Every finding on record at Highland Ridge Care Center, LLC

Based on observation, clinical record review and staff interviews, the facility failed to appropriately provided assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 3 residents reviewed (Resident #1 & #2). R#1 returned from a hospital stay, at which time staff failed to notice the resident had duplicate laxatives order for five days, and during that time the resident fell. R#2 complained of pain after a fall the facility staff failed to perform a thorough assessment, and call the physician provide intervention. The facility reported a census of 50 residents. 1.The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of diabetes mellitus, kidney disease, dementia, anxiety, depression and required maximal assistance for toileting, shower or bathing and personal hygiene. The MDS documentation revealed Resident #1 was incontinent of bowels and bladder. The brief interview for mental status (BIMS) score of 3 suggested severe cognitive impairment. The Care Plan with initiated date of 4/2/25 for Resident #1 identified a self-care performance deficit and directed the staff to bath, dress, groom, provide hygiene with the assistance of one staff member. The Progress Notes for Resident #1 revealed: 1. (General Note) On 10/24/25 Resident #1 completed taking full course of antibiotic for urinary tract infection on 10/23/25. 2. (Physician's Order Note) 10/25/25 On-call provider updated related to transcription error and multiple watery loose stools, ordered Miralax, Senna-s and Lactulose on hold until tomorrow morning. Discontinue extra dose of Miralax.3. On 10/29/25 at 2:26 pm, Resident #1 was observed laying on her back, on the shower floor, and a CNA was with her. The CNA reported she showered Resident #1 to cleanse her due to having loose stools all over her and she became combative, grabbed the grab bar in the shower room and slid on the wet floor. MAR October 2025 for Resident #1 revealed:1. On 9/11/25 order for MiraLAX Powder 17 grams (gm) gm per scoop, give 1 time a day for constipation, administered in the morning. Held on October 3rd, 4th, 25, & 26th. (MiraLAX also known as Polyethylene Glycol 3350 powder)2. On 10/17/25 order for Polyethylene Glycol 3350 powder give 1 scoop by mouth one time a day for constipation. Administered on 10/17/25 am then order changed the time to be administered in the evening. Administered on 10/18 through 10/24/25. On 10/25/25 held then discontinued. 3. On 10/18/25 order for Lactulose 10 gm per 15 milliliters (ml). Give 15 ml by mouth for constipation. Administered in the am and pm on 10/21/25 through 10/25/25 am. Held the pm dose on 10/25/25 and am dose 10/26/25. Resumed and administered on 10/26/25 pm and discontinued after the 10/29/25 am dose was given. 4. Senna S oral tablet 8.6-50 mg give 1 tablet two times a day for constipation. Administered in am and pm. Held pm dose on 10/25/25 and discontinued on 10/29/25 after am dose. 5. On 8/8/25 order for Bisacodyl Rectal Suppository 10mg insert 1 suppository rectally every 24 hours as needed for constipation. Administered on 10/16/25 at 1:48 pm. 6. On 4/2/25 order for Loperamide HCL 2 mg give 2 tablets by mouth as needed for loose stools. Give 2 tablets after the first loose stool & 1 tablet after each additional loose stool as needed with a maximum dose of 4 a day. This was not administered in October 2025 and was discontinued on 10/18/25. 7. On 10/17/25 order for Milk of Magnesia 400 mg/5 ml. give 30 ml by mouth every 24 hours as needed for constipation. This was not administered in October 2025. 8. Order on 4/2/25 for Polyethylene Glycol 3350 powder give 1 scoop by mouth every 24 hours as needed for constipation if no bowel movement for 3 days. Administered on 10/8/25 at 1:36 pm and 10/15/25 at 1:43 pm. Point Of Care document for Resident #1 bowel movements (BM) descriptions and shower revealed:1. On 10/21/25 1 medium putty like BM and 2 large BM loose diarrhea, received a dependent (helper does all of the effort or 2 or more helpers to complete the activity) shower 2. On 10/22/25 2 large BM loose diarrhea, received a dependent shower.3. On 10/23/25 1 large BM loose diarrhea.4. On 10/24/25 1 medium BM and 1 large BM both loose diarrheas, received a maximal assist shower. 5. On 10/25/25 2 medium BM both loose diarrheas. 6. On 10/26/25 No BM documented.7. On 10/27/25 1 large BM loose diarrhea, received a dependent shower. 8. On 10/28/25 1 large BM loose diarrhea, received a maximal assist shower9. On 10/29/25 1 large BM loose diarrhea. The shower was not documented that occurred during fall. Point of Care document for Resident #1 aggressive during care behavior, intervention, & effectiveness revealed:1. On 10/21/25 Aggressive during care day shift, redirect, intervention not effective.2. On 10/24/25 Aggressive during care evening shift, redirect, intervention not effective.3. On 10/25/25 Aggressive during care evening shift, conversation, intervention not effective. 4. On 10/26/25 Aggressive during care day shift, reassure, intervention not effective.5. On 10/28/25 Aggressive during care evening shift, reassure, intervention not effective.6. On 10/29/25 Aggressive during care overnight and evening shift, reassure, interventions not effective. Falls Follow up Form dated 10/29/25 at 2:46 pm for Resident #1 identified a change in elimination: Alteration from baseline bowel pattern. Staff completing the document: Staff I, Registered Nurse (RN) on 10/29/25 at 2:26 pm.admission Hospital record dated 10/29/25 for Resident #1 revealed the daughter at bedside reported mother fell in shower, used shower chair after being incontinent of stool (BM). Resident #1 slipped on the stool present on the shower floor. Resident #1 had diarrhea since 10/17/25 due to multiple laxatives.During an interview on 11/12/25 at 2:09 pm with Resident #1's daughter who was the POA, stated she had taken mother to hospital on [DATE] for back aches, slouching and she was treated for a urinary tract infection (UTI) with antibiotics. Daughter stated Resident #1 did not have a bowel movement for multiple days and the physician ordered Lactulose and MiraLAX, which she was already taking daily and Senna two times a day. Daughter stated she did not want her mother treated with Lactulose and was unaware the staff were giving the MiraLAX two times a day. The daughter stated her mother had diarrhea for a week and the facility staff stated she would cover herself in the bowel movement (BM) so she was showered daily. The daughter stated her mom did not like showers and on 10/29/25 the facility called her to report that she had slipped on the BM in the shower and fell.During an interview on 11/13/25 at 10:33 am, Staff E, Certified Nursing Assistant (CNA) stated she had notified nursing on multiple occasions that Resident #1 did not like showers and would require two CNA's to provide her showers due to aggressive behavior toward staff and attempts to get off the shower chair. Staff E stated Resident #1 was incontinent of bowels and would be found to have the BM on her hands and body multiple times that required a shower to remove it. During an interview on 11/13/25 at 9:22 pm, Staff K, CNA stated she had worked in the facility for a year. Staff K stated she worked the 6am to 2pm shift on 10/29/25. Staff K stated Resident #1 was not eating well and had requested to eat in her room. Staff K stated for the past 3-4 weeks Resident #1 began to deteriorate, slouched in her recliner and was more combative. Staff K stated she reported to the nurses for 2 weeks that something was wrong. Staff K stated she was aware that Resident #1 had a UTI but that day she was lethargic (weakness), slouching back in the recliner and patted abdomen saying ouch.During an interview on 11/12/25 at 3:28 pm, Staff A, CNA stated Resident #1 required two staff for 2 weeks almost daily for showers due to the diarrhea and having BM all over herself. During an interview on 11/13/25 at 11:36 am, Staff H, Life Enrichment (Activity) Assistant stated she was aware that Resident #1 would swing, kick, and bite staff. Staff H stated Resident #1 was strong and did not like showers but was covered with BM multiple of times.During an interview on 11/17/25 at 12:18 pm, Staff P, CNA stated Resident #1 was often confused and had declined, not willing to move, more combative, and incontinent of bowels. Staff P stated it took two CNA's to shower Resident #1, to clean her from the BM, and she would immediately get out of the shower chair as she hated showers. Staff P stated she reported to the nurses that it took 2 staff to provide care for Resident #1. During an interview on 11/19/25 at 1:01 pm The DON stated the clinical coordinator reviewed resident records. That information was then brought into the interdisciplinary team (IDT) meetings that occur daily in the mornings. The DON was unable to recall if Resident #1's bowel regimen, bought of diarrhea, or behaviors with ineffective interventions were brought to the attention of the IDT. Grievance form dated 10/28/25 received an e-mail on 10/28/25 at 7:09 am from Resident #1's daughter who was not satisfied with Resident #1's bowel regimen and meals for diabetics. Staff follow up: dietitian recommended daughter to utilize e-menu access. Followed up with a new bowel regimen. Dietitian offered a meeting, no response. Information relayed to the clinical and dietary staff & nutritionist. Dated 10/28/25 Staff S, Social Worker, Resident Services Director.2. The Quarterly MDS dated [DATE] for Resident #2 revealed the diagnoses of type 2 diabetes mellitus, Alzheimer's disease, bone density disorder, macular degeneration, and had a history of falls. Resident #2 required the use of walker, one staff to assist and a wheelchair and able to self-propel. Resident #2 required maximum assistance with toileting, dressing upper body and showers, and was dependent on staff for dressing her lower body. Resident #2 was independent with moving in a bed and was continent of bladder but had frequent incontinent bowel movements. During the assessment, Resident #2 had no complaints of pain, experienced two falls without injury and one fall with a minor injury, no major injuries noted. The Care Plan revised on 10/12/25 for Resident #2 directed staff to provide the assistance of one for transfers and ambulate with gait belt and wheelchair pulled behind her as she weakens and may need to sit quickly. The Care Plan directed staff to place her call light within reach, answer promptly and assist to bed when eye glasses and hearing aid was removed. Observe for agitation, restlessness, confusion and falls. The Progress notes for Resident #2 revealed on 10/26/25 at 8:56 pm, Staff O, Licensed Practical Nurse (LPN) documented at 7:15 pm, she was called by staff to respond as Resident #2 was laying on the floor on the right side next to her wheelchair and her head was resting on the wheel. Resident #2 was alert, smiling and talkative, stated she was standing next to the bed and went down to the floor. Resident #2 was able to move upper extremities and lower left extremity without pain. Resident #2 complained of right hip pain and initially was unable to move her right lower extremity due to the pain, cried out with attempted movement. Resident then spontaneously bent her right knee and lifted her foot into the air, held unsupported without discomfort. When attempted to roll Resident #2 to the left side, she cried out, grabbed her right hip and said oh it hurts. Staff assisted Resident #2 into a sitting position, resident stated she hurt just this one and grabbed her left hip. Assisted with two staff with the mechanical lift and stated it was fun but she did not recommend falling down to get one. Vital signs were BP 140/65, P 65, T 99.3, Oxygen Saturation 96% on room air. Resident #2 was able to move all extremities after she was in bed with no complaints of pain and reported to daughter who stated she did not want her sent for an evaluation, rather to wait a few hours and see how she does. The on-call manager Staff R, RN was notified and placed in the Medical Director's folder for notification. Falls Follow Up Form dated 10/26/25 at 7:15 pm for Resident #2 revealed:1. Vital Signs: T 99.3, P 65, BP 140/65, R 19, Oxygen Saturation 96% on room air.2. No change of condition identified for intrinsic risk factor.3. No change in elimination.4. No change in sensory impairments.5. No change in gait or balance.6. No pain7. Resident #2 did not remember she could not walk and got out of wheelchair to go to bed. 8. Short Term intervention: Don't leave Resident #2 in a wheelchair unattended. 9. Signed by Staff O, LPN on 10/26/25 at 10 pm.During an interview on 11/18/25 at 8:39 am, Resident #2's daughter Power of Attorney (POA) stated the facility nurse called her at 7:45 pm to report her mother fell to the floor, had some pain but after they got her into the bed, she was fine now with no complaints of pain. The daughter stated she told the nurse if she was not having pain, then they could wait and monitor her. The daughter stated she received a call at 1:44 am from the nurse who stated when they turned her mother, she had some pain that they treated with Tylenol and then she was just laying there without pain. The daughter stated they could call for a portable x-ray in the morning and she agreed. The daughter stated they had returned from a vacation and she had not slept yet. The daughter stated she slept in but had not received a call so she called at 12:07 pm and was informed they had not called the physician for the x-ray yet and the staff had her mother up in a wheelchair. The daughter requested to have her mother put in bed and call for an x-ray. The daughter stated she arrived to the center at 4:45 pm and the X-ray mobile unit had just left, and the nurse reported she was up for both meals, but was hooting and hollering all day and pushing on her hip and had trouble getting the x-rays done due to pain. The daughter stated she was a nurse and assessed her mother's hip and she moaned when touched and when the bed was elevated her mother grimaced. The daughter stated at 6:28 pm she went to the nurse station, was told the x-ray was not back yet, but the night nurse found the fax on the machine that read suspected fracture. The daughter stated she told the nurse to transfer her mother to the Orthopedic Hospital. The daughter stated the hospital nurse reported she was in so much pain that they administered Morphine. The daughter stated she could not send her mother back to the facility after surgery because of the poor assessment skills of the nurses. During an interview on 11/18/25 at 10:18 am Staff N, CNA stated she worked on 10/26/25 and provided care for Resident #2 who had a steady gait with the walker, then transferred to the wheelchair for supper. Staff N stated she found Resident #2 on the floor at the foot of her bed with her head against her wheelchair. Staff N radio called for Staff O, LPN, who responded immediately. Staff N stated Resident #2's right leg hurt her, she was screaming and clearly was in pain but she was able to pick it off the floor. Staff N stated she waited with Resident #2 on the floor while Staff O called the daughter. Staff N stated Staff O returned with the mechanical lift and Resident #2 screamed in pain when they got her off the floor and during care, changed the brief. Staff N stated she gave report to Staff J, CNA reported that Resident #2 fell and had increased pain when she provided care.During an interview on 11/18/25 at 11:28 am, Staff O, LPN stated three residents fell on [DATE] and Resident #2 was one of them. Staff O stated the staff called her to the room and Resident #2 was on the floor, unable to move her right leg and said it hurt but lifted it off the floor before she left the room to call her daughter so she felt it was fine. Staff O notified the daughter that her mother could move her leg and had intermittently had pain so she felt that it was not broken. Staff O stated she did not call and report to a physician but placed a report on the physician clip board. During an interview on 11/17/25 at 10:49 am, The Medical Director stated he was on vacation when Resident #2 fell, normally the facility will call the office or the emergency department team. The Medical Director stated if there was a significate change in a resident's condition, increased pain, no movement of an extremity or the family disagreed with the nurse recommendation, then the nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious. The Medical Director stated the facility could send a fax for the non-urgent situations. The Policy titled Fall Prevention and Management Program Policy dated 2021 revealed the nurse will immediately evaluate the resident for any injury, change in status or pain and will proceed with emergency procedures and interventions as indicated.

