. RN A stated she was not aware Resident #32 had a pus like discharge from his penis. RN A stated she was never told he was not eating or drinking. During an interview on [DATE] at 2:30 pm, the DON stated it was her expectation the nurse notified a NP or MD if a resident had a change in condition and notification could be made anytime during their shift. The DON stated with Resident #32 the facility was encouraging fluids. Resident #32 just finished IM [MEDICATION(S)], and was on [MEDICATION(S)] when he was discharged . The DON stated it was unfortunate Resident #32 expired and the facility was putting things in place to prevent residents from becoming dehydrated like starting hydration rounds and adding a hydration cart. The DON stated she did not know how Resident #32 became dehydrated. The DON stated she had not done in servicing with the staff on hydration, had not done an investigation about Resident #32's conditions that lead up to his death, and she had not implemented new interventions for hydration for dependent residents. The DON stated she had not gotten around to implementing those interventions yet. The DON stated no labs other than a UA were requested for Resident #32 prior to his discharge to the hospital. The DON stated [MEDICATION(S)] was not sensitive to (effective against) the fungus/yeast found in Resident #32's urine. The DON stated she expected the nurses to communicate all changes in resident behavior and major changes in vital signs to her and the MD. The DON stated that ice and water was passed twice a shift by the CNA assigned to the hall. In an interview on [DATE] at 2:47pm, the ADM said he expected for the nurses to communicate with doctors as needed to provide the best quality of care possible for each resident. The ADM and DON were notified on [DATE] at 3:05 pm, an Immediate Jeopardy situation was identified due to the above failures. The administrator was provided with the IJ template on [DATE] at 3:07 p.m. The following plan of removal was submitted by the facility and was accepted on [DATE] at 6:55 p.m.: 1. Identification of Residents Affected or Likely to be Affected: Immediately on [DATE]. The DON and ADONs completed a head-to-toe evaluation on all residents which included vital signs and hydration assessment (dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, constipation, dizziness on sitting/standing, confusion or change in mental status, decreased urinary output). The DON/ADON will notify the physician of residents identify to have a change of condition and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The DON/designee supervised the nurse aides who passed regular water to residents, refreshed bedside thick liquids, placed water within the resident's reach, and offered water to all residents. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____[DATE]____________ 2. Actions to Prevent Occurrence/Recurrence: On [DATE] DON/designee in serviced on the nurses and nurse and nurse aides on the Hydration Policy that addresses the evaluating the residents for signs/symptoms of dehydration, placing water within reach, providing sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. On [DATE] DON/designee in- serviced the nurses on the Notification of Change Guidelines that provide guidance on promptly informing 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. On [DATE] the DON/designee in-serviced the nurses on INTERACT 4.0 When to Notify the Physician and NP that provide guidance on signs/symptoms that require immediate notification On [DATE] the DON/designee will give a Post Test on the Hydration Policy, Notification of Change Guidelines, and INTERACT 4.0 No nurse or nurse aide will be allowed to start the shift until the in-services are completed Additional Actions to prevent recurrence. The DON and ADONs will complete walking rounds and observation on residents with a change of condition before the IDT Morning Meeting. The walking rounds and observation will be documented on the 24 hr. Report A review of the food intake, BMs, and weights in the past 24 hours will be completed by the DON and IDT during the Morning Meeting to identify the potential for dehydration. Residents identified with the potential for dehydration, the physician will be notified for further interventions. The DON/ADON will supervise the hydration pass three times a day to monitor that the nurses and aides are offering and assisting the resident to take fluids The nurses will check the placement of resident's water during their time on the unit, offer fluids and monitor that the nurse aides are offering water during resident contact. The Licensed Nurse will review the Med Aides Medication Administration Record at the end of each medication pass to identify BPs that require MD notification. The Licensed Nurse will initial the MAR verifying the audit was completed. The ADON will complete an audit daily of the Medication Aides' Medication Administration Record and validate the nurse has notified the physician of out-of-range BPs. The audit will be documented by the ADONs on a QAPI Tool daily for four weeks. The audit will be submitted to the DON. During the monthly QAA Meeting the DON will report and discuss the hydration process. The Administrator and QAA committee will validate that the hydration process is sustained monthly. Completion Date: [DATE] Monitoring of the POR included: Record review of the in-service on [DATE] at 1:00 PM provided to the nurse and nurse aides on the Hydration Policy that addressed evaluating the residents for signs/symptoms of dehydration, placing water within reach, providing sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Record review of the in-service on [DATE] at 1:00 PM, provided to the nurses on the Notification of Change Guidelines that provided guidance on promptly informing the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there was a change requiring notification. Record review of the in-service on [DATE] at 1:00 PM, provided to the nurses on INTERACT 4.0 When to Notify the Physician and NP that provided guidance on signs/symptoms that required immediate notification. Record review of the post test on the Hydration Policy, Notification of Change Guidelines, and INTERACT 4.0 revealed: - The Hydration Policy revealed the facility offers each resident sufficient fluids, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .The resident will be monitored for signs and symptoms of dehydration including, but not limited to: dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, constipation, change in mental status, and decreased urinary output The physician will be notified of signs and symptoms of dehydration, fluid overload, electrolyte imbalance, or conditions that may increase fluid needs, lack of improvement toward goals, and any complications associated with interventions. - Notification of Change Guidelines: to provide guidance on when to communicate acute Changes in status to MD, NP, and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member (s) of the following: 1. An accident resulting in injury to the resident that potentially requires physician intervention. 