Based on observation, clinical record review, family and staff interviews, the facility failed to provide appropriate and sufficient supervision to ensure each resident's individual safety and to prevent an avoidable accident for 2 of 3 residents reviewed for falls (Resident #1 & #2). The facility reported a census of 50 residents. 1. The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of Diabetes Mellitus, kidney disease, dementia, anxiety, depression, visual hallucinations, osteoarthritis and required maximal assistance for toileting, shower or bathing and personal hygiene with moderate assistance for dressing. Resident #1 required moderate assistance to transfer into and out of the shower and was independent with sit to stand, chair to bed transfers, and toilet transfers. Resident #1 was independent with ambulation up to 10 feet (ft) and required moderate assistance for ambulation 50 ft to 100 ft, utilizing a walker. The MDS documentation revealed Resident was unable to answer the pain assessment interview and the staff assessment for pain revealed Resident #1 had indicators of pain in non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements or postures observed for 1 to 2 days in the 5-day assessment. The MDS identified 1 fall without injury. Resident #1 rejected care for 3 days and had physical behavior symptoms directed toward others. Resident #1 was incontinent of bowels and bladder. The brief interview for mental status (BIMS) score of 3 suggested severe cognitive impairment. The Care Plan for Resident #1 revealed the risk for falls due to cognitive impairment, confusion, history of falls, incontinence and directed staff to alert the resident to changes to the environment. The care plan identified a self-care performance deficit and directed the staff to bath, dress, groom, provide hygiene with the assistance of one staff. The care plan identified an alteration in mood or behavioral expression, behaviors were physical or disruptive and directed staff to approach or speak in a calm manner, divert her attention and remove her from the situation. The Care Plan Conference on 10/11/25 for Resident #1 revealed:1. Required assistance of one with dressing, toileting and personal hygiene. 2. Her weights have been stable with August at 166.8, September at 166.8 and October at 168.8. 3. She had a fall in the last quarter where she was lowered to the floor.4. She spent most of her day in her room relaxing and watching television, coloring, or listening to music, enjoyed participating in exercise and afternoon socials.5. There were no concerns at the Care Plan Conference and the Power of Attorney (POA) daughter was not present.Point of Care document for Resident #1 was aggressive during care behavior, intervention, & effectiveness of the intervention revealed:1. On 10/21/25 Aggressive during care on the day shift, redirected and the intervention was not effective.2. On 10/24/25 Aggressive during shower & care on the evening shift, redirected and the intervention was not effective.3. On 10/25/25 Aggressive during care on the evening shift, conversation provided and the intervention was not effective. 4. On 10/26/25 Aggressive during care on the day shift, reassured and the intervention was not effective.5. On 10/28/25 Aggressive during shower & cares on the evening shift, reassured and the intervention was not effective.6. On 10/29/25 Aggressive during care overnight and the shower during the evening shift, reassured and both of the interventions were not effective. The Progress Notes for Resident #1 revealed:1. Resident was having high blood sugars (400) after readmission to the dementia unit on 10/18/25 and was treated for a urinary tract infection (UTI) with an antibiotic.2. On 10/25/25 Resident #1 completed the antibiotic and began having watery loose stools. 3. On 10/27/25 at 3:15 pm, Resident #1 was found on the floor in her room in front of her recliner, without injuries and the root cause analysis determined the silk pajamas was the reason she slipped out of the recliner.4. On 10/29/25 at 2:26 pm, Resident #1 was observed laying on her back, on the shower floor, and a CNA was with her. The CNA reported she showered Resident #1 to cleanse her due to having loose stools all over her and she became combative, grabbed the grab bar in the shower room and slid on the wet floor. Resident #1 said, Oh it hurts and screamed when nurse touched her left leg that was internally rotated. The daughter arrived to the facility around 3 pm and the ambulance arrived around 3:25 pm. Resident #1 was transferred to the tertiary hospital at 3:50 pm. The intervention was that Resident #1 needed assistance of 2 staff when completing care and showers. 5. On 10/31/2025 at 10:08, the Interdisciplinary Team (IDT) Root Cause Analysis: Regarding fall on 10/29/2025 at 2:26, Resident #1 was incontinent of bowel and staff attempted to give her a shower, she was combative and aggressive towards staff, grabbed the bar in the shower, stood up and slipped on the wet floor. The intervention based on root cause analysis: Staff education to step away and change staff members when resident was agitated and combative.Falls Follow up Form dated 10/29/25 at 2:46 pm for Resident #1 revealed:1. Vital Signs: Unable to take her blood pressure (BP), Temperature 98.0, Pulse (P) 99, Respirations 18, Oxygen Saturation 91%. 2. Change in condition: Range of motion.3. Sensory impairments: None.4. Change in elimination: Alteration from baseline bowel pattern.5. Gait/balance impairments: Change in Range of Motion (ROM).6. Pain: Competitiveness with staff7. Change in activity patterns: None 8. Extrinsic risk factors: Wet flooring.9. Summary: Resident #1 was combative with staff who attempted shower her. Resident #1 suddenly grabbed the bar in the shower area and pulled herself out of the shower chair and slid on the wet floor.10. Short term intervention: Needed an assist of 2 staff during cares and showers.11. Staff completing the document: Staff I, Registered Nurse (RN) on 10/29/25 at 2:26 pm.admission Hospital record dated 10/29/25 for Resident #1 revealed:1. Ground level fall in the shower at her dementia unit.2. Daughter at bedside reported mother fell in shower, used shower chair after being incontinent of stool (BM). Resident #1 slipped on the stool present on the shower floor. Resident #1 had diarrhea since 10/17/25 due to multiple laxatives, diagnosed with UTI on 10/17/25 treated with antibiotic and denied pain on urination. The daughter confirmed Do Not Resuscitate (DNR) status.3. On arrival, the vital signs were BP 147/104, P 96. Lab results revealed an elevated blood glucose level of 316, elevated white blood count (WBC) of 13.1, abnormal sodium 134, and calcium 8.3 levels.4. Imaging revealed a severe femoral fracture of the left knee with significant impaction and medial displacement as well as significant osteopenia. 5. Pain was managed with oral acetaminophen and oxycodone. 6. Consulted the Orthopedics, admitted for closed left distal (farthest away from the center of the body) periprosthetic (around a prosthetic) knee fracture.7. The daughter was the designated POA. 8. Assessment & Plan: Left distal femur fracture, Leukocytosis (abnormal elevated WBC), Asymptomatic (without symptoms) Bacteriuria (bacteria in the urine), Vascular Dementia, severe, with psychotic disturbance and Type 2 Diabetic Mellitus.9. Consult Notes Orthopedics: Past history for a left total knee replacement in 2005. Resident #1 ambulated with a walker and had not complained of left knee pain prior to the fall. The patient's daughter (POA) was consented for her to undergo a left femur operative fixation.10. Care Coordination Progress Note dated 11/3/25 with expected discharge date of 11/6/25. The Social Worker met with Resident #1's daughter, POA, at the resident's bedside to discuss the discharge plan and the need for physical and occupational therapy at a Skilled nursing facility. The patient came from a skilled nursing facility but the daughter refused for her to return there. During an interview on 11/12/25 at 2:09 pm with Resident #1's daughter who was the POA, stated she had taken her mother to hospital on [DATE] for back aches, slouching and she was treated for a urinary tract infection (UTI) with antibiotics. Daughter stated Resident #1 did not have a bowel movement for multiple days and the physician ordered Lactulose and MiraLAX, which she was already taking daily and Senna two times a day. Daughter stated she did not want her mother treated with Lactulose and was unaware the staff were giving the MiraLAX two times a day. The daughter stated her mother had diarrhea for a week and the facility staff stated she would cover herself in the bowel movement (BM) so she was showered daily. The daughter stated her mom did not like showers and on 10/29/25 the facility called her to report that she had slipped on the BM in the shower and fell. The daughter requested an ambulance and she was on her way there. The daughter stated on arrival, her mother was on the bathroom floor surrounded by BM, her left leg bowed out and her mother was screaming in pain. The daughter stated the ambulance took 20 minutes to arrive and their staff placed an Intravenous (IV) and gave her mother pain medication in the IV. The daughter stated her mother was on the shower floor for over an hour in pain. During an interview on 11/13/25 at 10:33 am, Staff E, Certified Nursing Assistant (CNA) stated she had notified nursing on multiple occasions that Resident #1 did not like showers and would require two CNA's to provide her showers due to aggressive behavior toward staff and attempts to get off the shower chair. Staff E stated Resident #1 was incontinent of bowels and would be found to have the BM on her hands and body multiple times that required a shower to remove it. During an interview on 11/13/25 at 9:22 pm, Staff K, CNA stated she had worked in the facility for a year. Staff K stated she worked the 6am to 2pm shift on 10/29/25. Staff K stated Resident #1 was not eating well and had requested to eat in her room. Staff K stated for the past 3-4 weeks Resident #1 began to deteriorate, slouched in her recliner and was more combative. Staff K stated she reported to the nurses for 2 weeks that something was wrong. Staff K stated she was aware that Resident #1 had a UTI but that day she was lethargic (weakness), slouching back in the recliner and patted abdomen saying ouch. Staff K stated at 2pm, she reported to Staff A, CNA that Resident #1 did not have a BM today. Staff K stated the brand-new CNA's only received 5-7 days of training and do not know the residents. Staff K stated she did not understand why they were not with a seasoned nurse and there were times when she had worked in the dementia unit by herself until someone came and she had left. Staff K stated Staff C, CNA had not worked in the dementia unit and Staff C, had assisted on 10/29/25 but did not toilet Resident #1. During an interview on 11/12/25 at 3:28 pm, Staff A, CNA stated she obtained the CNA certification in September 2025 and this was her first employment as a CNA. Staff A stated she was trained by another new CNA that had been employed by the facility for a month and felt the training was lacking skills to equip her to manage the residents with aggressive dementia behaviors. Staff A stated she worked the unit multiple times by herself during a shift or with a staff member who was not certified to assist her with providing care to the residents who needed two staff for assistance. Staff A stated on 10/29/25 at 2 pm, Resident #1 had BM all over her and the second CNA called in to say she would be late. Staff A stated she had requested assistance and a CNA had come in to the room to provide gowns and to transfer Resident #1 to the shower chair but she was left to complete the shower alone. Staff A stated she called on the radio for staff assistance again as Resident #1 became aggressive but there was no response and during the shower, Resident #1 fell. Staff A stated Resident #1 required two staff for 2 weeks almost daily for showers due to the diarrhea and having BM all over herself. Staff A stated on 11/11/25, the CNA was pulled from the dementia unit to assist in the main facility and was left to provide care alone for two hours then again for an hour at the end of shift. Staff A stated an activity person would be there until 5 pm but she cannot assist her with the residents except to monitor them. During an interview on 11/13/25 at 10:54 am, Staff C, CNA stated she had only worked in the dementia unit a few times, for four hours at most, to provide assistance. Staff C stated she had worked in the dementia unit on 10/29/25 but was pulled to assist the other 3 halls as a float CNA. Staff C stated she was aware someone had called in to report they would be late and she had answered a radio call to assist transfer Resident #1 to the shower chair. Staff C stated she then left the unit and went to the bathroom. Staff C stated she had never assisted Resident #1 with a shower and was unaware Staff A, CNA was alone on the dementia unit. Staff C stated she was aware there should be two staff in the dementia unit and an activity staff worked on the unit until 5 pm but was not certified to assist with resident care. During an interview on 11/13/25 at 11:36 am, Staff H, Life Enrichment (Activity) Assistant stated on 10/29/25, the day shift staff had left, Staff A, CNA was by herself and was unsure other staff was aware she was alone, Staff H stated she had not informed Staff L, CNA Scheduler that Staff A was by herself. Staff H stated there were usually two staff and could not count herself as the 2nd as she was not certified. Staff H stated she turned her radio down to low as it would aggravate the residents in the living area, failed to hear Staff A's calls for assistance, but was aware that Resident #1 would swing, kick, and bite staff. Staff H stated Resident #1 was strong and did not like showers but was covered with BM multiple of times. Staff H stated that Staff K, CNA was still in the unit when Staff A, CNA came out of Resident #1 room, stated she was covered in BM and asked for gowns. Staff H stated she called on radio for gowns and Staff K stated she wished she could help then left the unit. Staff H stated she did not report to Staff L, CNA Scheduler that Staff A needed assistance. Staff H stated she did not see Staff C, CNA come into the unit as the residents in the living area thought people were in the TV and she attempted to calm them down with exercise and a snack. Staff H stated she had become aware something was wrong when the nurse arrived, then the daughter arrived and the ambulance came after 3:30 pm. Staff H stated Staff B, CNA had arrived to work and both Staff A and Staff B began to prepare for supper. Staff H stated when she would leave at 5 pm, the residents start to sundown (late afternoon and evening, patients experience increased confusion, agitation, anxiety and irritability) and she felt sorry for the new girls as it was so hard. During an interview on 11/13/25 at 12:22 pm, Staff L CNA Scheduler stated in the dementia unit, she scheduled two CNA's on the day and evening shifts and the activity staff from 9am to 5 pm. Staff L stated if staff were late then the charge nurse would take care of it in the evenings. Staff L stated she was not aware that Staff B, CNA was late on 10/29/25 and was unaware that Resident #1 had fallen. During an interview on 11/13/25 at 1:12 pm, Staff I, Registered Nurse stated she was the charge nurse on 10/29/25 and was unaware staff had called in late for their shift in the dementia unit or that Staff A, CNA was working by herself. Staff I stated she was unaware that Resident #1 was combative during showers. Staff I stated she was aware that when Resident #1 was resistive, it would take two staff to shower her, but she was not always resistive. Staff I stated she was unaware Staff A was working without a 2nd CNA when she had radio called for assistance. During an interview on 11/17/25 at 8:45 am, Staff F, RN stated she had worked on 10/29/25, assigned to pass medications in two halls. Staff F stated she had heard a call on the radio that room [ROOM NUMBER] (Resident #1) had a large loose BM and they needed gowns. Staff F stated she answered the call to inform them that the gowns were located in the basement storage area. The CNA then called out for assistance. Staff F stated she was unaware that Staff B, CNA was to arrive late and Staff A, CNA was by herself in the dementia unit. During an interview on 11/17/25 at 12:18 pm, Staff P, CNA stated Resident #1 was often confused and had declined, not willing to move, more combative, and incontinent of bowels. Staff P stated it took two CNA's to shower Resident #1, to clean her from the BM, and she would immediately get out of the shower chair as she hated showers. Staff P stated she reported to the nurses that it took 2 staff to provide care for Resident #1. Staff P stated the management provided a float CNA after 5pm in the dementia unit but that changed after the census dropped. Staff P stated the census was low in the main facility, not the dementia unit where the rooms were full. During an interview on 11/17/25 at 9:52 am, Staff Q, RN stated she had spoken with the Administrator about her concerns with guidance and training as the entire 2nd shift was new and they had an increase in falls. Staff Q stated the census was down in the main area but the census was not down on the dementia unit. Interview on 11/13/25 at 12:49 pm The Administrator stated there must always be two certified staff on the dementia unit during the day and evening shifts. The Administrator was unaware that Staff A, CNA was alone in the unit on 10/29/25 at the beginning of the shift and at times during shifts on breaks.2. The MDS dated [DATE] for Resident #2 revealed the diagnoses of type 2 diabetes mellitus, Alzheimer's disease, bone density disorder, macular degeneration, and had a history of falls. Resident #2 required the use of walker, one staff to assist and a wheelchair and able to self-propel. Resident #2 required maximum assistance with toileting, dressing upper body and showers, and was dependent on staff for dressing her lower body. Resident #2 was independent with moving in a bed and was continent of bladder but had frequent incontinent bowel movements. During the assessment, Resident #2 had no complaints of pain, experienced two falls without injury and one fall with a minor injury, no major injuries noted. The Care Plan revised on 10/12/25 for Resident #2 directed staff to provide the assistance of one for transfers and ambulate with gait belt and wheelchair pulled behind her as she weakens and may need to sit quickly. The Care Plan directed staff to place her call light within reach, answer promptly and assist to bed when eye glasses and hearing aid was removed. Observe for agitation, restlessness, confusion and falls. The Progress notes for Resident #2 revealed on 10/26/25 at 8:56 pm, Staff O, Licensed Practical Nurse (LPN) documented at 7:15 pm, she was called by staff to respond as Resident #2 was laying on the floor on the right side next to her wheelchair and her head was resting on the wheel. Resident #2 was alert, smiling and talkative, stated she was standing next to the bed and went down to the floor. Resident #2 was able to move upper extremities and lower left extremity without pain. Resident #2 complained of right hip pain and initially was unable to move her right lower extremity due to the pain, cried out with attempted movement. Resident then spontaneously bent her right knee and lifted her foot into the air, held unsupported without discomfort. When attempted to roll Resident #2 to the left side, she cried out, grabbed her right hip and said oh it hurts. Staff assisted Resident #2 into a sitting position, stated she hurt just this one and grabbed her left hip. Assisted with two staff with the mechanical lift and stated it was fun but she did not recommend falling down to get one. Vital signs were BP 140/65, P 65, T 99.3, Oxygen Saturation 96% on room air. Resident #2 was able to move all extremities after she was in bed with no complaints of pain and reported to daughter who stated she did not want her sent for an evaluation, rather to wait a few hours and see how she does. The on-call manager Staff R, RN was notified and placed in the Medical Director's folder for notification. Falls Follow Up Form dated 10/26/25 at 7:15 pm for Resident #2 revealed:1. Vital Signs: T 99.3, P 65, BP 140/65, R 19, Oxygen Saturation 96% on room air.2. No change of condition identified for intrinsic risk factor.3. No change in elimination.4. No change in sensory impairments.5. No change in gait or balance.6. No pain7. Resident #2 did not remember she could not walk and got out of wheelchair to go to bed. 8. Short Term intervention: Don't leave Resident #2 in a wheelchair unattended. 9. Signed by Staff O, LPN on 10/26/25 at 10 pm.During an interview on 11/18/25 at 8:39 am, Resident #2's daughter Power of Attorney (POA) stated she was visiting her mother on 10/26/25 and left about 6 pm after taking her mother in the wheelchair to her room. The daughter stated she gave the call light to her mother and had the TV on to occupy her as there were no staff around. The daughter stated the facility nurse called her at 7:45 pm to report her mother fell to the floor, had some pain but after they got her into the bed, she was fine now with no complaints of pain. The daughter stated she told the nurse if she was not having pain, then they could wait and monitor her. The daughter stated she received a call at 1:44 am from the nurse who stated when they turned her mother, she had some pain that they treated with Tylenol and then she was just laying there without pain. The daughter stated they could call for a portable x-ray in the morning and she agreed. The daughter stated they had returned from a vacation and she had not slept yet. The daughter stated she slept in but had not received a call so she called at 12:07 pm and was informed they had not called the physician for the x-ray yet and the staff had her mother up in a wheelchair. The daughter requested to have her mother put in bed and call for an x-ray but was told it was they were waiting to allow the mobile unit to have their lunch time. The daughter stated she told the nurse to call them and when she called back, her mother was next in line. The daughter stated she called her sisters and based on what the staff informed her, she was having no pain and up to the wheelchair, then she must be ok. The daughter stated she arrived to the center at 4:45 pm and the X-ray mobile unit had just left, and the nurse reported she was up for both meals, but was hooting and hollering all day and pushing on her hip and had trouble getting the x-rays done due to pain. The daughter stated she was a nurse and assessed her mother's hip and she moaned when touched and when the bed was elevated her mother grimaced. The daughter stated at 6:28 pm she went to the nurse station, was told the x-ray was not back yet, but the night nurse found the fax on the machine that read suspected fracture. The daughter stated she told the nurse to transfer her mother to the Orthopedic Hospital. The daughter stated the hospital nurse reported she was in so much pain that they administered Morphine. The daughter stated she could not send her mother back to the facility after surgery because of the poor assessment skills of the nurses. During an interview on 11/18/25 at 10:18 am Staff N, CNA stated she worked on 10/26/25 and provided care for Resident #2 who had a steady gait with the walker, then transferred to the wheelchair for supper. Staff N stated her daughter and husband just returned from vacation and visited with Resident #2 in the dining room. Staff N stated she had a busy evening and the last time she visualized them, they were together in Resident #2's room. Staff N stated she need assistance transferring a different resident and Staff M, CNA assisted then she asked Staff M to check on Resident #2. Staff N stated when she completed with those cares, she found Resident #2 on the floor at the foot of her bed with her head against her wheelchair. Staff N radio called for Staff O, LPN, who responded immediately. Staff N stated Resident #2's right leg hurt her, she was screaming and clearly was in pain but she was able to pick it off the floor. Staff N stated she waited with Resident #2 on the floor while Staff O called the daughter. Staff N stated Staff O returned with the mechanical lift and Resident #2 screamed in pain when they got her off the floor and during care, changed the brief. Staff N stated she gave report to Staff J, CNA reported that Resident #2 fell and had increased pain when she provided care. During an interview on 11/18/25 at 11:28 am, Staff O, LPN stated three residents fell on [DATE] and Resident #2 was one of them. Staff O stated the staff called her to the room and Resident #2 was on the floor, unable to move her right leg and said it hurt but lifted it off the floor before she left the room to call her daughter so she felt it was fine. Staff O notified the daughter that her mother could move her leg and had intermittently had pain so she felt that it was not broken. Staff O stated she returned to Resident #2's room, assisted with the mechanical lift and not complaining of pain. Staff O stated Staff N, CAN provided care to Resident #2 and did not report further complaints of pain. Staff O stated she did not offer Tylenol as Resident #2 was sleeping when she had assessed her again and was not alarmed. Staff O stated she reported to the night nurse that she had three falls to complete assessments checks. Staff O stated Resident #2 had dementia and the daughter took her to her room. Staff O stated the staff do not leave Resident #2 in the wheelchair in her room due to she had fallen before and she will follow family direction, and the daughter told her to monitor her. Staff O stated she did not call and report to a physician but placed a report on the physician clip board. During an interview on 11/18/25 at 3:09 pm, Staff M, CNA stated on 10/26/25 she worked the 2p-6pm shift. Staff M stated after the evening meal time, she assisted Staff N, CNA with a transfer of a resident and was asked to check on Resident #2 in her room. Staff M stated Staff D, Certified Medication Assistant, reported Resident #2 was in her room and she was not to be in her room by herself in the wheelchair because she would get up and fall. Staff M stated Resident #2 was in her wheelchair in her room and stated she assumed that Staff N or Staff D would take care of her and returned to her assigned unit. Staff M stated she heard on the radio that Resident #2 was on the floor shortly after and returned to find Resident #2 on the floor with Staff M and the nurse. Staff M stated she did not remember Resident #2 moving her legs but she yelled out in pain when she was turned on her side for the mechanical lift sling to be placed under her. During an interview on 11/19/25 at 2:46 pm, Staff D, CMA stated he was passing medication on 10/26/25 and was aware Resident #2's daughter pushed her into her room, left her in the wheelchair at 6:45pm with the TV was on, she was fine. Staff D stated he left the room to pass medication when Staff N, CNA called on the radio for assistance and when he responded, Resident #2 was on the floor. Staff D stated Staff N and the nurse were present and stated they did not need his assistance and no one requested for him to give prn pain medication to Resident #2.During an interview on 11/17/25 at 10:49 am, The Medical Director stated he was on vacation when Resident #2 fell, normally the facility will call the office or the emergency department team. The Medical Director stated if there was a significate change in a resident's condition, increased pain, no movement of an extremity or the family disagreed with the nurse recommendation, then the nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious. The Medical Director stated the facility could send a fax for the non-urgent situations. The IDT (Interdisciplinary Team) meeting was held on 10/28/2025 to review the event on 10/26/25. Root cause analysis determined that the resident had self-transferred from her wheelchair to bed and lost balance. The intervention established was to avoid leaving the resident in her wheelchair unattended in her room. The effectiveness of this intervention was to be monitored, and the care plan would be updated accordingly. Resident #2 was transferred to hospital for further evaluation and the investigation is ongoing. The Facility Assessment stated staffing levels were assessed to determine if capable of admitting additional patients, and may hold admissions based on staff levels or if staff are not trained in the areas of care that a new admission may require. Acuity management was based on the census report, related to activities of daily living needs and historical trends. The number of staff will be prioritized based on the residents with higher needs. Staff was instructed not to perform a task that they do not feel competent to perform. The assessment was reviewed with the Quality Assurance and Performance Improvements and Quality Assurance Committee on 4/16/25.The Policy titled Fall Prevention and Management Program Policy dated 2021 revealed the Clinical Coordinator was responsible for the supervision of the personnel in delivering safe and personalized care, to evaluate the effectiveness of interventions and to collaborate with the interdisciplinary team in the prevention of falls. The prevention interventions/strategies included the care plans will indicate the resident specific interventions to prevent falls. The nurse will notify 911, the primary physician and the nurse practitioner based on the initial evaluation.