2. An emergency response situation that requires EMS involvement. 3. A significant change in the physical, mental and psychological status of the resident. 4. The need to significantly alter the resident's treatment. 5. A decision to transfer or discharge the resident to another facility. 6. A change in room or roommate assignment. 7. A change in resident rights under Federal or State law, including changes to items and services included under State plans. 8. The facility's Medical Director will be contacted if the attending physician can not be contacted and/or does not respond timely. - Interact 4.0 SBAR document was to be completed when any change of condition occurs entirely. The MD was to be called using the SBAR as a guide to ensure nothing was missed when a clinical assessment was conveyed to the MD. Interviews conducted on [DATE] at (1:40 p.m., CNA G)(1:45 p.m., CNA H); (2:08 p.m. CNA F), (2:13pm CNA I); (2:20 p.m. CNA J), (2:28 p.m. CNAK), (2:38 p.m. CNA I), (2:50p.m. LVN L), (2:55p.m.LVN M), (3:02pm RN A), (3:15pm LVN N), and (3:22pm LVN O) revealed they had received education on signs and symptoms of dehydration, reporting changes in condition, communication of held medication, notifying the MD, new process of reporting abnormal B/P to nurse, ensuring hydration is in reach and offered to all residents according to diet, and new hydration cart schedule. The interview revealed staff was aware of the facility's policy on notification of changes to the MD with acceptable time frames. The staff revealed the nurse assigned to the resident would notify the MD of abnormal vital signs. The staff revealed they all must assist with passing ice and water twice each shift and offering hydration at least every 2 hours. The staff revealed the use of a hydration cart by the CNAs at 10am-2pm and 8pm for added hydration. Record reviews of all hydration assessment audits on [DATE] revealed the DON, ADON and MDS nurse assessed each resident in the facility for signs and symptoms of dehydration, recorded the information and noted one resident that needed intervention. The DON notified the MD and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a policy, dated [DATE], titled Hydration revealed the facility offers each resident sufficient fluids, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .The resident will be monitored for signs and symptoms of dehydration including, but not limited to: dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, constipation, change in mental status, and decreased urinary output The physician will be notified of signs and symptoms of dehydration, fluid overload, electrolyte imbalance, or conditions that may increase fluid needs, lack of improvement toward goals, and any complications associated with interventions. The DON was informed the Immediate Jeopardy was removed on [DATE] at 2:34 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to consult with the physician for a significant change in condition for 1 of 5 resident reviewed for physician notification. (Resident #1) The facility did not report to the physician when Resident #1's family reported to RN [NAME] on [DATE] she was not herself and had increased sleepiness and when MA G and CNA B reported to LVN H, LVN J, and RN A the resident was not herself, had difficulty swallowing her medication, and had a grayish color. Resident #1 was found deceased on [DATE]. This failure could place residents with a change of condition at risk for adverse effects from not receiving medical treatment to prevent exacerbations and/or complications of disease processes. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#1's medication [MEDICATION NAME] (for pain in lower extremities) increased from 300 mg to 600 mg daily at bedtime. The most recent MDS, a quarterly assessment, dated [DATE] indicated Resident #1 was cognitively intact, she understood and was understood by others. The MDS indicated Resident #1 required supervision with bed mobility, eating, toileting and personal hygiene. The MDS indicated she required extensive assistance with dressing, was occasionally incontinent of bladder and always continent of bowel. A care plan dated [DATE] indicated Resident #1 had impaired respiratory status due to a [DIAGNOSES REDACTED]. The care plan indicated Resident #1 was oxygen dependent and interventions included to monitor for signs and symptoms of respiratory distress and report to the physician as needed. The interventions indicated the signs of respiratory distress could include an increased respiratory rate, [MEDICAL CONDITION](increased heart rate), diaphoresis (excessive sweating), lethargy, confusion and changes in color such as a bluish or grey tint. A MAR indicated [REDACTED]. A notation on the back of the MAR indicated [REDACTED]. The notation was initialed by MA G and signed by LVN [NAME] There was no indication in Resident #1's medical record of notification of the physician of her changes or medication held. A nursing progress note dated [DATE] at 7:10 a.m., signed by RN [NAME] indicated Resident #1 was found in the bathroom slumped over in wheelchair and had no signs of life, no respirations, no carotid pulse and no peripheral pulse. The note indicated the resident's face and extremities appeared purple and cold. During an interview on [DATE] at 12:16 p.m., family member #1 said he visited Resident #1 on [DATE] at approximately 10 a.m. He said she was not feeling well, and he was concerned because he was going out of town for a couple of days. Family member #1 said he returned to the facility at around 1 p.m., and Resident #1 continued to complain of not feeling well. He said her color was pale and she seemed sleepy. Family member #1 said he asked MA G to hold her [MEDICATION NAME] at bedtime because she seemed groggy and out of it. He said he asked RN [NAME] to check on her because he was concerned and let him know if she needed anything. Family member #1 said he told 2 CNAs to look in on her and he could not recall their name. During an interview on [DATE] at 1:36 p.m., family member #2 said he visited Resident #1 on [DATE] between 5 p.m. and 7 p.m. He said she looked groggy and her eyes were glazed. Family member #2 said he asked a nurse, unable to recall her name, to hold her [MEDICATION NAME] 600 mg that evening. He said he told several of the staff to keep an eye on Resident #1 because he was worried. He said he was not able to give the names of the staff he spoke to because he did not know them by name. Family member #2 said on [DATE] at approximately 7:15 a.m., he was notified Resident #1 was found deceased . During an interview on [DATE] at 6:12 a.m., RN [NAME] said on [DATE] familiy membdf #1 visited Resident #1 a couple of times during his 6 a.m. to 6 p.m. shift. He said family member #1 was leaving to go out of town and asked him to check on the resident because she was not feeling well. RN [NAME] said this information was in passing as the family member was leaving the facility and it was not unusual for him to request staff to check on Resident #1. RN [NAME] said he did not do an assessment on Resident #1 because he was the RN supervisor and he was pulled in different directions. RN [NAME] said he did not tell LVN J, who was the charge nurse assigned to Resident #1 of the family members request to check on her. During an interview on [DATE] at 12:06 p.m., MA C said on [DATE] she walked past Resident #1's room after lunch. She said the resident was in her wheelchair sitting in the door way. MA C said Resident #1's face was swollen, and her color was pale. She said she asked her if she felt bad and the resident said she was not feeling good. MA C said she asked Resident #1 if she needed anything and she answered no. MA C said she did not remember if she told the charge nurse. During an interview on [DATE] at 9:56 a.m., MA G said on [DATE] during her 2:00 p.m. to 10:00 p.m. shift, Resident #1 had difficulty swallowing her 7:00 p.m. medications and this was unusual. She said the resident was not talkative like she usually was and said she did not feel good. MA G said Resident #1 was short of breath, but this was not unusual for her and she was using her oxygen. MA G said Resident #1's face was puffy, and her color was grayish. MA G said she reported Resident #1's difficulty swallowing medications and her concerns to LVN J and asked her to check on her. She said she did not see LVN J check on her because she was busy passing medications. MA G said family member #2 asked her to keep an eye on Resident #1 during her shift because he was worried about her. MA G said the family member was concerned about her not acting like herself and asked that her [MEDICATION NAME] 600 mg not be administered. MA G said she did not give the medication and she reported his request to LVN [NAME] MA G said at 10:15 p.m., she checked on Resident #1 and she was awake. During an interview on [DATE] at 2:36 p.m., LVN J said on [DATE] she worked 2:00 p.m. to 10:00 p.m. and Resident #1's family members asked to hold the 9:00 p.m., dose of [MEDICATION NAME] because she was sleepier than usual. She said the medication was held and she did not assess the resident or notify the physician. LVN J said it was not unusual for the resident to be sleepy and groggy because of her disease process. LVN J said she was told Resident #1 did not feel well by MA G and she did not write it on the 24-hour report because it was not unusual for her to feel bad. During an interview on [DATE] at 5:08 a.m., RN A said on [DATE] she was not scheduled to work the hall Resident #1 resided on. She said when she arrived to work around 9:45 p.m., MA G informed her Resident #1 was not feeling well and did not look herself. RN A said she reported the information to LVN H whom was assigned to Resident #1. RN A said she did not see Resident #1 during her shift. During an interview on [DATE] at 2:10 p.m., LVN H said she arrived to work on [DATE] at about 9:45 p.m. She said MA G told her Resident #1 was not feeling well during the evening shift. LVN H said she did not get any information from LVN J about the [MEDICATION NAME] medication being held and there was nothing on the 24-hour report to indicate concerns for Resident #1. She said she did not assess Resident #1 for the concerns reported to her by MA [NAME] LVN H said Resident #1 was independent and if she needed anything she used her call light. LVN H said she changed Resident #1's oxygen tubing during her shift and she could not remember the exact time. She said Resident #1 was sitting on the side of the bed with her oxygen on and had no complaints. During an interview on [DATE] at 5:35 a.m., CNA B said on [DATE] at approximately 11 p.m., Resident #1 was sitting in the wheelchair in her doorway. She said the resident's face was puffy and grayish in color. CNA B said Resident #1 told her she did not fell very well. CNA B said she reported to LVN H Resident #1 did not feel well, her face was swollen, and her color was grayish. CNA B said Resident #1 usually used her call light during the 10 p.m. to 6 a.m. shift to request Tylenol and an ice pack but she did not use her call light during her shift on [DATE]. CNA B said she did not check on Resident #1 during her shift on [DATE]. During an interview on [DATE] at 5:15 a.m., CNA D said on [DATE] at approximately 11:30 p.m., she entered Resident #1's room to fill her pitcher with water and ice. She said the resident was sleeping and she was wearing her oxygen mask. CNA D said Resident #1 usually used her call light during the 10 p.m. to 6 a.m. shift and requested Tylenol and an ice pack but she did not use the call light on [DATE] during her shift. During an interview on [DATE] at 5:51 a.m., the ADON said Resident #1's death was unexpected. She said she was notified on [DATE] around 7:15 a.m., by RN [NAME] of Resident #1's death. She said he told her she was found in her bathroom sitting in her wheelchair. The ADON said no one informed her Resident #1 had complained of not feeling well on [DATE]. During an interview on [DATE] at 3:12 p.m., the DON said she expected the CNAs to tell the LVN charge nurse if a resident had a change in condition