Based on clinical record review, family and staff interviews, and policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents reviewed (Resident #2). The MDS dated [DATE] for Resident #2 revealed the diagnoses of type 2 diabetes mellitus, Alzheimer's disease, bone density disorder, macular degeneration, and had a history of falls. Resident #2 required the use of walker, one staff to assist and a wheelchair and able to self-propel. Resident #2 required maximum assistance with toileting, dressing upper body and showers, and was dependent on staff for dressing her lower body. Resident #2 was independent with moving in a bed and was continent of bladder but had frequent incontinent bowel movements. During the assessment, Resident #2 had no complaints of pain, experienced two falls without injury and one fall with a minor injury, no major injuries noted. The MDS documented that the resident scored a 3 out 15 for the Brief Interview for Mental Status (BIMS), which indicated severely impaired cognitive status.The Care Plan revised on 10/12/25 for Resident #2 directed staff to provide the assistance of one for transfers and ambulate with gait belt and wheelchair pulled behind her as she weakens and may need to sit quickly. The Care Plan directed staff to place her call light within reach, answer promptly and assist to bed when eye glasses and hearing aid was removed. Observe for agitation, restlessness, confusion and falls. The Progress notes for Resident #2 revealed on 10/26/25 at 8:56 pm, Staff O, Licensed Practical Nurse (LPN) documented at 7:15 pm, she was called by staff to respond as Resident #2 was laying on the floor on the right side next to her wheelchair and her head was resting on the wheel. Resident #2 was alert, smiling and talkative, stated she was standing next to the bed and went down to the floor. Resident #2 was able to move upper extremities and lower left extremity without pain. Resident #2 complained of right hip pain and initially was unable to move her right lower extremity due to the pain, cried out with attempted movement. Resident then spontaneously bent her right knee and lifted her foot into the air, held unsupported without discomfort. When attempted to roll Resident #2 to the left side, she cried out, grabbed her right hip and said oh it hurts. Staff assisted Resident #2 into a sitting position, stated she hurt just this one and grabbed her left hip. Assisted with two staff with the mechanical lift and stated it was fun but she did not recommend falling down to get one. Vital signs were BP 140/65, P 65, T 99.3, Oxygen Saturation 96% on room air. Resident #2 was able to move all extremities after she was in bed with no complaints of pain and reported to daughter who stated she did not want her sent for an evaluation, rather to wait a few hours and see how she does. The on-call manager Staff R, RN was notified and placed in the Medical Director's folder for notification.MAR October 2025 for Resident #2 revealed Acetaminophen (Tylenol) 325 milligrams (mg), administer 2 tablets every 4 hours as needed for pain (not to exceed 3000mg/24hrs). Administered on 10/27/25 at 1:03 am for pain described as 4/10 and at 1:08 PM for pain described as 5/10. During an interview on 11/18/25 at 8:39 am, Resident #2's daughter Power of Attorney (POA) stated she was visiting her mother on 10/26/25 and left about 6 pm after taking her mother in the wheelchair to her room. The daughter stated she gave the call light to her mother and had the TV on to occupy her as there were no staff around. The daughter stated the facility nurse called her at 7:45 pm to report her mother fell to the floor, had some pain but after they got her into the bed, she was fine now with no complaints of pain. The daughter stated she told the nurse if she was not having pain, then they could wait and monitor her. The daughter stated she received a call at 1:44 am from the nurse who stated when they turned her mother, she had some pain that they treated with Tylenol and then she was just laying there without pain. The daughter stated she arrived to the center at 4:45 pm and the X-ray mobile unit had just left, and the nurse reported she was up for both meals, but was hooting and hollering all day and pushing on her hip and had trouble getting the x-rays done due to pain. The daughter stated she was a nurse and assessed her mother's hip and she moaned when touched and when the bed was elevated her mother grimaced. The daughter stated at 6:28 pm she went to the nurse station, was told the x-ray was not back yet, but the night nurse found the fax on the machine that read suspected fracture. The daughter stated the hospital nurse reported she was in so much pain that they administered Morphine. The daughter stated she could not send her mother back to the facility after surgery because of the poor assessment skills of the nurses.During an interview on 11/18/25 at 10:18 am Staff N, CNA stated she worked on 10/26/25 and provided care for Resident #2 who had a steady gait with the walker, then transferred to the wheelchair for supper. Staff N stated she found Resident #2 on the floor at the foot of her bed with her head against her wheelchair. Staff N radio called for Staff O, LPN, who responded immediately. Staff N stated Resident #2's right leg hurt her, she was screaming and clearly was in pain but she was able to pick it off the floor. Staff N stated she waited with Resident #2 on the floor while Staff O called the daughter. Staff N stated Staff O returned with the mechanical lift and Resident #2 screamed in pain when they got her off the floor and during care, changed the brief. Staff N stated she gave report to Staff J, CNA reported that Resident #2 fell and had increased pain when she provided care.During an interview on 11/18/25 at 11:28 am, Staff O, LPN stated three residents fell on [DATE] and Resident #2 was one of them. Staff O stated the staff called her to the room and Resident #2 was on the floor, unable to move her right leg and said it hurt but lifted it off the floor before she left the room to call her daughter so she felt it was fine. Staff O notified the daughter that her mother could move her leg and had intermittently had pain so she felt that it was not broken. Staff O stated she returned to Resident #2's room, assisted with the mechanical lift and not complaining of pain. Staff O stated Staff N, CAN provided care to Resident #2 and did not report further complaints of pain. Staff O stated she did not offer Tylenol as Resident #2 was sleeping when she had assessed her again and was not alarmed.During an interview on 10/26/25 at 3:09 pm, Staff M, CNA stated on 10/26/25 she worked the 2p-6pm shift. Staff M stated she heard on the radio that Resident #2 was on the floor shortly after and returned to find Resident #2 on the floor with Staff M and the nurse. Staff M stated she did not remember Resident #2 moving her legs but she yelled out in pain when she was turned on her side for the mechanical lift sling to be placed under her. Staff D stated Staff N and the nurse were present and stated they did not need his assistance and no one requested for him to give prn pain medication to Resident #2.During an interview on 11/13/25 at 1:12 pm, Staff I, Registered Nurse stated she was the charge nurse on 10/26/25 at 10pm and during report, Staff O, LPN informed her that Resident #2 had fallen, complained of pain but was able to move. Staff I stated she was told to monitor for pain. Staff I stated the CNA tried to change Resident #2 during the night as she was wet with urine, and had to stop the care due to complaint of pain. Staff I stated she assessed Resident #2 who said she could not move, hurt too much and Tylenol was administered. Staff I stated 30 minutes passed and Resident #2 continued to complain of pain with care. Staff I attempted to raise Resident #2's leg and she said enough of that it hurts. Staff I stated she called the daughter immediately as she was concerned about a fracture but the daughter did not want to send her mother to the hospital, just continue to monitor because the other nurse said she could move her legs. Staff I stated she told the oncoming nurse Staff G, LPN to call the doctor to obtain an order for a portable x-ray. Staff I stated it only hurt Resident #2 when she was moved.The Progress Note on 10/27/25 at 1:39 am, Staff O, RN documented she assisted the staff to change Resident #2's brief and attempted to roll her on her side, she yelled out of pain and reports pain on her right hip down to right knee without shortening or external rotation of limbs noted. Resident #2 was able to move her left leg without issues. Resident #2 was able to move her right lower leg a bit to the right but was not able to bend or raise it because of pain. Resident #2 was able to slightly bend her right leg with support. Called the POA to update resident's condition and requested to continue to monitor her mom, give pain pills as needed and do a portable Xray in the morning. On 10/27/25 at 3:44 am the Tylenol was effective. During an interview on 11/17/25 at 2:36 pm, Staff G, LPN stated Resident #2 was usually up for meals and ambulated, but in report on 10/27/25 at 6 am, she was informed of her fall and pain with range of motion focused on her right leg to hip. Staff G stated she peeked in to Resident #2's room at 7 am to find her asleep. Staff G stated the assessment at 9:45 am revealed pain in Resident #2's right hip, grabbed her upper thigh, but was unable to describe the pain. Staff G stated the CNA's then transferred Resident #2 to a wheelchair, who said ouch a couple of times when stood and reported the pain location in the right hip. Staff G stated she did not treat the pain at that time as it was brief. Staff G stated she spoke with the daughter around lunch time, reported her mom had pain and the daughter was concerned with the time it was going to take for the x-ray, so she was making arrangements to come to see her mother. Staff G stated when the portable x-ray staff attempted to roll Resident #2, she verbalized pain, Oh my god that hurts and grabbed at her right hip. Staff G stated the daughter arrived when the x-ray staff left at 4 pm. Staff G stated at 6pm, she gave report to the oncoming nurse when the daughter approached the desk requesting the x-ray results. Staff G stated the result revealed a possible fracture and she had a concern with pain management during care. Staff G stated she did not remember administering pain medication as Resident #2 only complained of pain during care and she was not crying. The Progress Note on 10/27/25 at 7:30 am, Staff G, LPN documented she assisted staff with cares of Resident #2 who stated the right hip hurts pretty bad but not too bad at the moment. When attempted to turn Resident #2 in bed, she cried out to stop, it's really hurting. Resident #2 then stated that she wanted to get up for breakfast, two staff stood and pivoted to her to a wheelchair. Resident #2 considered the pain of the transfer a 6/10, once she sat in the wheelchair, no further complaint of pain. At 1:08 pm Tylenol was administered for pain and was effective. At 6:35 pm the x-ray results were reviewed with the POA at bedside. At 8:10 pm the ambulance arrived with departure to the hospital at 8:20 pm. During an interview on 11/17/25 at 10:49 am, The Medical Director stated he was on vacation when Resident #2 fell, normally the facility will call the office or the emergency department team. The Medical Director stated if there was a significate change in a resident's condition, increased pain, no movement of an extremity or the family disagreed with the nurse recommendation, then the nurse could call the Emergency Room. The Medical Director stated he reviewed Resident #2's situation with the fall, and initially the family declined to send her, but if there was a change or the nurse suspected a fracture and it was overnight, then they are to call the Emergency Room. There is staff on call 24/7 there for anything serious. The Medical Director stated the facility could send a fax for the non-urgent situations. Pain Assessment and Management Policy dated 2025 revealed the purpose was to properly identify, treat and manage pain and discomfort by the observations and statements of staff and resident feedback. The procedure included the evaluation of resident reports or signs of increased pain and factors such as activities or care that exacerbate pain.