and to follow up with the LVN to make sure they were heard. The DON said the LVN charge nurse should have assessed Resident #1 when her son requested the medication [MEDICATION NAME] to be held because of increased sleepiness. The DON she expected the charge nurse to notify the physician if a resident had a change of condition. The DON said staff do not generally check on residents whom are independent unless they use the call light. She said after the death of Resident #1 she instructed the staff to check on all resident's every 2 hours. The DON said she did not document the instruction to staff to check on all residents every 2 hours or obtain a signature of attendance. During an interview on [DATE] at 6:38 a.m., the administrator said Resident #1 died on the morning of [DATE]. She said she and the DON did an internal investigation at the request of the resident's family because the funeral home told the family the resident had been deceased for several hours. The administrator said upon viewing the video and gathering statements from staff the resident was last seen in her room awake with no complaints at approximately 5:30 a.m., by LVN H when she changed out the oxygen tubing. The administrator said LVN H was seen on camera entering the resident's room and exited approximately 10 minutes later. The administrator said Resident #1 was found by staff at approximately 7 a.m. in her wheelchair in the bathroom and she was not breathing and did not have a pulse. The administrator said there had been about an hour and a half window from the time she was last seen prior to her expiration. She said the video footage indicated Resident #1 was seen at approximately 12:30 a.m. and again at 5:30 a.m. The administrator said the resident was not checked every two hours because she was independent and capable of using her call light. She said it was not unusual for Resident #1 to feel bad because of her [DIAGNOSES REDACTED]. She said the LVN charge nurse probably should have assessed Resident #1 and notified the physician if needed. A policy titled Notification of Changes dated [DATE] indicated .the policy was to provide guidance on when to communicate acute changes in status to MD, NP and responsible party .the facility will immediately report to the physician of a significant change in the physical, mental or psychosocial status of the resident .

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 5 residents reviewed for quality of care. (Resident #1) The facility did not identify a change of condition and report to the physician when Resident #1's family reported to RN [NAME] on [DATE] she was not herself and had increased sleepiness and MA G and CNA B reported to LVN H, LVN J, and RN A the resident was not herself, had difficulty swallowing her medication, and had a grayish color. Resident #1 was found deceased on [DATE]. This failure could place residents with a change of condition at risk for adverse effects from not receiving medical treatment to prevent exacerbations and complications of disease processes. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].#1's medication [MEDICATION NAME] (for pain in lower extremities) increased from 300 mg to 600 mg daily at bedtime. The most recent MDS, a quarterly assessment, dated [DATE] indicated Resident #1 was cognitively intact, she understood and was understood by others. The MDS indicated Resident #1 required supervision with bed mobility, eating, toileting and personal hygiene. The MDS indicated she required extensive assistance with dressing, was occasionally incontinent of bladder and always continent of bowel. A care plan dated [DATE] indicated Resident #1 had impaired respiratory status due to a [DIAGNOSES REDACTED]. The care plan indicated Resident #1 was oxygen dependent and interventions included to monitor for signs and symptoms of respiratory distress and report to the physician as needed. The interventions indicated the signs of respiratory distress could include an increased respiratory rate, [MEDICAL CONDITION](increased heart rate), diaphoresis (excessive sweating), lethargy, confusion and changes in color such as a bluish or grey tint. A MAR indicated [REDACTED]. A notation on the back of the MAR indicated [REDACTED]. The notation was initialed by MA G and signed by LVN [NAME] There was no indication in Resident #1's medical record of notification of the physician of her changes or medication held. A nursing progress note dated [DATE] at 7:10 a.m., signed by RN [NAME] indicated Resident #1 was found in the bathroom slumped over in wheelchair and had no signs of life, no respirations, no carotid pulse and no peripheral pulse. The note indicated the resident's face and extremities appeared purple and cold. During an interview on [DATE] at 12:16 p.m., family member #1 said he visited Resident #1 on [DATE] at approximately 10 a.m. He said she was not feeling well, and he was concerned because he was going out of town for a couple of days. Family member #1 said he returned to the facility at around 1 p.m., and Resident #1 continued to complain of not feeling well. He said her color was pale and she seemed sleepy. Family member #1 said he asked MA G to hold her [MEDICATION NAME] at bedtime because she seemed groggy and out of it. He said he asked RN [NAME] to check on her because he was concerned and let him know if she needed anything. Family member #1 said he told 2 CNAs to look in on her and he could not recall their name. During an interview on [DATE] at 1:36 p.m., family member #2 said he visited Resident #1 on [DATE] between 5 p.m. and 7 p.m. He said she looked groggy and her eyes were glazed. Family member #2 said he asked a nurse, unable to recall her name, to hold her [MEDICATION NAME] 600 mg that evening. He said he told several of the staff to keep an eye on Resident #1 because he was worried. He said he was not able to give the names of the staff he spoke to because he did not know them by name. Family member #2 said on [DATE] at approximately 7:15 a.m., he was notified Resident #1 was found deceased . During an interview on [DATE] at 6:12 a.m., RN [NAME] said on [DATE] family member #1 visited Resident #1 a couple of times during his 6 a.m. to 6 p.m. shift. He said family member #1 was leaving to go out of town and asked him to check on the resident because she was not feeling well. RN [NAME] said this information was in passing as the family member was leaving the