Based on record review, staff interviews and facility assessment review, the facility failed to ensure there was a sufficient number of direct care staff to provide care for residents with dementia, mental and psychosocial disorder. The facility also failed to provide supervision and skills training for staff in how to approach a resident who may be agitated, combative, verbally or physically aggressive, or anxious, and how and when to obtain assistance in managing a resident with behavior symptoms. The facility reported a census of 50 residents. The findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed the diagnoses of dementia, anxiety, depression, visual hallucinations and required maximal assistance for toileting, shower or bathing and personal hygiene with moderate assistance for dressing. Resident #1 rejected care for 3 of the 5 days reviewed and had physical behavior symptoms directed toward others. Resident #1 was incontinent of bowels and bladder. The brief interview for mental status (BIMS) score of 3 suggested severe cognitive impairment. Point of Care document for Resident #1 was aggressive during care behavior, intervention, & effectiveness of the intervention revealed:1. On 10/21/25 Aggressive during care on the day shift, redirected and the intervention was not effective.2. On 10/24/25 Aggressive during care on the evening shift, redirected and the intervention was not effective.3. On 10/25/25 Aggressive during care on the evening shift, conversation provided and the intervention was not effective. 4. On 10/26/25 Aggressive during care on the day shift, reassured and the intervention was not effective.5. On 10/28/25 Aggressive during care on the evening shift, reassured and the intervention was not effective.6. On 10/29/25 Aggressive during care overnight and evening shift, reassured and both of the interventions were not effective. During an interview on 11/13/25 at 10:33 am, Staff E, Certified Nursing Assistant (CNA) stated she had notified nursing on multiple occasions that Resident #1 did not like showers and would require two CNA's to provide her showers due to aggressive behavior toward staff and attempts to get off the shower chair. Staff E stated Resident #1 was incontinent of bowels and would be found to have the bowel movement (BM) on her hands and body multiple times that required a shower to remove it. During an interview on 11/12/25 at 3:28 pm, Staff A, CNA stated she obtained the CNA certification in September 2025 and this was her first employment as a CNA. Staff A stated she was trained by another new CNA that had been employed by the facility for a month and felt the training was lacking skills to equip her to manage the residents with aggressive dementia behaviors. Staff A stated she worked the unit multiple times by herself during a shift or with a staff member who was not certified to assist her with providing care to the residents who needed two staff for assistance. Staff A stated on 10/29/25 at 2 pm, Resident #1 had BM all over her and the second CNA called in to say she would be late. Staff A stated she had requested assistance and a CNA had come in to the room to provide gowns and to transfer Resident #1 to the shower chair but she was left to complete the shower alone. Staff A stated she called on the radio for staff assistance again as Resident #1 became aggressive but there was no response and during the shower, Resident #1 fell. Staff A stated Resident #1 required two staff for 2 weeks almost daily for showers due to the diarrhea and having BM all over herself. Staff A stated on 11/11/25, the CNA was pulled from the dementia unit to assist in the main facility and was left to provide care alone for two hours then again for an hour at the end of shift. Staff A stated an activity person would be there until 5 pm but she cannot assist her with the residents except to monitor them. During an interview on 11/12/25 at 4:02 pm, Staff B, CNA stated she had obtained the certification in August of 2025 and was trained to work in the main facility by Staff C, CNA. Staff B stated the typical people that received showers in the dementia unit required two CNA's to assist due to their dementia and behaviors. Staff B stated she had called the facility on 10/29/25 to notify them she would be late to work on 2nd shift and when she had arrived, Resident #1 was on the floor in the shower, assisted by Staff A, CNA and Staff I, Registered Nurse. During an interview on 11/13/25 at 10:54 am, Staff C, CNA stated she had only worked in the dementia unit a few times for four hours or to provide assistance. Staff C stated she had worked in the dementia unit on 10/29/25 but was pulled to assist the other 3 halls as a float CNA. Staff C stated she was aware someone had called in to report they would be late and answered a radio call to assist to transfer Resident #1 to the shower chair. Staff C stated she had never assisted Resident #1 with a shower and was unaware Staff A, CNA was alone on the dementia unit. Staff C stated she was aware there should be two staff in the dementia unit and an activity staff worked on the unit until 5 pm but was not certified to assist with resident care. During an interview on 11/13/25 at 11:36 am, Staff H, Life Enrichment (Activity) Assistant stated she had participated in a D.O.V.E. (Development through Observation, Validation and Enrichment) program that the facility used to provide in the past and it taught how to communicate and manage behaviors for people with dementia. Staff H stated now the new CNA's must complete a training online before they can work the behavior unit. Staff H stated the younger staff have not had experience with dementia residents and do not know how to communicate with them. Staff H stated the dementia unit is full and have a lot of behaviors and described working on the unit as hard right now. Staff H stated on 10/29/25, the day shift staff had left, Staff A, CNA was by herself and was unsure other staff was aware she was alone, Staff H stated she had not informed Staff L, CNA Scheduler that Staff A was by herself. Staff H stated there were usually two staff and could not count herself as the 2nd as she was not certified. Staff H stated she provided activities throughout the day in the living area, exercise at 3pm then a social with hydration and a snack before she left at 5 pm. Staff H stated she turns her radio down to low as it would aggravate the residents in the living area, failed to hear Staff A's calls for assistance, but was aware that Resident #1 would swing, kick, and bite staff. Staff H stated Resident #1 was strong and did not like showers but was covered with BM multiple of times. Staff H stated the afternoons was when the residents were always mean. During an interview on 11/13/25 at 12:22 pm, Staff L CNA Scheduler stated in the dementia unit, she scheduled two CNA's on the day and evening shifts and the activity staff from 9am to 5 pm. Staff L stated if were late then the charge nurse would take care of it in the evenings. Staff L stated she would rotate the staff out of the dementia unit to prevent burn-out. Staff L stated she was not aware that Staff B, CNA was late on 10/29/25 and was unaware that Resident #1 had fallen. Staff L stated the new staff would be onboarded with policies then trained but the trainer had been on maternity leave and the entire 2nd shift was hired at the same time so she was unsure of who had trained Staff A, CNA. During an interview on 11/13/25 at 1:12 pm, Staff I, Registered Nurse stated she was the charge nurse on 10/29/25 and was unaware staff had called in late for their shift in the dementia unit or that Staff A, CNA was working by herself. Staff I stated she was unaware that Resident #1 was combative during showers. Staff I stated she was aware that when Resident #1 was resistive, it would take two staff to shower her, but she was not always resistive. Staff I stated that staff would receive a two-week orientation and felt that Staff B, CNA was off orientation and appropriate to be the senior trainer for Staff A, CNA. Staff I stated she was unaware Staff A was working without a 2nd CNA when she had radio called for assistance. Staff I stated the staff are to call to inform the nurse if they need to leave early so she can send staff to assist the dementia unit. During an interview on 11/13/25 at 8:45 pm, Staff F, RN stated she noticed the facility had several new CNA's and they were trained in the main facility on hire then management assigned them to work on halls by themselves and that was concerning. Staff F stated she thought they should put more experienced staff on those halls. Staff F stated she was aware that Staff B, CNA was only hired for a month, a new CNA with no experience, who trained Staff A, CNA in the dementia unit, who was also a new CNA without experience. During an interview on 11/17/25 at 9:52 an, Staff Q, RN stated she had spoken with the Administrator about her concerns with guidance and training as the entire 2nd shift was new and they had an increase in falls. Staff Q stated the census was down in the main area but the census was not down on the dementia unit. Staff Q stated the charge nurse was required to sign off on the training the staff receive, provide care for 50 residents and may not get it everything but there was no time for follow-up. A review of staff training documents revealed Staff A, CNA was 80% completed with the resident rights and 80 to 90% completed with multiple dementia trainings. Staff B, CNA was 80% completed with multiple dementia trainings. Interview on 11/13/25 at 12:49 pm, The Administrator stated there must always be 2 certified staff in the dementia unit during the day and evening shifts and 1 CNA on the night shift. The Administrator stated she was unaware that Staff A, CNA was the only CNA in the dementia unit on 10/29/25 at the time of Resident #1's fall, at the beginning of the shifts when staff came in late and at the time staff would take a break on multiple occasions. The Administrator stated dementia training for staff was to be completed before the staff could work in the dementia unit. The Administrator stated the Clinical Coordinator's review resident documentation to monitor if interventions were effective and she was unaware that Resident #1's behavior interventions were not effective during care. The Facility Assessment stated staffing levels were assessed to determine if capable of admitting additional patients, and may hold admissions based on staff levels or if staff are not trained in the areas of care that a new admission may require. Acuity management was based on the census report, related to activities of daily living needs and historical trends. The number of staff will be prioritized based on the residents with higher needs. Staff was instructed not to perform a task that they do not feel competent to perform. The assessment was reviewed with the Quality Assurance and Performance Improvements and Quality Assurance Committee on 4/16/25.In an email on 11/17/25 at 7:45 am, The Administrator stated, While we do not have a standalone written staffing policy specifically for this unit, our approach is guided by resident-centered care principles and regulatory requirements. To ensure appropriate coverage and quality of care, we continuously evaluate staffing levels and make adjustments as needed. We are committed to meeting or exceeding all state and federal staffing requirements.

Based on observation, clinical record review, review of facility policy, personnel file review, resident and staff interview, the facility to ensure staff provided care with dignity and respect for 4 of 33 residents reviewed (Residents #1, #18, #31 and #49). The facility reported a census of 51 residents.Findings include: 1.The Minimum Data Set (MDS) assessment for Resident #1 dated 8/19/25 revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS revealed the resident had a diagnosis of Alzheimer's disease, used a wheelchair and was dependent on staff for toileting, transfers, and repositioning in bed. On 9/8/25 at 10:23 AM, interview conducted with the resident in Resident #1's room. The door to the room was shut to maintain the resident's privacy. At 10:29 AM during the interview Staff A, Certified Nurses Aide (CNA), opened the resident's room door and entered without knocking or announcing herself. Staff A dropped off the resident's breakfast, provided set up assistance, and left the room. When the resident queried if staff usually knocked before they entered the room, the resident stated, No, they (staff) just walk in. On 9/08/25 at 12:48 PM, observation revealed Staff A, CNA, entered Resident #1's room with her lunch without announcing herself or knocking.On 9/10/25 at 8:33 AM, Staff D, Registered Nurse (RN), entered Resident #1's room to perform wound care on the resident's sacral/coccyx wound. Staff E, Clinical Coordinator, entered the resident's room as well and reported being present to observe. The resident was lying in bed, and wound care supplies were observed in the over bed table. Staff D, raised the bed, removed the resident's call light, and pulled back the blanket covering the resident to the mid abdominal area. Staff E moved to the right side of the resident's bed (side nearest the outside wall) and faced the doorway. Staff E helped to position the resident on her right side with the blanket still covering the lower half of the resident. Staff D began opening wound care supplies including gauze pads, barrier film packages, and the package for the wound dressing. At 8:39 AM, Staff A, CNA, knocked as she was opening the door. Staff A immediately entered the room without announcing herself, or waiting for a reply to her knock. Staff A stood near the door for a few seconds, did not say anything, left the room, and shut the door behind herself. Still at 8:39 AM, Staff D gloved, and pulled the blanket down that was covering the resident's bare buttocks. Staff D began cleaning the coccyx wound area with gauze soaked in Normal Saline. At 8:41 AM, Staff A opened the resident's room door and entered without knocking or announcing herself. Staff A pushed a mechanical standing lift through the door, and exposed the resident's bare buttocks to the hallway while they pushed the lift into the room. Staff A then shut the room door. Staff E was facing the doorway when Staff A entered. Staff D and Staff E did not make any comment to Staff regarding entering the Resident's room. On 9/10/2025 at 11:53 AM, Staff C, Oral Medication Technician (OMT)/CNA reported staff received yearly education on respecting resident's rights. The education included instructions to knock before entering a room, announce who they were and tell the resident what they were going to do before starting whatever task they were doing. Staff C denied observing any staff not knocking before entering a residents' rooms. If staff were performing personal cares with a resident, and another staff knocked on the door to enter the resident's room, they would tell they staff they were giving cares. Staff were supposed to wait to enter until the resident was covered. On 9/10/2025 at 12:51 PM, Staff E reported that she observed Staff A enter Resident #1's room, knock, not announce herself, enter the room immediately after knocking, and not allow the staff in room time to respond. Staff E reported she then observed Staff A stand with the door open, then leave, come back to the resident's room and enter with the mechanical lift without knocking or announcing herself. Staff E reported she should have spoken up at that time, and did not know why she didn't. Staff E explained all staff received computer education in relation to resident dignity. Staff were taught to knock and announce who they were to the resident. If a door was shut and staff were doing cares, they were taught to yell out that they were doing cares if someone knocked on the door to enter. Staff E explained she reported Staff A to Staff A's supervisor. 2. The MDS assessment for Resident #49 dated 8/12/25 revealed the resident was severely cognitively impaired, and had diagnoses of dementia and anxiety disorder. The resident utilized a walker and wheelchair.On 9/08/25 at 12:12 PM, observation revealed Staff A provided hands on assistance while Resident #49 ambulated into the dining room with a walker and a gait belt around her waist. Staff A directed and assisted Resident #49 to sit in a straight-back chair located approximately 1.5 to 2 feet away from the dining room table. While standing behind the resident and without voicing her intent, Staff A lifted the left side of the chair the resident was sitting in off the dining room floor and pulled the chair forward, causing the resident's top half of her body tip in the chair to the right. The resident displayed a startled movement and grabbed for the chair and table to balance herself. Staff A then dropped the chair and repeated the movement on the right side of the chair.3. The MDS assessment for Resident #18 dated 8/26/25 revealed the resident scored13 out of 15 on BIMS exam, which indicated intact cognition. On 9/10/25 at 11:45 AM, observation revealed Staff B, CNA, knocked, announced herself, entered Resident #18's room with a mechanical lift and shut the door. At 11:46 AM, Staff C, CNA, opened the door and entered Resident #18's room without knocking or announcing herself, and then shut the room door.4. The MDS assessment for Resident #31 dated 7/8/25 revealed the resident had a BIMS score of 13 out of 15. On 9/10/25 at 11:51 AM, observation revealed Staff A walked into Resident #31's room without knocking, and walked up to the resident.On 9/10/2025 at 1:03 PM, the Administrator reported they had just provided education to Staff A, CNA, on Monday regarding concerns observed by staff on 9/8/25, and would provide education again if needed. On 9/10/2025 at 3:26 PM, review of the personnel file for Staff A revealed the following: Staff A had a hire date of 3/2/2018, and Staff A received education on 9/10/25 for the above mentioned dignity concerns. The Notice of Coaching/Education included the following: At this point in time further discussion may be warranted for corrective action regarding the following areas where improvements need to be observed: infection control, resident privacy, resident rights, & resident dignity. Review of the facility policy, titled Privacy and Dignity Policy dated April 2025 revealed staff would provide privacy and dignity while performing any personal care for residents and residents. Staff were to cover upper and lower body parts as needed to prevent unnecessary exposure of breasts and/or perineal areas. Staff would respect residents private space by knocking on doors and requesting permission before entering.

Based on clinical record review, facility discharge list, facility policy review, and staff interview, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of residents for 3 of 3 residents sampled (Resident #56, #58 and #59) with a discharge to home. The facility reported a census of 51 residents. Findings include:Review of list of resident discharged from the facility, dated 6/1/25 to present (9/8/25), revealed a total of 3 residents discharged from the facility to home, Residents #56, #58 and #59.1.The Minimum Data Set (MDS) assessment for Resident #56 dated 7/10/25 indicated the resident was admitted to the facility on [DATE] and discharged on 7/10/25. A Discharge Summary/Recapitulation of Stay dated 7/7/25, included documentation the resident planned to discharge home with home health services including skilled nursing, occupational and physical therapy services. On 9/10/25, review of the clinical record revealed a lack of documentation regarding notification of the State Long-Term Care Ombudsman of the discharge for Resident #56.2. The MDS assessment for Resident #58 dated 6/28/25 indicated the resident was admitted to the facility on [DATE] and discharged on 6/28/25. The Progress Note dated 6/28/25 revealed the resident discharged to home. On 9/10/25, review of the clinical record revealed a lack of documentation regarding notification of the State Long-Term Care Ombudsman of the discharge for Resident #58.3. The MDS assessment for Resident #59 dated 7/14/25 indicated the resident was admitted to the facility on [DATE] and discharged on 7/14/25. A Progress Note titled Recapitulation of Stay and Discharge summary dated [DATE] revealed the resident discharged to home. On 9/10/25, review of the clinical record revealed a lack of documentation regarding notification of the State Long-Term Care (LTC) Ombudsman of the discharge for Resident #59.On 9/10/2025 at 1:18 PM, the Administrator reported she thought they were not notifying the LTC Ombudsman for discharges to home, only for hospital transfers. The Administrator reported she talked with Corporate staff, and they were not aware of need to contact LTC Ombudsman for residents that discharged to home. On 9/10/2025 at 1:31 PM Administrator confirmed facility staff had not notified the LTC Ombudsman regarding Resident #56's discharge from the facility to home. On 9/10/2025 at 1:45 PM, the Administrator confirmed facility staff had not notified the LTC Ombudsman regarding Resident #58's and Resident #59's discharge from the facility to home. Administrator reported a plan to start notifying the LTC Ombudsman of all discharges from the facility.Review of the facility's policy titled Discharge and Transfer Policy dated 3/2025 revealed, facility staff must send a copy of the resident's discharge notice to the Office of the State Long Term Care Ombudsman at the same time the facility issued the notice to the resident. The facility must issue the notice of discharge at 30 days in advance of the discharge unless the resident heath improves sufficiently to a more immediate discharge.

Based on clinical record review, observation, facility policy review, resident and staff interview, nursing staff failed to perform assessment and intervention of a resident (Resident #28) after a meal observation revealed staff served the resident food the resident had documented as an allergy. The facility reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #28 dated 8/17/25 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. The Care Plan for Resident #28 included an intervention dated 9/22/24 to for staff to provide and serve the resident's diet as ordered. The main page of the electronic clinical record for Resident #28 identified the resident had a food allergy to shellfish (shrimp, crab, lobster, oysters, clams, mussels and scallops).A History and Physical report dated 8/8/25 scanned into the clinical record revealed Resident #28's had an allergic reaction of hives (small red bumps on the skin) to shellfish. On 9/8/25 at 12:16 PM, observation revealed Staff F, Server (dietary), set up the food to be served for Resident #28 on kitchen counter. Staff B, Certified Nurses Aide (CNA), took Resident #28's lunch to the table and set the food in front of the resident. The lunch included breaded coconut shrimp.On 9/8/25 at 12:18 PM, Resident #28 was observed to eat her lunch independently, including the breaded shrimp. On 9/8/25 at 12:24 PM, Staff A, CNA, stopped as she was walking by Resident #28 and looked at the resident's plate. Staff A told the resident she could not have shrimp because the resident was allergic to the shrimp, and removed the entire food plate from the resident. Staff A proceeded to alert Staff F of the allergy concern. Staff A brought the resident a replacement lunch.On 9/8/25, review of the food service ticket for Resident #28's lunch on 9/8/25 revealed a food order for coconut shrimp. The food service ticket included the following information printed in red: Allergens: Shell Fish.On 9/08/25 at 1:06 PM, Staff C, Oral Medication Technician (OMT), who was working in the same hall that Resident #28 resided, reported there was one nurse for the all of the resident halls in the building and identified the nurse for 9/8/25 was Staff H, Registered Nurse (RN). On 09/08/25 at 1:10 PM, Staff confirmed she was the nurse for all the residents. Staff H denied anyone had alerted her that Resident #28 had been served and ate shrimp at lunch. On 9/8/25 at 2:17 PM, during an interview with Resident #28 and a family member, Resident #28 reported when she had eaten shellfish in the past, she got itchy; she denied having any difficulty with her throat or swallowing issues after eating shellfish in the past. The Resident reported she only ate one to two of the shrimp before staff removed it from her at lunch. Resident #28 reported nursing staff had not checked on her since she ate the shrimp at lunch. The resident denied any allergic reaction symptoms at the time of the interview. On 9/08/2025 at 2:48 PM, Staff G, Clinical Coordinator, reported she was unaware that staff had served Resident #28 shellfish for lunch. Staff G reported the expectation that the CNA would have notified dietary staff and the charge nurse immediately in order to assess the resident for an allergic reaction. The charge nurse would then notify the resident's physician of the exposure to the allergen and of any symptoms. On 9/10/25, review of the clinical record for Resident #28 revealed the following:A progress note titled General Note dated 9/8/25 at 1:30 PM, documented as late entry, revealed CNA reported the resident ate one to two shrimp during lunch and the resident had an allergy history to shellfish. The note included documentation of a vital sign assessment of the resident including a blood pressure of 137/76, pulse 60, respirations 18, and temperature 97.1, blood oxygen saturation level of 94 percent and complaints of itchiness in the resident's hands. The resident refused as needed Benadryl (antihistamine) and denied any shortness of breath or dyspnea (difficulty breathing). The nurse documented she notified the resident's primary care physician via fax.Review of the facility policy, titled Food Allergy Policy, dated 9/2025, revealed staff were document food allergies upon admission and review during care planning development.

Based on clinical record review, meal service observation, review of facility policy, resident and staff interview, the facility failed to ensure they did not serve a resident food that was known to cause an allergic response during 1 of 2 resident meal service observations (Resident #28). The facility reported a census of 51 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #28 dated 8/17/25 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status exam, which indicated intact cognition. The Care Plan for Resident #28 included an intervention dated 9/22/24 to for staff to provide and serve the resident's diet as ordered. The main page of the electronic clinical record for Resident #28 identified the resident had a food allergy to shellfish (shrimp, crab, lobster, oysters, clams, mussels and scallops).A History and Physical report dated 8/8/25 scanned into the clinical record revealed Resident #28 had an allergic reaction of hives (small red bumps on the skin) to shellfish. On 9/8/25 at 12:16 PM, observation revealed Staff F, Server (dietary), set up the food to be served for Resident #28 on kitchen counter. Staff B, Certified Nurses Aide (CNA), took Resident #28's lunch to the table and set the food in front of the resident. The lunch included breaded coconut shrimp.On 9/8/25 at 12:18 PM, Resident #28 ate her lunch independently, including the breaded shrimp. On 9/8/25 at 12:24 PM, Staff A, CNA, stopped as she was walking by Resident #28 and looked at the resident's plate. Staff A told the resident she could not have shrimp because the resident was allergic to the shrimp, and removed the entire food plate from the resident. Staff A proceeded to alert Staff F of the allergy concern. Staff A brought the resident a replacement lunch.On 9/8/25, review of the food service ticket for Resident #28's lunch on 9/8/25 revealed a food order for coconut shrimp. The food service ticket included the following information printed in red: Allergens: Shell Fish.On 9/8/25 at 2:17 PM, during an interview with Resident #28 and a family member, Resident #28 reported when she had ate shellfish in the past, she got itchy; she denied having any difficulty with her throat or swallowing issues after eating shellfish. The Resident reported she only ate one to two of the shrimp before staff removed it from her. The resident denied any allergic reactions symptoms at the time of the interview. Review of the facility policy, titled Food Allergy Policy, dated 9/2025, revealed staff were document food allergies upon admission and review during care planning development. Allergy information must be visible to nutrition and culinary staff on food tickets. Food servers and cooks were trained to confirm allergy precautions prior to meal service.

Based on observation, clinical record review, and staff interviews the facility failed to investigate an injury of unknown origin for 1 of 6 residents (Resident #3) reviewed. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #3, dated 2/14/24, revealed diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and anxiety. The resident was unable to complete the Brief Interview for Mental Status (BIMS) due to short- and long-term memory problems. The MDS indicated a need for partial to moderate assistance with toileting and bathing, and supervision or touch assistance with personal hygiene. The Care Plan, dated 2/8/24, included focus areas for impaired skin integrity, and for risks of falls. The focus area for skin integrity included an intervention to assess/evaluate my risk status per policy, upon admission, quarterly and as needed. indicated the resident was at risk for impaired skin integrity. Another area indicated a psychosocial well-being problem related to anxiety, dementia with behavioral disturbance, and impaired cognition/communication. Neither addressed picking or scratching as symptoms or behaviors to monitor. A Progress Note dated 4/26/24 at 3:10 AM indicated the resident was scratching the back of his head and picking at scabs, small amounts of dried blood noted. A Progress Note dated 4/26/24 at 10:55 AM documented the resident had dried blood on his head due to picking at scabs and scratching his head. The Progress Notes lacked assessment information, including origin, size and notification of the provider. A document titled Body Audit - V4 on 4/28/24 at 5:48 PM documented a skin alteration on top of the scalp as scratches healing with no signs of infection. The clinical record lacked information, including origin, size and notification of the provider. A document titled Task: Skin Observation documented the resident had a skin alteration on 4/26/24 at 3:40 AM, and on 4/27/24 at 10:15 AM. The skin alteration on 4/26/24 at 3:40 AM assessed as an open area. The 4/27/24 at 10:15 AM assessed the area as not open. On 5/15/24 at 1:32 PM observed the resident resting on a sofa in his room. The area in question on his head appeared healed. The resident moved independently on the sofa and his walker was nearby. The resident's legs were tangled in his blanket as he rolled into a seated position. He fell back asleep, still sitting up. Resident remained in that position at 1:54 PM. During an interview on 5/14/24 at 9:21 AM Staff C, Registered Nurse (RN) stated she was told the resident was confused and knelt down on the floor to pick something up and did not have a fall. She stated there was a dressing on his head and she was not sure what it was from. On 5/14/24 at 10:08 AM Staff A, Certified Nursing Assistant (CNA), stated Resident #3 had fallen a couple of times. She thought he had scratched his head this time, but later noted the area started to bruise and thought it might be from a fall. She reported this to a nurse and to the DON. A clinical record review revealed a lack of documentation regarding a resident fall. During an interview 5/14/24 at 1:41 PM, Staff B, CNA, stated on that she did not see the incident but worked with the resident. She stated he was acting out of the ordinary. She stated she saw a spot of blood on the floor and talked to the nurse. The CNA noted that the resident would not remember if he was on the floor and no one actually saw him fall or on the floor. During an interview with the Director of Nursing (DON) on 5/14/24 at 4:42 PM, she stated the nurse was called in because the resident's head was bleeding. She cleaned and dressed it. The nurse thought it was scratching and picking. The DON said he did this behaviorally and it could cause bruising. During an interview on 5/16/24 at 8:49 AM, the DON stated if there is an concern with a resident and it is unknown what occurred the facility would try to figure out what happened. This involves talking to the resident, look at staffing patterns, resident behavior, time of day, if anything different about the day, resident behaviors related to possible urinary tract infection or respiratory concern. When asked how the process for different accounts of a concern is handled, the DON stated determine if resident can answer questions, look at information have, look at injury, what is the injury consistent with, try to assess is there is anything can figure out. It is detective work, and need to err on the side of caution.

Based on clinical record review, interviews, and policy review the facility failed to complete neurological assessments after unwitnessed falls for 1 of 6 residents (Residents #2 )reviewed. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #2, dated 3/5/24, included diagnoses of vascular dementia with psychotic disturbance, anxiety disorder, and insomnia. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 5 out of 15, which indicated severely impaired cognition. Progress notes dated 2/2024 x 2, 2/29/24, 3/11/24, 3/13/24 x 2, 3/15/24, 3/17/24, 3/19/24, 3/23/24, 3/24/24, 3/30/24, 4/18/24 x 2, 4/22/24, and 4/25/24 documented Resident #2 ' s unwitnessed falls. Facility documentation titled Neuro-Check Flow Sheet documented neurological assessments were completed for the fall that occurred on 3/23/24. The facility lacked neurological assessments for the other 15 unwitnessed falls. During an interview with Staff C, Registered Nurse (RN), on 5/14/24 at 9:21 AM she indicated that staff should start neurological assessments with unwitnessed falls, as well as if the resident 's health declined or if they aren't sure if the resident hit their head. Staff E, RN stated on 5/14/24 at 3:48 PM the policy for falls was to start neurological assessments to determine resident status. With a lower BIMS it could be difficult to tell if the resident was a good witness and necessary to start the checks. She stated it is better to be safe than sorry. Staff E stated she recently laminated and posted the policy at the main nursing station in case staff had questions. An interview with the Director of Nursing (DON) on 5/14/24 at 4:42 PM revealed the interdisciplinary team (IDT) completed fall follow up. She stated the policy for starting neurological assessments with residents with cognitive impairment was not different and they just took what they said at face value. A policy titled Fall Prevention and Management Program Policy, modified April 2021, stated members of the interdisciplinary team were responsible for assessing, treating, and implementing strategies for the prevention of resident falls. For unwitnessed falls where the resident is not able to state if they hit their head, staff should perform neuro checks for 3 days according to a documented protocol. The policy lacked clarification regarding residents with impaired cognition.