facility and it was not unusual for him to request staff to check on Resident #1. RN [NAME] said he did not do an assessment on Resident #1 because he was the RN supervisor and he was pulled in different directions. RN [NAME] said he did not tell LVN J, who was the charge nurse assigned to Resident #1 of the family members request to check on her. During an interview on [DATE] at 12:06 p.m., MA C said on [DATE] she walked past Resident #1's room after lunch. She said the resident was in her wheelchair sitting in the door way. MA C said Resident #1's face was swollen, and her color was pale. She said she asked her if she felt bad and the resident said she was not feeling good. MA C said she asked Resident #1 if she needed anything and she answered no. MA C said she did not remember if she told the charge nurse. During an interview on [DATE] at 9:56 a.m., MA G said on [DATE] during her 2:00 p.m. to 10:00 p.m. shift, Resident #1 had difficulty swallowing her 7:00 p.m. medications and this was unusual. She said the resident was not talkative like she usually was and said she did not feel good. MA G said Resident #1 was short of breath, but this was not unusual for her and she was using her oxygen. MA G said Resident #1's face was puffy, and her color was grayish. MA G said she reported Resident #1's difficulty swallowing medications and her concerns to LVN J and asked her to check on her. She said she did not see LVN J check on her because she was busy passing medications. MA G said family member #2 asked her to keep an eye on Resident #1 during her shift because he was worried about her. MA G said the family member was concerned about her not acting like herself and asked that her [MEDICATION NAME] 600 mg not be administered. MA G said she did not give the medication and she reported his request to LVN [NAME] MA G said at 10:15 p.m., she checked on Resident #1 and she was awake. During an interview on [DATE] at 2:36 p.m., LVN J said on [DATE] she worked 2:00 p.m. to 10:00 p.m. and Resident #1's family members asked to hold the 9:00 p.m., dose of [MEDICATION NAME] because she was sleepier than usual. She said the medication was held and she did not assess the resident or notify the physician. LVN J said it was not unusual for the resident to be sleepy and groggy because of her disease process. LVN J said she was told Resident #1 did not feel well by MA G and she did not write it on the 24-hour report because it was not unusual for her to feel bad. During an interview on [DATE] at 5:08 a.m., RN A said on [DATE] she was not scheduled to work the hall Resident #1 resided on. She said when she arrived to work around 9:45 p.m., MA G informed her Resident #1 was not feeling well and did not look herself. RN A said she reported the information to LVN H whom was assigned to Resident #1. RN A said she did not see Resident #1 during her shift. During an interview on [DATE] at 2:10 p.m., LVN H said she arrived to work on [DATE] at about 9:45 p.m. She said MA G told her Resident #1 was not feeling well during the evening shift. LVN H said she did not get any information from LVN J about the [MEDICATION NAME] medication being held and there was nothing on the 24-hour report to indicate concerns for Resident #1. She said she did not assess Resident #1 for the concerns reported to her by MA [NAME] LVN H said Resident #1 was independent and if she needed anything she used her call light. LVN H said she changed Resident #1's oxygen tubing during her shift and she could not remember the exact time. She said Resident #1 was sitting on the side of the bed with her oxygen on and had no complaints. During an interview on [DATE] at 5:35 a.m., CNA B said on [DATE] at approximately 11 p.m., Resident #1 was sitting in the wheelchair in her doorway. She said the resident's face was puffy and grayish in color. CNA B said Resident #1 told her she did not fell very well. CNA B said she reported to LVN H Resident #1 did not feel well, her face was swollen, and her color was grayish. CNA B said Resident #1 usually used her call light during the 10 p.m. to 6 a.m. shift to request Tylenol and an ice pack but she did not use her call light during her shift on [DATE]. CNA B said she did not check on Resident #1 during her shift on [DATE]. During an interview on [DATE] at 5:15 a.m., CNA D said on [DATE] at approximately 11:30 p.m., she entered Resident #1's room to fill her pitcher with water and ice. She said the resident was sleeping and she was wearing her oxygen mask. CNA D said Resident #1 usually used her call light during the 10 p.m. to 6 a.m. shift and requested Tylenol and an ice pack but she did not use the call light on [DATE] during her shift. During an interview on [DATE] at 5:51 a.m., the ADON said Resident #1's death was unexpected. She said she was notified on [DATE] around 7:15 a.m., by RN [NAME] of Resident #1's death. She said he told her she was found in her bathroom sitting in her wheelchair. The ADON said no one informed her Resident #1 had complained of not feeling well on [DATE]. During an interview on [DATE] at 3:12 p.m., the DON said she expected the CNAs to tell the LVN charge nurse if a resident had a change in condition and to follow up with the LVN to make sure they were heard. The DON said the LVN charge nurse should have assessed Resident #1 when her son requested the medication [MEDICATION NAME] to be held because of increased sleepiness. The DON she expected the charge nurse to notify the physician if a resident had a change of condition. The DON said staff do not generally check on residents whom are independent unless they use the call light. She said after the death of Resident #1 she instructed the staff to check on all resident's every 2 hours. The DON said she did not document the instruction to staff to check on all residents every 2 hours or obtain a signature of attendance. During an interview on [DATE] at 6:38 a.m., the administrator said Resident #1 died on the morning of [DATE]. She said she and the DON did an internal investigation at the request of the resident's family because the funeral home told the family the resident had been deceased for several hours. The administrator said upon viewing the video and gathering statements from staff the resident was last seen in her room awake with no complaints at approximately 5:30 a.m., by LVN H when she changed out the oxygen tubing. The administrator said LVN H was seen on camera entering