Based on clinical record review, family interview, physician interview, staff interviews, and facility policy review, the facility failed to provide appropriate assessment and interventions for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff failed to immediately call 911, call the physician, call the family, or conduct neurological assessments as per policy. The facility staff moved the resident to the shower and then to bed. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur. The failure of assessing the resident properly and seeking immediate emergency treatment caused an Immediate Jeopardy (IJ) to the health and safety of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 11:00 a.m. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Resident #158 was discharged from the facility on [DATE]. 2. The 24-hour Summary Reports will be reviewed from [DATE] through [DATE] to determine whether resident assessments and subsequent intervention were implemented for residents experiencing a change of condition. If additional residents are identified who did not receive adequate assessment or subsequent intervention, the residents will be reassessed, and the respective Physician's will be notified. Completion date: [DATE] 3. All Nurses will be educated on the facility Post-Fall Check List, Fall Prevention and Management Program Policy, Microlearning: Observation and Reporting (the educator will also include the incident in question as an ancillary case study to the Microlearning), and the Communication and Notification - Staff, Practitioner, and Resident Representative Policy. Completion date: [DATE]. For nurses who are not available for training by the designated completion date (e.g., on FMLA, PRN and at College, on PTO), they will not be allowed to work a shift until they receive this training. 4. The 24-hour summary report will be reviewed daily by the interdisciplinary team (IDT) to ensure all resident changes of condition are identified timely and appropriate assessment and intervention occur. Completion date: [DATE]. 5. The Clinical Administrator or designee will attend the IDT meetings two times per week x 6 weeks to ensure the 24-hour summary report reviews are occurring and to ensure all resident changes of condition are identified timely and appropriate assessment and intervention occur. Date monitoring will be initiated by (completion date): [DATE]. 6. The facility Policy: Fall Prevention and Management Program Policy with a modified date of [DATE] was reviewed on [DATE] and remains appropriate. 7. The facility Policy: Communication and Notification - Staff, Practitioners, and Resident Representatives Policy with a modified date of [DATE] was reviewed on [DATE] and remains appropriate. The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 revealed the following diagnosis; dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. The MDS recorded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal hygiene. The MDS coded that the resident was able to ambulate independently with a walker. The Care Plan dated [DATE] directed staff to administer pain medication as ordered and to monitor for both verbal and nonverbal signs and symptoms of pain and discomfort. The care plan instructed staff to monitor for signs or symptoms of further mood decline and update the physician as needed. A Progress Note dated [DATE] at 9:45 PM revealed Resident #158 yelled for help, found on the floor outside of the bathroom, laying on her right side, complained of pain all over, range of motion (ROM) and neurological checks were normal, and therefore the resident was moved from the floor with the assistance of 2 staff. The entry recorded an injury described as a 3 centimeter (cm) by 5 cm hematoma (localized bleeding, bruise) and 3 cm by 1 cm skin tear to the right eye. The entry documented the notification of the On-Call Registered Nurse (RN) Staff A, and a fax to Staff H, Physician, and that the Power of Attorney (POA) would be notified in the morning. The document titled Resident Occurrence dated [DATE] revealed: a. Resident #158 yelling, found outside bathroom door. b. Last observed in the dining room at 9:15 PM. c. Resident walking, no walker. d. Prevention from occurring again: frequent checks. e. Position of resident, on right side with gripper socks on, not wearing glasses. f. The floor was shiny. g. Signature Staff B, RN; Staff G, Certified Nursing Assistant (CNA); and Staff D, CNA. The document titled Neuro Check Flow Sheet for Resident #158 revealed: a. On [DATE] at 9:45 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with vital signs (VS) recorded as blood pressure (BP) ,d+[DATE] pulse (P) 68 and no change from baseline assessment. The entry lacked a pain assessment. b. On [DATE] at 10:00 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with VS: BP ,d+[DATE] P 64, and no change from baseline assessment. The entry lacked documentation of a pain assessment. c. On [DATE] at 11:00 PM, the resident alert, neuro checks normal, pupils equal, reactive, brisk, with VS: BP ,d+[DATE], P 63, and no change from baseline assessment. The entry lacked documentation of a pain assessment. d. On [DATE] at 12:00 AM, the resident slept with VS: BP ,d+[DATE], P 74, and no change in baseline assessment. The entry lacked documentation of a comprehensive neuro check, pupil assessment, or pain assessment. e. On [DATE] at 2:00 AM, the resident was sleeping. The entry lacked documentation of a comprehensive neuro check, pupil assessment, measurement of VS, and pain assessments. f. On [DATE] at 4:00 AM, the resident slept with VS: BP ,d+[DATE], P 63, and no change in the baseline assessment. The entry lacked documentation of comprehensive neuro check, pupil assessment, and pain assessments. g. On [DATE] at 8:00 AM, the resident was sent to the hospital. h. Signature Staff B, RN The document titled Falls Follow up Form dated [DATE] at 9:45 PM recorded the following: a. Identified Resident #158. b. Vital Signs BP ,d+[DATE], Pulse 68, Respirations 18, Temperature 97.8, Oxygen Saturation 94%. c. The document lacked the following assessments: -Change of condition. -Sensory impairments. -Change in elimination. -Gait balance impairment: ROM, change in the ability to transfer. -Change in activity pattern: Sleep. -Pain. d. Analysis and Summary of causal factors: -Coming from the bathroom. -Not using a walker. e. Interventions: -Frequent checks. -Reminder to use the walker. f. Signature by Staff B, RN. A Facility Fax dated [DATE] at 10:55 PM revealed: a. Resident #158 was found on the floor. b. Vital signs Blood Pressure ,d+[DATE] Pulse 60. c. Hematoma and skin tear to the right eye. d. ROM and neurological checks are normal. e. Pain all over. f. Physician signature received on [DATE]. The Medication Administration Record (MAR) dated [DATE] for Resident #158 revealed: a. Acetaminophen (a.k.a. Tylenol) 325 milligrams (mg) to be administered four times a day. b. Acetaminophen administered on [DATE] four times, the last dose at bedtime. c. Fentanyl (narcotic pain medication) 12 micrograms/hour 72 hour patch. d. Fentanyl patch last applied on [DATE]. e. MAR lacked an order for as needed (PRN) pain medication. f. MAR lacked documentation of a Standing Order pain medication administered on [DATE] - [DATE]. A Change of Condition Note dated [DATE] at 6:30 AM revealed Resident #158 complained of pain to the right upper extremity (RUE), refused to move the arm, and yelled out in pain when the nurse touched RUE. The documentation revealed Staff H, the POA, Staff A, and Emergency Medical Services (EMS) were notified and a report was called to the emergency room (ER) Nurse. Resident #158 was transferred to the local hospital at 6:47 AM. The Local Hospital ER Notes dated [DATE] at 7:10 AM revealed Resident #158 arrived via ambulance laying on her left side, unable to roll over onto her back, guarding her right arm, and she yelled no with a light touch to the deformity noted on the right humerus. The notes documented the resident's left lower extremity shortened and rotated, a laceration with dried blood present above her right eye, and diffuse bruising around the right orbit. The x-ray of the right shoulder revealed a displaced fracture of the right humerus and the x-ray of the right hip revealed a displaced right femur fracture; the resident was treated with oxygen and Dilaudid pain medication. A Progress Note dated [DATE] at 5:26 PM documented a phone call placed to the local hospital for an update on Resident #158 and the resident was diagnosed with a fractured right shoulder, fractured right hip, and required a higher level of care therefore transferred to a tertiary hospital. A Progress Note on [DATE] at 6:57 AM documented notification given to Staff H that Resident #158 admitted to the tertiary hospital. A Progress Note on [DATE] at 11:51 AM revealed Staff H acknowledged the fax received in regards to Resident #158's fall. A Facility Fax dated [DATE] at 5:49 AM revealed: a. Resident #158 was transferred to the local hospital for an evaluation. b. Resident #158 was subsequently transferred to tertiary hospital and admitted for hip and shoulder fractures. c. Physician signature received on [DATE]. A Hospital Report on [DATE] at 1:58 PM revealed: a. Resident #158 was admitted due to uncontrolled pain. b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture. c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner). d. Recommendation to the family was to focus on comfort care with Hospice support for pain management. e. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family. A Progress Note on [DATE] at 11:50 AM revealed Resident #158 returned from the hospital via ambulance, drowsy but responsive to pain. The entry recorded the resident had a fracture to right humeral head and femoral neck, multiple bruises to face and right arm due to recent a fall on [DATE]. The entry documented the resident admitted to Hospice care and treated with Oxycodone (narcotic pain medication) 2.25 milliliters (ml) for the pain. A Progress Note on [DATE] at 1:30 PM revealed Resident #158 passed away with family at bedside. During an interview on [DATE] at 1:59 PM, Staff J, CNA stated that after a normal fall, the staff use the walkie to call the nurse who does the evaluation, measures vitals, and the staff would use a sling and Hoyer (mechanical lift) to get the resident up unless the resident can get up on their own. Staff J stated if a resident could stand, then they would get up themselves. During an interview on [DATE] at 2:16 PM, Staff B, RN stated Resident #158 was independent with ambulation. Staff B reported the resident fell close to the shift change in the bathroom, cut her eyebrow, it was not actively bleeding, but the resident had blood on the floor, her hands and her legs. Staff B stated the staff cleaned up the blood, assessed her neuro's, range of motion, vital signs and Staff B told the staff to get the resident up to a shower chair. Staff B stated the staff stood the resident, pivoted her to the shower chair, and washed off the blood. Staff B stated she completed the fall paperwork and sent the incident paperwork to Staff A. Staff B stated the staff dressed the resident and put her to bed. Staff B stated the resident was in pain but could not tell Staff B where the pain was located. Staff B said at 4:30 AM or 5:00 AM the staff tried to move the resident and the resident's arm hurt. Staff B stated she didn't remember notifying the doctor but she did send a fax to him. Staff B stated Resident #158 was bleeding and she applied first aid. During a family interview on [DATE] at 2:33 PM, the POA stated she was not notified on the evening Resident #158 fell . The POA stated the staff said the resident fell around 9:00 PM or 10:00 PM and they didn't call her until 6:30 AM to ask if she could go to the hospital. The POA stated the staff reported they got the resident up and put her in the shower due to having blood everywhere. The POA voiced the prognosis and the resident's ability to do therapy was poor. The POA stated they offered comfort care so she agreed to that and the resident returned to the facility where she died on [DATE]. The POA voiced that the facility left the resident there to suffer in pain all that night with a fractured hip and shoulder. The POA stated the resident resided at the facility for 8 years and when the staff said they didn't want to bother her in the middle of the night, she asked the nurse when 9:30 PM considered the middle of the night, but the staff would not answer her. In an interview on [DATE] at 3:53 PM, Staff K, RN stated when a resident fell the nursing staff followed the fall protocol, obtained vital signs, performed an assessment of the extremities and pain, and charted observations to include the position of the resident, the wheelchair or walker, and what the resident wore. Staff K stated if a resident could stand, they moved them. Staff K stated the protocol was to call the doctor and hospital intervention if needed; fax the physician if no visible injuries. Staff K stated on [DATE] she arrived at 6 AM and during the nurse report, the night nurse stated Resident #158 fell in the Memory Care Unit and bumped her head. Staff K stated that Staff B, RN claimed the staff found the resident and there was so much blood that the staff showered the resident before they put her to bed. Staff K stated Staff B reported that Resident #158 had a head injury of a skin tear but was not sent to the hospital. Staff K stated the resident was really in so much pain, it could be seen on her face and when they moved the resident ' s arm she shouted in pain. Staff K stated Staff B then called the On-Call nurse, the doctor and family at 6:30 AM. Staff K stated the POA called back and asked her if the staff normally showered someone after a fall. Staff K said she responded that the night nurse said they had to because there was so much blood they couldn't find where it was coming from. In an interview on [DATE] at 8:05 PM, Staff G, CNA stated she found Resident #158 on the floor on [DATE] at 9:30 PM. Staff G voiced she would not forget it because it was traumatic for her. Staff G stated Staff D, CNA heard Resident #158 called out and she found the resident lying on the floor just inside her bathroom, in her bedroom, on her right side in the fetal position. Staff G reported the resident was not lying still and she moved around in the blood. Staff G recalled blood being present on the floor, up the wall, in the resident ' s hair, and on the left side of her head, hands and legs. Staff G stated she called the nurse with the walkie and put a pillow under the resident ' s head. Staff G reported there was so much blood that she started wiping the resident ' s hands off with a washcloth to see where it was coming from. Staff G commented that the resident ' s left side of her face and hair were red. Staff G stated Staff B, RN came in, took the vital signs and instructed her to get Resident #158 in the shower to wash away the blood. Staff G said the resident ' s pajamas were soaked in blood. Staff G stated Staff B assisted to stand Resident #158 up, pivoted her into a shower chair, washed her off, then started to dress the resident. Staff G recalled Resident #158 said it hurt and told them not to push when they applied the gripper socks and pants. Staff G stated Staff D helped to push the shower chair next to the bed, they stood Resident #158 and pulled up her pants, pivoted her and put her into the bed. Staff G stated she asked Staff B if she thought they should send the resident out due to the resident losing so much blood but Staff B did not. During an interview on [DATE] at 7:50 AM, Staff A, RN Clinical Administrator stated she did not know about the fall until the morning of [DATE] at 6:30 AM and she said to send the resident to the hospital. Staff A stated the staff knew they could call ,d+[DATE] and the expectation was to call with a fall. Staff A reported they did not investigate the fall and they did not interview the staff. Staff A stated that Resident #158 was ambulatory and therefore no self report was made to the state. Staff A stated the fall happened during her first week at the facility. During an interview on [DATE] at 9:05 AM, Staff H, Physician responded if anyone found a resident on the floor, he would expect the staff to look for any visible wounds, assess for pain in any extremity and if they had a visible head wound, there may be a hemorrhage so of course to call 911. Staff H stated the staff could call ,d+[DATE] to report a fall and receive orders for treatment. In a subsequent interview on [DATE] at 10:28 AM, Staff H, Physician stated a review of the call logs revealed that there was no call for a fall on Resident #158 and he did not remember receiving one. Staff H stated he found a fax dated [DATE] at 10:45 PM that documented Resident #158 was found on the floor on her right side, her range of motion and neuro's were normal, she had a hematoma and complained of pain all over. Staff H commented that looking at the fax, the staff should have called 911. Staff H stated another fax received on Monday [DATE] at 5:49 AM documented the resident transferred to the local hospital. Staff H said a 2nd fax received on [DATE] at 3:47 PM notified him of the resident's death, 2 hours after Resident #158 passed away. During an interview on [DATE] at 8:08 AM, Staff E, CNA reported working for the facility for [AGE] years. Staff E stated on [DATE] at 10:00 PM she received a report that Resident #158 fell and the other CNA's had showered her. Staff E recalled Resident #158 wore a nightgown and laid in bed shaking. Staff E said the resident didn't verbalize and she didn't even touch the resident that night as the resident laid at the head of the bed but had turned herself around with her head at the foot of the bed. Staff E voiced she didn't touch the resident, provide check and change care, or turn the resident because she didn't want to cause her any more pain. Staff E reported the resident laid in the fetal position in bed all night shaking. Staff E voiced the resident was shaking really badly and the resident did not shake normally and therefore Staff E was not comfortable with doing anything with the resident. Staff E recalled thinking why didn ' t they send her out. Staff E stated that Resident #158 remained at the facility as of 6 AM when her shift was complete. Staff E stated the Memory Care Unit was where she worked and Resident #158 normally slept all night and would get up when she needed to use the bathroom. During an interview on [DATE] at 11:00 AM, Staff B, RN stated Resident #158 was able to sit up, had full range of motion to her arms and legs, and no complaints of pain. Staff B said she wanted the resident cleaned up as she had dried blood in her hair, on her hands, and legs. Staff B stated she gave the instruction for the CNA's to get Resident #158 showered. Staff B said while she observed, the resident alternated cradling her arms in her lap. Staff B stated the CNA's put the residents arms in her gown, they wheeled the shower chair over to the bed and put the resident to bed onto her right side and covered her. Staff B said she completed another set of vital signs and neurological checks. Staff B reported when she returned an hour later the resident slept and she was sleeping every time Staff B went into her room. Staff B stated she had notified the On-Call Nurse, Staff A, with a text, who responded ok. Staff B said she continued neuros during the night and the resident ' s eye was bruised. Staff B stated Staff E called at midnight, reporting Resident #158 was experiencing pain. Staff B commented the resident didn't look like she was in distress, nothing unusual. Staff B stated that Staff E reported Resident #158 was moving around in her bed, laid toward her headboard and other times her head toward the foot board. Staff B administered an as needed (prn) Tylenol at midnight per the standing order. Staff B voiced she didn't document it as the stomach pain was normal for the resident. Staff B stated she did not notify the doctor in this case as there was a standing order. Staff B reported at 4:00 to 5:00 AM, the resident said ouch, don't touch her arm. Staff B stated she updated Staff A with a text at that time that she was working on sending the resident out for further evaluation. Staff B stated she made the decision to send the resident out. Staff B said she notified the POA at 4:00 -5:00 AM letting her know the resident fell the night before, cut above her eyebrow, they cleaned her up in the shower, completed neuro checks and she had a change. Staff B stated the resident didn't want to move her right arm so Staff B wanted to send the resident out if the POA was okay with it. Staff B stated she called the provider to get the order and called the ER at the local hospital to give a report. During an interview on [DATE] at 9:24 AM, Staff A, RN, Clinical Administrator stated she checked for a text from Staff B on the evening of [DATE] and she did not get a text or call. Staff A stated she did not get a call until [DATE] at 6:30 AM when she said to send Resident #158 to the hospital. During an interview on [DATE] at 2:30 PM, Staff L, Advanced Registered Nurse Practitioner (ARNP), stated she remembered receiving a call on [DATE] from the nurse asking permission to send the resident to the hospital. Staff L reported she was on call for the providers in that area and at the hospital emergency room (ER). Staff L stated the staff did not call the physician when Resident #158 fell at 9:00 PM on [DATE]. Staff L voiced the whole thing was not right as Staff B said they found the resident down, put her back to bed, and the resident didn't want to get up in the morning, so they needed permission to send her. Staff L stated the resident had a head injury, there was shortening of the resident's right leg and it was rotated outward, the resident guarded her right arm screaming if staff touched it, and they gave the resident nothing for her pain. Staff L stated the staff should have called the on-call provider at the time Resident #158 was found on the floor to seek treatment orders; the on-call providers take calls ,d+[DATE]. The policy titled Fall Prevention and Management dated [DATE] revealed: a. The Clinical Administrator is responsible for assuring implementation of this policy. b. All staff are responsible for implementing the intent and directives contained within this policy. c. The Nurse will immediately evaluate the resident for any injury, change in status and/ or pain and will proceed with emergency procedures and interventions as indicated. d. Suspected head injury or possible significant injury or fracture: the resident is not to be moved until emergency personnel have arrived unless it is determined that the resident is at risk for injuring self further or is at risk for further injury if they are not moved. e. The Nurse will notify 911, the primary physician and/or Nurse Practitioner (NP) and the RN in charge as indicated based on the initial evaluation and the resident care plan. f. The Staff Nurse will complete the resident Occurrence Report and notify the physician and responsible party. g. Minor Head Trauma or Unwitnessed Fall where the resident is not able to state if they hit their head 1. Determine vital signs including orthostatic blood pressures. 2. Determine circumstances leading to the fall and interventions. 3. Perform Neuro Checks: a. Day 1: i. Every 15 minutes x 2 ii. Every hour x 2 iii. Every 2 hours x 2 iv. Every 4 hours x 2 b. Days 2 and 3: i. Every shift c. Alert the Physician or NP with any changes. h. An entry into the medical record will be completed to include: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, responsible party notification, nursing actions.

Based on clinical record review, family interview, staff interviews, and facility policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents (Resident #158). Clinical record review revealed on [DATE] at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff moved the resident to the shower and then to bed and the resident reported pain that was not treated. Upon arrival of the next shift 9 hours later, the facility sent the resident to the emergency room (ER) where the resident was assessed to have fractures of the humerus and femur and immediately treated for pain; the resident admitting diagnoses included uncontrolled pain. The failure created an immediate jeopardy to the health and safety of the resident. The facility reported a census of 57 residents. After a QA Review, the State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 12:30 p.m. related to pain management. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Resident #158 was discharged from the facility on [DATE]. 2. The staff nurse in question was separated from the resident and put on indefinite suspension beginning [DATE] pending outcome of Dependent Adult Abuse investigation. 3. All clinical staff educated on the Pain Assessment and Management Policy. Staff education occurred on [DATE], [DATE], and [DATE]. Any staff who were PRN (casual status), student status, leave status, or who otherwise did not work on a routine basis were allowed to work the floor until after the time they had been able to be educated on the Pain Assessment and Management Policy. 4. The facility Pain Assessment and Management Policy was reviewed on [DATE] with no subsequent changes. 5. The Clinical Administrator, Care Center Administrator or designee will interview 25% of care center residents per week x 4 weeks to determine if licensed staff are responsive to resident pain. This will include staff and family interviews for residents in the CCDI household. Any identified issues will be referred to the subsequent QAPI meeting. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 revealed the following diagnosis; dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. The MDS recorded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal hygiene. The MDS coded that the resident was able to ambulate independently with a walker. The Care Plan dated [DATE] directed staff to administer pain medication as ordered and to monitor for both verbal and nonverbal signs and symptoms of pain and discomfort. The care plan instructed staff to monitor for signs or symptoms of further mood decline and update the physician as needed. A Progress Note dated [DATE] at 9:45 PM revealed Resident #158 yelled for help, found on the floor outside of the bathroom, laying on her right side, complained of pain all over, range of motion (ROM) and neurological checks were normal, and therefore the resident was moved from the floor with the assistance of 2 staff. The entry recorded an injury described as a 3 centimeter (cm) by 5 cm hematoma (localized bleeding, bruise) and 3 cm by 1 cm skin tear to the right eye. The entry documented the notification of the On-Call Registered Nurse (RN) Staff A, and a fax to Staff H, Physician, and that the Power of Attorney (POA) would be notified in the morning. The document titled Resident Occurrence dated [DATE] revealed: a. Resident #158 yelling, found outside bathroom door. b. Last observed in the dining room at 9:15 PM. c. Resident walking, no walker. d. Prevention from occurring again: frequent checks. e. Position of resident, on right side with gripper socks on, not wearing glasses. f. The floor was shiny. g. Signature Staff B, RN; Staff G, Certified Nursing Assistant (CNA); and Staff D, CNA. The document titled Neuro Check Flow Sheet for Resident #158 revealed: a. On [DATE] at 9:45 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with vital signs (VS) recorded as blood pressure (BP) ,d+[DATE] pulse (P) 68 and no change from baseline assessment. The entry lacked a pain assessment. b. On [DATE] at 10:00 PM, the resident alert, neuro check normal, pupils equal, reactive, brisk, with VS: BP ,d+[DATE] P 64, and no change from baseline assessment. The entry lacked documentation of a pain assessment. c. On [DATE] at 11:00 PM, the resident alert, neuro checks normal, pupils equal, reactive, brisk, with VS: BP ,d+[DATE], P 63, and no change from baseline assessment. The entry lacked documentation of a pain assessment. d. On [DATE] at 12:00 AM, the resident slept with VS: BP ,d+[DATE], P 74, and no change in baseline assessment. The entry lacked documentation of a comprehensive neuro check, pupil assessment, or pain assessment. e. On [DATE] at 2:00 AM, the resident was sleeping. The entry lacked documentation of a comprehensive neuro check, pupil assessment, measurement of VS, and pain assessments. f. On [DATE] at 4:00 AM, the resident slept with VS: BP ,d+[DATE], P 63, and no change in the baseline assessment. The entry lacked documentation of comprehensive neuro check, pupil assessment, and pain assessments. g. On [DATE] at 8:00 AM, the resident was sent to the hospital. h. Signature Staff B, RN The document titled Falls Follow up Form dated [DATE] at 9:45 PM recorded the following: a. Identified Resident #158. b. Vital Signs BP ,d+[DATE], Pulse 68, Respirations 18, Temperature 97.8, Oxygen Saturation 94%. c. The document lacked the following assessments: -Change of condition. -Sensory impairments. -Change in elimination. -Gait balance impairment: ROM, change in the ability to transfer. -Change in activity pattern: Sleep. -Pain. d. Analysis and Summary of causal factors: -Coming from the bathroom. -Not using a walker. e. Interventions: -Frequent checks. -Reminder to use the walker. f. Signature by Staff B, RN. A Facility Fax dated [DATE] at 10:55 PM revealed: a. Resident #158 was found on the floor. b. Vital signs Blood Pressure ,d+[DATE] Pulse 60. c. Hematoma and skin tear to the right eye. d. ROM and neurological checks are normal. e. Pain all over. f. Physician signature received on [DATE]. The Medication Administration Record (MAR) dated [DATE] for Resident #158 revealed: a. Acetaminophen (a.k.a. Tylenol) 325 milligrams (mg) to be administered four times a day. b. Acetaminophen administered on [DATE] four times, the last dose at bedtime. c. Fentanyl (narcotic pain medication) 12 micrograms/hour 72 hour patch. d. Fentanyl patch last applied on [DATE]. e. MAR lacked an order for as needed (PRN) pain medication. f. MAR lacked documentation of a Standing Order pain medication administered on [DATE] - [DATE]. A Change of Condition Note dated [DATE] at 6:30 AM revealed Resident #158 complained of pain to the right upper extremity (RUE), refused to move the arm, and yelled out in pain when the nurse touched RUE. The documentation revealed Staff H, the POA, Staff A, and Emergency Medical Services (EMS) were notified and a report was called to the emergency room (ER) Nurse. Resident #158 was transferred to the local hospital at 6:47 AM. The Local Hospital ER Notes dated [DATE] at 7:10 AM revealed Resident #158 arrived via ambulance laying on her left side, unable to roll over onto her back, guarding her right arm, and she yelled no with a light touch to the deformity noted on the right humerus. The notes documented the resident's left lower extremity shortened and rotated, a laceration with dried blood present above her right eye, and diffuse bruising around the right orbit. The x-ray of the right shoulder revealed a displaced fracture of the right humerus and the x-ray of the right hip revealed a displaced right femur fracture; the resident was treated with oxygen and Dilaudid pain medication. A Progress Note dated [DATE] at 5:26 PM documented a phone call placed to the local hospital for an update on Resident #158 and the resident was diagnosed with a fractured right shoulder, fractured right hip, and required a higher level of care therefore transferred to a tertiary hospital. A Progress Note on [DATE] at 6:57 AM documented notification given to Staff H that Resident #158 admitted to the tertiary hospital. A Progress Note on [DATE] at 11:51 AM revealed Staff H acknowledged the fax received in regards to Resident #158's fall. A Facility Fax dated [DATE] at 5:49 AM revealed: a. Resident #158 was transferred to the local hospital for an evaluation. b. Resident #158 was subsequently transferred to tertiary hospital and admitted for hip and shoulder fractures. c. Physician signature received on [DATE]. A Hospital Report on [DATE] at 1:58 PM revealed: a. Resident #158 was admitted due to uncontrolled pain. b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture. c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner). d. Recommendation to the family was to focus on comfort care with Hospice support for pain management. e. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family. A Progress Note on [DATE] at 11:50 AM revealed Resident #158 returned from the hospital via ambulance, drowsy but responsive to pain. The entry recorded the resident had a fracture to right humeral head and femoral neck, multiple bruises to face and right arm due to recent a fall on [DATE]. The entry documented the resident admitted to Hospice care and treated with Oxycodone (narcotic pain medication) 2.25 milliliters (ml) for the pain. A Progress Note on [DATE] at 1:30 PM revealed Resident #158 passed away with family at bedside. During an interview on [DATE] at 2:16 PM, Staff B, RN stated Resident #158 was independent with ambulation. Staff B reported the resident fell close to the shift change in the bathroom, cut her eyebrow, it was not actively bleeding, but the resident had blood on the floor, her hands and her legs. Staff B stated the staff cleaned up the blood, assessed her neuro's, range of motion, vital signs and Staff B told the staff to get the resident up to a shower chair. Staff B stated the staff stood the resident, pivoted her to the shower chair, and washed off the blood. Staff B stated she completed the fall paperwork and sent the incident paperwork to Staff A. Staff B stated the staff dressed the resident and put her to bed. Staff B stated the resident was in pain but could not tell Staff B where the pain was located. Staff B said at 4:30 AM or 5:00 AM the staff tried to move the resident and the resident's arm hurt. Staff B stated she didn't remember notifying the doctor but she did send a fax to him. Staff B stated Resident #158 was bleeding and she applied first aid. During a family interview on [DATE] at 2:33 PM, the POA stated she was not notified on the evening Resident #158 fell . The POA stated the staff said the resident fell around 9:00 PM or 10:00 PM and they didn't call her until 6:30 AM to ask if she could go to the hospital. The POA stated the staff reported they got the resident up and put her in the shower due to having blood everywhere. The POA voiced the prognosis and the resident's ability to do therapy was poor. The POA stated they offered comfort care so she agreed to that and the resident returned to the facility where she died on [DATE]. The POA voiced that the facility left the resident there to suffer in pain all that night with a fractured hip and shoulder. The POA stated the resident resided at the facility for 8 years and when the staff said they didn't want to bother her in the middle of the night, she asked the nurse when 9:30 PM considered the middle of the night, but the staff would not answer her. In an interview on [DATE] at 3:53 PM, Staff K, RN stated when a resident fell the nursing staff followed the fall protocol, obtained vital signs, performed an assessment of the extremities and pain, and charted observations to include the position of the resident, the wheelchair or walker, and what the resident wore. Staff K stated if a resident could stand, they moved them. Staff K stated the protocol was to call the doctor and hospital intervention if needed; fax the physician if no visible injuries. Staff K stated on [DATE] she arrived at 6 AM and during the nurse report, the night nurse stated Resident #158 fell in the Memory Care Unit and bumped her head. Staff K stated that Staff B, RN claimed the staff found the resident and there was so much blood that the staff showered the resident before they put her to bed. Staff K stated Staff B reported that Resident #158 had a head injury of a skin tear but was not sent to the hospital. Staff K stated the resident was really in so much pain, it could be seen on her face and when they moved the resident ' s arm she shouted in pain. Staff K stated Staff B then called the On-Call nurse, the doctor and family at 6:30 AM. In an interview on [DATE] at 8:05 PM, Staff G, CNA stated she found Resident #158 on the floor on [DATE] at 9:30 PM. Staff G voiced she would not forget it because it was traumatic for her. Staff G stated Staff D, CNA heard Resident #158 called out and she found the resident lying on the floor just inside her bathroom, in her bedroom, on her right side in the fetal position. Staff G reported the resident was not lying still and she moved around in the blood. Staff G recalled blood being present on the floor, up the wall, in the resident ' s hair, and on the left side of her head, hands and legs. Staff G stated she called the nurse with the walkie and put a pillow under the resident ' s head. Staff G reported there was so much blood that she started wiping the resident ' s hands off with a washcloth to see where it was coming from. Staff G commented that the resident ' s left side of her face and hair were red. Staff G stated Staff B, RN came in, took the vital signs and instructed her to get Resident #158 in the shower to wash away the blood. Staff G said the resident ' s pajamas were soaked in blood. Staff G stated Staff B assisted to stand Resident #158 up, pivoted her into a shower chair, washed her off, then started to dress the resident. Staff G recalled Resident #158 said it hurt and told them not to push when they applied the gripper socks and pants. Staff G stated Staff D helped to push the shower chair next to the bed, they stood Resident #158 and pulled up her pants, pivoted her and put her into the bed. During an interview on [DATE] at 7:50 AM, Staff A, RN Clinical Administrator stated she did not know about the fall until the morning of [DATE] at 6:30 AM and she said to send the resident to the hospital. Staff A stated the staff knew they could call ,d+[DATE] and the expectation was to call with a fall. During an interview on [DATE] at 9:05 AM, Staff H, Physician responded if anyone found a resident on the floor, he would expect the staff to look for any visible wounds, assess for pain in any extremity and if they had a visible head wound, there may be a hemorrhage so of course to call 911. Staff H stated the staff could call ,d+[DATE] to report a fall and receive orders for treatment. In a subsequent interview on [DATE] at 10:28 AM, Staff H, Physician stated a review of the call logs revealed that there was no call for a fall on Resident #158 and he did not remember receiving one. Staff H stated he found a fax dated [DATE] at 10:45 PM that documented Resident #158 was found on the floor on her right side, her range of motion and neuro's were normal, she had a hematoma and complained of pain all over. Staff H commented that looking at the fax, the staff should have called 911. Staff H stated another fax received on Monday [DATE] at 5:49 AM documented the resident transferred to the local hospital. Staff H said a 2nd fax received on [DATE] at 3:47 PM notified him of the resident's death, 2 hours after Resident #158 passed away. During an interview on [DATE] at 8:08 AM, Staff E, CNA reported working for the facility for [AGE] years. Staff E stated on [DATE] at 10:00 PM she received a report that Resident #158 fell and the other CNA's had showered her. Staff E recalled Resident #158 wore a nightgown and laid in bed shaking. Staff E said the resident didn't verbalize and she didn't even touch the resident that night as the resident laid at the head of the bed but had turned herself around with her head at the foot of the bed. Staff E voiced she didn't touch the resident, provide check and change care, or turn the resident because she didn't want to cause her any more pain. Staff E reported the resident laid in the fetal position in bed all night shaking. Staff E voiced the resident was shaking really badly and the resident did not shake normally and therefore Staff E was not comfortable with doing anything with the resident. Staff E recalled thinking why didn ' t they send her out. Staff E stated that Resident #158 remained at the facility as of 6 AM when her shift was complete. Staff E stated the Memory Care Unit was where she worked and Resident #158 normally slept all night and would get up when she needed to use the bathroom. During an interview on [DATE] at 11:00 AM, Staff B, RN stated Resident #158 was able to sit up, had full range of motion to her arms and legs, and no complaints of pain. Staff B said she wanted the resident cleaned up as she had dried blood in her hair, on her hands, and legs. Staff B stated she gave the instruction for the CNA's to get Resident #158 showered. Staff B said while she observed, the resident alternated cradling her arms in her lap. Staff B stated the CNA's put the residents arms in her gown, they wheeled the shower chair over to the bed and put the resident to bed onto her right side and covered her. Staff B said she completed another set of vital signs and neurological checks. Staff B reported when she returned an hour later the resident slept and she was sleeping every time Staff B went into her room. Staff B stated she had notified the On-Call Nurse, Staff A, with a text, who responded ok. Staff B said she continued neuros during the night and the resident ' s eye was bruised. Staff B stated Staff E called at midnight, reporting Resident #158 was experiencing pain. Staff B commented the resident didn't look like she was in distress, nothing unusual. Staff B stated that Staff E reported Resident #158 was moving around in her bed, laid toward her headboard and other times her head toward the foot board. Staff B administered an as needed (prn) Tylenol at midnight per the standing order. Staff B voiced she didn't document it as the stomach pain was normal for the resident. Staff B stated she did not notify the doctor in this case as there was a standing order. Staff B reported at 4:00 to 5:00 AM, the resident said ouch, don't touch her arm. Staff B stated she updated Staff A with a text at that time that she was working on sending the resident out for further evaluation. Staff B stated she made the decision to send the resident out. Staff B said she notified the POA at 4:00 -5:00 AM letting her know the resident fell the night before, cut above her eyebrow, they cleaned her up in the shower, completed neuro checks and she had a change. Staff B stated the resident didn't want to move her right arm so Staff B wanted to send the resident out if the POA was okay with it. Staff B stated she called the provider to get the order and called the ER at the local hospital to give a report. During an interview on [DATE] at 2:30 PM, Staff L, Advanced Registered Nurse Practitioner (ARNP), stated she remembered receiving a call on [DATE] from the nurse asking permission to send the resident to the hospital. Staff L reported she was on call for the providers in that area and at the hospital emergency room (ER). Staff L stated the staff did not call the physician when Resident #158 fell at 9:00 PM on [DATE]. Staff L voiced the whole thing was not right as Staff B said they found the resident down, put her back to bed, and the resident didn't want to get up in the morning, so they needed permission to send her. Staff L stated the resident had a head injury, there was shortening of the resident's right leg and it was rotated outward, the resident guarded her right arm screaming if staff touched it, and they gave the resident nothing for her pain. Staff L stated the staff should have called the on-call provider at the time Resident #158 was found on the floor to seek treatment orders; the on-call providers take calls ,d+[DATE]. The policy titled Fall Prevention and Management dated [DATE] revealed: a. The Clinical Administrator is responsible for assuring implementation of this policy. b. All staff are responsible for implementing the intent and directives contained within this policy. c. The Nurse will immediately evaluate the resident for any injury, change in status and/ or pain and will proceed with emergency procedures and interventions as indicated. d. Suspected head injury or possible significant injury or fracture: the resident is not to be moved until emergency personnel have arrived unless it is determined that the resident is at risk for injuring self further or is at risk for further injury if they are not moved. e. The Nurse will notify 911, the primary physician and/or Nurse Practitioner (NP) and the RN in charge as indicated based on the initial evaluation and the resident care plan. f. The Staff Nurse will complete the resident Occurrence Report and notify the physician and responsible party. g. Minor Head Trauma or Unwitnessed Fall where the resident is not able to state if they hit their head 1. Determine vital signs including orthostatic blood pressures. 2. Determine circumstances leading to the fall and interventions. 3. Perform Neuro Checks: a. Day 1: i. Every 15 minutes x 2 ii. Every hour x 2 iii. Every 2 hours x 2 iv. Every 4 hours x 2 b. Days 2 and 3: i. Every shift c. Alert the Physician or NP with any changes. h. An entry into the medical record will be completed to include: patient appearance at time of discovery, patient response to event, evidence of injury, location, medical provider notification, responsible party notification, nursing actions.