the resident's room and exited approximately 10 minutes later. The administrator said Resident #1 was found by staff at approximately 7 a.m. in her wheelchair in the bathroom and she was not breathing and did not have a pulse. The administrator said there had been about an hour and a half window from the time she was last seen prior to her expiration. She said the video footage indicated Resident #1 was seen at approximately 12:30 a.m. and again at 5:30 a.m. The administrator said the resident was not checked every two hours because she was independent and capable of using her call light. She said it was not unusual for Resident #1 to feel bad because of her [DIAGNOSES REDACTED]. She said the LVN charge nurse probably should have assessed Resident #1 and notified the physician if needed. A policy titled Notification of Changes dated [DATE] indicated .the policy was to provide guidance on when to communicate acute changes in status to MD, NP and responsible party .the facility will immediately report to the physician of a significant change in the physical, mental or psychosocial status of the resident .

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 3 of 9 residents reviewed for accidents. (Resident #s 2, 9 and 10) Resident #2 was at risk for falls. The facility did not implement fall preventative measures and Resident #2 fell from her bed on 11/23/12. She received a hematoma (collection of blood outside the blood vessels) to the right side of her forehead and right elbow, a skin tear to right great toe and the left side of her lip. Resident #2 continued to complain of pain following her fall and on 11/26/12 an x ray indicated a deformity of the left humerus (upper arm bone) that could represent a fracture (break). Resident #9 fell from his bed 10/12/12, 10/22/12 and 11/7/12. The facility did not implement interventions to supervise Resident #9 or prevent future falls. Resident #10 fell from his bed 9/11/12, 9/29/12 and 11/8/12. The facility did not implement interventions to supervise Resident #10 or prevent future falls. This failure could place 16 residents who were high risk for falls at risk for injury. Findings included: 1. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 usually made herself understood and usually understood others, had trouble concentrating, was restless and fidgety, was dependent for transfers, and required two staff support for transfers. She was non-ambulatory, unsteady, and only able to steady herself with staff support. She had a fall with a fracture before her admission to the facility. An admission assessment dated [DATE] indicated Resident #2 was a high risk for falls and staff should consider environmental risk factors in Resident #2's fall prevention interventions. She was at high risk for falls due to having fallen in the last 90 days, had a change in cognitive status during the last 90 days, was easily distracted, and had periods of restlessness. The assessment indicated staff should consider environmental risk factors. The section titled nursing admission history/evaluation /care plan did not include interventions to address Resident #2's risk for falls. An incident report dated 11/23/12 at 7:15 a.m. indicated Resident #2 was found on the right side of the bed with her upper body on the floor and her lower body on the bed. The incident report indicated she had a hematoma on the right side of her forehead and right elbow and a skin tear on her right great toe. The incident report indicated she was taken to the emergency room by EMS for evaluation. The incident investigation attached to the incident report indicated Resident #2 was unable to explain what happened. The environment section of the investigation was not addressed. The section titled contributing health history indicated Resident #2 had a [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] indicated Resident #2 was a high risk for falls due to disorientation, history of falls, incontinence, poor vision, and poor balance. An x-ray report dated 11/26/12 indicated Resident #2 had a deformity to the left proximal humerus (arm) which could represent a fracture. Physician orders [REDACTED]. *"landing pad" (fall mat) next to bed-check every shift; * sling to left arm; *make appointment with orthopedic doctor; * air mattress with bolsters; and * bed/chair alarm. The nursing care plan dated 11/26/12 (after the fall) indicated Resident #2 had difficulty making decisions and had impaired thought processes. Her care plan indicated she had impaired mobility and was at risk of falling. Interventions included: *wearing tennis shoes; *remind to ask for assist; *landing pad (fall mat); *personal mobility alarm; and *bed in lowest position. During an observation on 11/28/12 at 1:25 p.m., Resident #2 was asleep on a low air loss mattress with bolsters (long narrow pillow or cushion for positioning). The height of the bed was in a raised position. Resident #2 was positioned toward the right edge of the bed. Resident #2 was pale. Her left arm was in a sling and she had an 8 cm by 8 cm purple hematoma on the right side of her forehead. A personal mobility/pressure alarm was underneath her. There was not a fall mat beside her bed. During an observation and interview on 11/28/12 at 1:45 p.m., Resident #2 was in bed. There was not a fall mat beside her bed. She was lethargic. Her speech was rambling and non-sensical Resident #2 had a 3 cm by 3 cm purple hematoma on her right elbow. The height of her bed was in a raised position. Resident #2 was unable to demonstrate the proper use of her call light. Her family member said Resident #2 had fallen at home and been forgetful. He said she had not been eating the last two days and had been complaining more of the pain in her left arm since the fall. He said she had been sleeping more, been weaker and more confused the last two days. The family said there was not a fall mat or alarm in use until after Resident #2 fell on [DATE]. He said she was supposed to go to the orthopedic doctor today regarding her fractured arm, but was being sent to the emergency room . During an interview on 11/29/12 at 10:55 a.m., LVN C said she sent Resident #2 to the emergency room after her fall on 11/23/12. She said Resident #2 had a history of [REDACTED].#2 on the floor just after shift change at 7:15 a.m. She said Resident #2 was on an air mattress without bolsters at the time of her fall. LVN C said Resident #2 did not have any preventative fall precautions in place prior to her fall other than keeping her call light in reach and her bed height in a low position. She said she placed a personal mobility alarm on Resident #2 when she returned from the emergency room . She said prior to the fall on 11/23/12, Resident #2 was eating approximately 100% of her meals and had no problems drinking enough fluids. She said since the fall, Resident #2 was not eating or drinking well. She said Resident #2 had not eaten for 2 days. She said Resident #2 had become weaker and more confused and was sleeping more since the fall. She said Resident #2 had increased complaints of pain since her fall related to the possible fracture of her left arm. During an interview on 11/28/12 at 1:30 p.m., CNA F said Resident #2 fell out of bed last week and had a bruise and a broken arm. She said Resident #2 had declined and had not been eating or drinking well since her fall. CNA F said after Resident #2, fell a landing pad (fall mat) and personal alarm were added to her care. CNA F said she was not sure why the fall mat was not beside the bed. She said she was not aware Resident #2 was a high fall risk prior to her fall on 11/23/12. She said nurses rarely informed CNAs about resident risks. She said for fall precautions, the CNAs would lower the bed, place the call light within reach, and remind residents to call for help. CNA F said most residents had care plans that informed CNAs of resident care needs. She said Resident #2 did not have resident care plan. During an interview on 11/ 28/12 at 1:40 p.m., CNA E said Resident #2 was confused and unable to ambulate. She said Resident #2 fell out of bed last Friday. She said Resident #2 had declined since the fall and had not been eating or drinking very well. She said Resident #2 did not have a fall mat or personal alarm until after her fall on 11/23/12. CNA E said no one had ever told her Resident #2 was a high risk for falls. She said she was not sure why the fall mat was not in place. She said the nurses were not good about communicating with the nurse aides about resident care. CNA E said Resident #2 did not have a CNA care plan. Meal intake records for November 2012 indicated Resident #2 was eating 100% of her breakfast and lunch and 75% of her evening meal prior to the fall on 11/23/12. 11/25/12 she ate 50% of her breakfast, 50% of her lunch, and refused the evening meal. On 11/26/12 and 11/27/12, she refused all meals and fluids. During an interview on 11/28/12 at 2:15 p.m., the DON said Resident #2 fell out of bed 11/23/12 and EMS transferred her to the emergency room for evaluation. She said on 11/26/12 a chest x ray was ordered to rule out pneumonia because the Resident #2 was not eating or drinking well since the fall. Resident #2's fractured arm was identified as a result of the chest x-ray. The DON said residents at high risk for falls have fall preventions such as mobility alarms, beds in low position, and fall mats. She said no interventions were in place for Resident #2 prior to her fall on 11/23/12 because she did not consider her a fall risk. The DON said her investigation of Resident #2's fall was not complete. She said she was unable to determine how Resident #2 fell off the bed. She said Resident #2 was now supposed to have a mattress with bolsters and a fall mat. The DON said she did not have a system in place to monitor for effectiveness of interventions. A hospital history and physical examination [REDACTED]. The examination indicated the chief complaint was weakness, confusion, decreased appetite, and fluid intake. The assessment and plan included fluids for dehydration and evaluation for fracture of left arm. 2. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #9 was severely cognitively impaired, required extensive assist of two staff members for transfers, was unsteady and only able to stabilize himself with staff assistance. The MDS indicated he had a history of [REDACTED]. The care plan dated 9/21/12 indicated Resident #9 had impaired thought processes, a potential for falls, and had fallen 10/22/12. Care plan interventions included: *staff education-keep bed low position; *encourage resident to request assistance; and *make sure call light was in reach. The accident and incident report log dated October and November 2012 indicated Resident #9 fell on : *10/22/12; *10/31/12; and *11/7/12. The incident report dated 10/22/12 indicated Resident #9 fell from bed. The additional comments section of the report indicated interventions to prevent reoccurrence: bed in low position, call light in reach, and encourage calling for assistance. The investigations section indicated Resident #2 had dementia and no new interventions were required. The incident report dated 10/31/12 indicated Resident #9 was found sitting on the floor beside his bed. The investigation report indicated Resident #9 was confused and disoriented, had a history of [REDACTED]. The section titled interventions implemented to reduce recurrences was blank. The incident report dated 11/7/12 indicated Resident #9 slid off his bed and was disoriented. The investigation section indicated Resident #9 was to receive visual checks while in bed. Resident #9's clinical record did not contain documentation of visual checks while in bed. During an observation on 11/28/12 at 2:45 p.m., Resident #9 was in bed. He was restless and confused. He was unable to carry on a meaningful conversation. His call light was in place, but he was not able to demonstrate proper use of the call light. There was not a fall mat bedside his bed. His bed height was in the raised position. During an observation on 11/29/12 at 8:00 a.m., Resident #9 was awake in bed. The bed height was in the raised position. The call light was attached to the blanket, but Resident #9 was unable to demonstrate proper use of the call light. He was not able to answer simple direct questions or carry on a conversation. The fall mat was not beside the bed. During an observation on 11/29/12 at 9:45 a.m., Resident #9 was in alone in his room in his wheel chair. There was no mobility alarm on the wheelchair. Resident #9 was confused and unable carry on a meaningful conversation. He was unable to demonstrate proper use of his call light. During an interview on 11/28/12 at 1:45 p.m., the DON said she reviewed the accident and incident reports for Resident #9. She said interventions for fall prevention included; keeping the bed in low position, call light in reach, and a mobility alarm. She identified Resident #9 as a high fall risk but said she did not know of anything else to do. The DON said a fall risk assessment to identify Resident #9's fall risk factors had not been completed. She said a fall risk assessment should be completed after each fall and then weekly for four weeks. During an interview on 11/29/12 at 9:30 a.m., CNA L said Resident #9 was confused and disoriented, unable to use the call light or make his needs known. She said Resident #9 got restless at times and tried to get out of bed without help. He was supposed to have a mobility alarm while in bed and in the chair. She said his bed height should be in the low position. CNA L said she was not aware of interventions for visual checks for Resident #9 while in bed. During an interview on 11/29/12 at 10:00 a.m., CNA M said Resident #9 had a history of [REDACTED]. She said the call light was within his reach but he did not know when to use it. She said his alarm was to be on him at all times. She said she was not aware of any new interventions since his last fall. CNA M said she was no aware of the need for visual checks for Resident #9 while in bed. 3. Physician orders [REDACTED]. The most recent MDS dated [DATE], indicated Resident #10 was understood by others and could understand others, had difficulty concentrating, required total support of two staff for bed mobility, did not transfer or ambulate, and had impairment of both his arms and legs. The care plan dated 9/18/12 indicated Resident #10 had impaired thought processes, difficulty making decisions, impaired mobility and had a potential for falls. Care plan interventions included: *keep bed in lowest position; *assure shoes worn with non-skid soles; *transfers per nursing assistants; and *keep call light within reach. Accident and incident logs dated September and November 2012 indicated Resident #10 had falls on the following dates: *9/11/12; *9/29/12; and *11/8/12. The incident report dated 9/11/12 indicated Resident #10 fell out of his bed while trying to reach his bedside table. The incident report indicated Resident #10 sustained four skin tears on his left shoulder and arm as a result of the fall. The investigation section indicated interventions to prevent further occurrences were to check resident more frequently and make sure the bedside table was within reach. The incident report dated 9/29/12 indicated Resident #10 rolled off his air mattress onto the floor. The investigation section of the report indicated to hold his Coumadin (blood thinning medication) for 3 days. There were no new interventions to prevent future occurrences indicated on the report. The incident report dated 11/8/12 indicated Resident #10 fell from his bed. The incident report indicated Resident #10 sustained an abrasion to his right cheek. The investigation did not address any new interventions to prevent future reoccurrences. A fall risk assessment dated [DATE] indicated Resident #10 was a high risk for falls due to disorientation, 1-2 falls in the last 3 months, incontinence, poor vision, use of medications, and [DIAGNOSES REDACTED]. During an observation on 11/28/12 at 1:50 p.m., Resident #10 was awake, but restless. His call light was within reach but he was unable to demonstrate its use or carry on a meaningful conversation. He was on a low air loss mattress without bolsters. The bed height was in the raised position. There was not a fall mat beside his bed. During an observation on 11/28/12 at 4:00 p.m., Resident #10 was awake and calm, alert and oriented to name and place. His was on a low air loss mattress without bolsters; his bed height was in the raised position. There was no fall mat beside his bed. He was unable to demonstrate proper use of the call light. During an observation on 11/29/12 at 8:30 a.m., Resident #10 was awake and alert to name only, and unable to demonstrate how to use his call light. He was on a low air loss mattress without bolsters. His bed height was in the raised position. There was no fall mat at the bedside. During an interview on 11/28/12 at 2:40 p.m., CNA K said Resident #10 was confused at times and restless. She said interventions to prevent falls for Resident #10 included lowering the bed, keeping the call light in reach, the bedside table close and checking on him often. She said she did not believe he would use his call light if he needed anything due to his confusion. CNA K said she was unaware that Resident #10 was to have a fall mat in use. During an interview on 11/28/12 at 3:00 p.m., CNA L said Resident #10 was confused at times, and required assistance for all ADLs. She said she was not aware that Resident #10 was to have a fall mat beside his bed. She said fall prevention precautions for Resident #10 included keeping the call light in reach, the bed in low position and the bedside table close. During an interview on 11/28/12 at 3:30 p.m., LVN A said Resident #10 had fallen from his bed several times in the past few months. She said he was confused and restless at times. She said she was not sure what interventions were in place to prevent falls for Resident #10. Accident/Incident report logs indicated the following: *September 2012 falls 19; *October 2012 falls 27; and *November 2012 falls 27. During an interview on 11/29/12 at 5; 0 p.m., the DON said she did not have a system in place for analyzing falls. She said falls risk assessments should be completed on admission, after falls and then with each quarterly MDS assessment. She was unable to locate fall risk assessments on Residents #2, 9 and 10 that should have been done after falls had occurred. The DON said she did not have a method for determining how long an intervention of visual checks every 30 minutes or every hour would be continued. The facility Fall Assessment & Management policy dated January 2007 indicated: "....facility should implement fall risk assessments on admission, following acute falls, quarterly and annually. The care plan should reflect measurable goals and interventions/approaches implemented." The policy indicated the facility evaluates the individual's progress over time in relations to a problem, condition, or symptom, consider the effectiveness of the interventions, and make a systemic determination about what to do next. A list provided by the DON on 11/29/12 indicated 16 residents were at high risk of falls.