Based on policy review and staff interviews the facility failed to provide an Infection Preventionist with specialized training or certification to monitor and provide oversight for the facility's Infection Prevention and Control Program. The facility reported a census of 57 residents. Findings Include: The policy, entitled Infection Prevention and Control Manual and dated 2020, documented the facility Infection Preventionist is responsible for the facility's Infection Prevention and Control Program. On 8/16/23 at 9:31 AM, Staff B, Clinical Coordinator for Infection Control and Education, provided documentation that her Infection Preventionist Training was incomplete. Staff B demonstrated a lack of understanding of information necessary to complete her duties as the facility Infection Preventionist. Staff B indicated she took over the Infection Preventionionist role in June 2023. On 8/17/23 at 9:21 AM Staff A, Director of Nursing (DON), indicated the last certified Infection Preventionist left in May 2023.

Based on clinical record review, physician interview, family interview, staff interviews, and facility policy review, the facility failed to notify the physician and family in a timely manner when acute changes occurred in a resident's physical condition for 1 of 3 residents reviewed (Resident #158). Clinical record review revealed on 6/2/23 at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of bleeding. The facility staff failed to immediately call 911, call the physician, and call the family for 9 hours. The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #158 included the following diagnoses: dementia, anxiety, depression, glaucoma, high blood pressure and kidney disease. The MDS recoreded the resident's cognitive skills for daily decision making as moderately impaired and the resident required supervision with limited assistance of 1 person for bed mobility, toileting and personal hygiene. The MDS coded the resident as able to ambulate independently with a walker. The Care Plan dated 6/1/23 directed staff to administer pain medication as ordered and to monitor for both verbal and nonverbal signs and symptoms of pain and discomfort. The care plan instructed staff to monitor for signs or symptoms of further mood decline and update the physician as needed. A Progress Note dated 6/2/23 at 9:45 PM, revealed Resident #158 yelled for help, found on the floor outside of the bathroom, laying on her right side, complained of pain all over, range of motion (ROM) and neurological checks were normal, and therefore the resident was moved from the floor with the assistance of 2 staff. The injury described was a 3 centimeter (cm) by 5 cm hematoma (localized bleeding, bruise) and 3 cm by 1 cm skin tear to the right eye. The documentation revealed the notification of the On-Call Registered Nurse (RN), Staff A and a fax to Staff H, Physician, and would notify the Power of Attorney (POA) in the morning. The Change of Condition note dated 6/3/23 at 6:30 AM, revealed Resident #158 complained of pain to the right upper extremity (RUE), refused to move the arm and yelled out in pain when the nurse touched RUE. The documentation revealed Staff H, the POA, Staff A and Emergency Medical Services (EMS) were notified and a report was called to the emergency room (ER) Nurse. Resident #158 was transferred to the local hospital at 6:47 AM. Review of a facility Fax dated 6/2/23 at 10:55 PM revealed the following: a. Resident #158 was found on the floor. b. Vital signs Blood Pressure 146/68 Pulse 60. c. Hematoma and skin tear to the right eye. d. ROM and neurological checks are normal. e. Pain all over. f. Physician signature received on 6/5/23. A Progress Note on 6/5/23 at 6:57 AM, revealed notification of Staff H that Resident #158 was admitted to the tertiary hospital. A Progress Note on 6/5/23 at 11:51 AM, revealed Staff H acknowledged the fall fax received in regards to Resident #158. Review of a facility Fax dated 6/5/23 at 5:49 AM revealed the following: a. Resident #158 was transferred to the local hospital for an evaluation. b. Resident #158 was subsequently transferred to tertiary hospital and admitted for hip and shoulder fractures. c. Physician signature received on 6/5/23. Review of the Local Hospital Report on 6/5/23 at 1:58 PM revealed: a. Resident #158 was admitted due to uncontrolled pain. b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture. c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner). d. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family. During an interview on 8/15/23 at 2:16 PM, Staff B, RN stated Resident #158 was independent with ambulation, she fell close to shift change in the bathroom, cut her eyebrow, it was not actively bleeding, but she had blood on the floor, her hands and her legs. Staff B stated the staff cleaned up the blood, assessed the resident's neuro's and range of motion, vital signs and told the staff to get her up to a shower chair. Staff B stated she completed the fall paperwork and sent the incident paperwork to Staff A, RN. Staff B stated the staff dressed the resident and put her to bed. Staff B stated the resident was in pain but could not tell her where the pain was located, then at 4:30 or 5:00 AM, the staff tried to move the resident and her arm hurt. Staff B stated she did not remember notifying the doctor, but she did send a fax to him. Staff B stated Resident #158 was bleeding and she applied first aid. During a family interview on 8/15/23 at 2:33 PM, the POA stated she was not notified on the evening Resident #158 fell . The POA stated the staff said the resident fell around 9:00 or 10:00 PM and they didn't call her until 6:30 AM to ask if she could go to the hospital. The POA stated the resident resided at the facility for 8 years and when the staff said they didn't want to bother her in the middle of the night, she asked the nurse when was 9:30 PM considered the middle of the night, but the staff would not answer her. During an interview on 8/16/23 at 9:05 AM, Staff H stated if anyone was found on the floor, he would expect the staff to look for any visible wounds, assess for pain in any extremity and if they had a visible head wound, there may be a hemorrhage so of course to call 911. Staff H stated the staff could call 24/7 to report a fall and receive orders for treatment. In a subsequent interview on 8/16/23 at 10:28 AM, Staff H, Physician stated a review of the call logs revealed that there was no call for a fall on Resident #158 and he did not remember receiving one. Staff H stated he found a fax dated 6/2/23 at 10:45 PM that documented Resident #158 was found on the floor on her right side, her range of motion and neuro's were normal, she had a hematoma and complained of pain all over. Staff H commented that looking at the fax, the staff should have called 911. Staff H stated another fax received on Monday 6/5/23 at 5:49 AM documented the resident transferred to the local hospital. Staff H said a 2nd fax received on 6/12/23 at 3:47 PM notified him of the resident's death, 2 hours after Resident #158 passed away. During an interview on 8/22/23 at 9:24 AM, Staff A, RN/Clinical Administrator, stated she checked for a text from Staff B on the evening of 6/2/23 and she did not get a text or call. Staff A stated she did not get a call until 6/3/23 at 6:30 am when she said to send Resident #158 to the hospital. During an interview on 8/22/23 at 2:30 PM, Staff L, Advanced Registered Nurse Practioner (ARNP), stated she remembered receiving a call on 6/3/23 from the nurse asking permission to send the resident to the hospital. Staff L reported she was on call for the providers in that area and at the hospital emergency room (ER). Staff L stated the staff did not call the physician when Resident #158 fell at 9:00 PM on 6/2/23. Staff L voiced the whole thing was not right as Staff B said they found the resident down, put her back to bed, and the resident didn't want to get up in the morning, so they needed permission to send her. Staff L stated the resident had a head injury, there was shortening of the resident's right leg and it was rotated outward, the resident guarded her right arm screaming if staff touched it, and they gave the resident nothing for her pain. Staff L stated the staff should have called the on-call provider at the time Resident #158 was found on the floor to seek treatment orders; the on-call providers take calls 24/7. The policy titled Fall Prevention and Management dated April 2021 revealed: a. The Clinical Administrator is responsible for assuring implementation of this policy. b. All staff are responsible for implementing the intent and directives contained within this policy. c. The Nurse will immediately evaluate the resident for any injury, change in status and/or pain and will proceed with emergency procedures and interventions as indicated. d. Suspected head injury or possible significant injury or fracture: the resident is not to be moved until emergency personnel have arrived unless it is determined that the resident is at risk for injuring self further or is at risk for further injury if they are not moved. e. The Nurse will notify 911, the Primary Physician and/or Nurse Practitioner (NP) and the RN in charge as indicated based on the initial evaluation and the resident care plan. f. The Staff Nurse will complete the resident Occurrence Report and notify the Physician and responsible party.

Based on personnel file review, staff interview and policy review the facility failed to assure 1 of 5 staff reviewed met the requirements for Mandatory Adult Abuse Training (Staff D). The facility reported a census of 57 residents. Findings Include: Record review of the personnel record for Staff D, Certified Nursing Assistant (CNA), shown a hire date of 1/4/22. Staff D completed the two-hour Dependent Adult Abuse Mandatory Training on 4/9/20. The Renewal training due to be completed by 4/9/23 was not documented. In an interview on 8/17/23 at 11:06 AM, Staff C, the Administrative Support Staff acknowledged the expectation for staff to complete the two-hour Dependent Adult Mandatory Reporter Training every three years. The facility Abuse Policy with a modified Date of January 2023, documented each employee shall be required to complete training including Iowa Dependent Adult Abuse Training for Iowa. The Iowa Department of Health and Human Services recorded, beginning 7/01/19 the two-hour Dependent Adult Abuse Training is required every three years for Mandatory Reporters.

Based on clinical record review, staff interview, and facility policy review the facility failed to complete a follow-up Preadmission Screening and Resident Review (PASRR) for one out of one resident reviewed in the current sample who had a change in mental health diagnoses (Resident #12). The facility reported a census of 57 residents. Findings Include: The Minimum Data Set (MDS) Assessment at admission for resident #12, dated 7/1/21 included Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. The MDS recorded Resident #12 diagnoses included heart disease, non-Alzheimer's dementia of uncertain or unknown etiology. The MDS coded that antipsychotics were not given during the last seven days. The Minimum Data Set (MDS) assessment dated [DATE] included a BIMS score of 5 out of 15, indicating severe cognitive deficit. The MDS recorded Resident #12 diagnoses that included heart disease, non-Alzheimer's dementia of uncertain or unknown etiology with additional diagnosis added after admission of psychotic disorder with delusions due to physiological condition. The MDS coded that antipsychotics are given on a routine basis. The Care Plan completed 6/30/23 revealed Resident #12 at risk for behavioral health issues related to psychotic disorder with delusions. The Care Plan documented focus due to use of anti-psychotic medications. Resident to be free of drug related complications with interventions included to monitor and report reactions. The Medication Administration Record (MAR) for August 2023 completed up to August 16, 2023 revealed the resident was given the following medications daily related to psychotic disorder with delusions: a. Mirtazapine (antidepressant medication) Tablet 15 milligrams (mg) by mouth at bedtime b. Olanzapine (antipsychotic medication) 5 mg twice a day The Notice of PASRR Level 1 Screen outcome dated prior to admission to the nursing facility on 5/13/21 documented primary medical conditions requiring nursing facility included mild cognitive impairment. The Notice relayed no mental health diagnosis is known or suspected for Resident #12. The outcome section relayed no evidence of a serious behavioral condition. If changes occur, a new screening must be submitted. On 8/16/23 at 4:11 PM, Staff A, the Clinical Administrator, acknowledged a new PASRR screening should have been requested due to resident new mental health diagnosis after admission. The facility provided PASRR Policy modified November 2022 documented the federally mandated pre-screening process for facility admission to evaluate for mental disorders. The negative Level 1 ends the pre-screen process unless a possible serious mental disorder arises later.

Based on record review, staff interviews, review of facility policy, and review of Centers for Medicare and Medicaid Services (CMS) COVID-19 testing requirements, the facility failed to ensure 1 of 1 partially vaccinated staff was tested for COVID-19 to prevent the spread of COVID-19. Specifically, the facility failed to ensure Staff B, a Certified Nursing Assistant (CNA), who was not fully vaccinated, was tested for COVID-19 based on county transmission rates and during a COVID-19 outbreak in the facility. The facility reported a census of 51 residents. Findings Include: A review of the facility policy titled, COVID-19 Staff Vaccination Policy, revised on 02/03/2022, revealed To protect our Staff, residents, and guests by lowering the risk of acquiring or transmitting [CONDITION(S)]-Cov-2 (COVID-19), and to comply with regulatory requirements, including rules issued by the U.S. Centers for Medicare and Medicaid (CMS), [the facility] has adopted this policy regarding COVID-19 vaccination .The following precautions apply to exempt unvaccinated staff in [the facility] . vi. Complete testing in the routine cadence as set forth in QSO-20-38-NH-Revised [Quality Safety & Oversight memorandum from CMS] which is based upon the CDC [Centers for Disease Control and Prevention] County Transmission Rate .vii. Complete outbreak testing as indicated by positive case exposure at the individual site. A review of QSO-20-38-NH CMS Memorandum, dated 08/26/2020, revealed Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency .The facility should test all staff, who are not up-to-date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week. Facilities should monitor their level of community transmission every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table above. According to the Routine Testing Table, if the Level of COVID-19 community transmission was high (red) or substantial (orange), the minimum testing frequency of staff who were not up-to-date was required twice per week. If the transmission rate was moderate (yellow), minimum testing was once a week. No testing was recommended if the transmission rate was low (blue). Continued review of QSO-20-38-NH CMS Memorandum revealed, Testing of Staff and Residents During an Outbreak Investigation A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [CONDITION(S)] transmission .Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. A review of Iowa COVID-19 Tracker, retrieved from https://iowacovid19tracker.org/, revealed in February 2022 through 03/14/2022, the transmission rate for the county where the facility was located was high (red). The transmission rate for 04/04/2022, 04/18/2022, and 05/02/2022 was high (red) or substantial (orange). On 05/16/2022, the transmission rate had dropped to moderate (yellow). A review of emails to residents and families revealed on 02/02/2022, the Administrator sent an email notification that a resident had tested positive for COVID-19 on 02/01/2022. According to the email, We will continue to test all [facility] staff regardless of vaccination status twice per week. Further review of emails revealed on 02/06/2022, another five residents tested positive, a staff member tested positive on 02/05/2022, and the facility remained in outbreak status. Continued review of emails to residents and families revealed on 03/04/2022, a total of 15 staff and 16 residents had tested positive for COVID-19 and there had been three resident deaths after testing positive. The email revealed the facility would remain in outbreak status until 03/16/2022, if no additional residents tested positive and would continue to test unvaccinated staff twice per week. According to an email to residents and families dated 03/17/2022, the outbreak status was completed because of going 28 days without an additional resident testing positive for COVID-19. The email revealed the facility would continue to test unvaccinated staff twice weekly. A review of a COVID-19 Vaccine Record Card revealed Staff B, a Certified Nursing Assistant (CNA), received the first dose of a COVID-19 vaccine on 11/23/2021. There was no documented evidence Staff B received the second dose of the COVID-19 vaccine. A review of Staff B's work schedule revealed the CNA began working on 01/29/2022 and continued to work through May 2022. A review of a Testing Log for the week of 01/24/2022 to 01/30/2022 revealed the facility tested Staff B for COVID-19 on 01/29/2022 and the result was negative. There was no other documented evidence the facility tested Staff B for COVID-19 from February through May 2022. An interview with Staff B on 06/02/2022 at 2:27 PM, revealed prior to 06/02/2022, Staff B had not received a second dose of the COVID-19 vaccine. Staff B stated when he/she worked at the facility, Staff B wore a N95 mask and goggles. A follow-up interview to discuss COVID-19 testing was attempted with Staff B on 06/03/2022 at 10:00 AM. Staff B did not return the phone call. During an interview on 06/03/2022 at 12:26 PM, Staff A, the Infection Control and Prevention Specialist, indicated she was not aware that Staff B was not being tested for COVID-19 according to the county positivity rate. Staff A stated it was Staff E, the Health Unit Coordinator's responsibility to keep up with staff testing. A follow-up interview with Staff A on 06/03/2022 at 2:19 PM, revealed positivity rates were posted at the time clock and when the county positivity rate was high, all unvaccinated staff and staff who were not up-to-date on vaccines were required to test two times per week. Staff A indicated that Staff F, the Office Manager/Human Resources, was monitoring testing and was responsible for adding staff names who required testing to a list. During an interview on 06/03/2022 at 12:40 PM, Staff E, the Health Unit Coordinator, revealed it was her responsibility to enter staff names on a master list and to highlight the names of staff members who were unvaccinated. She indicated that Staff B's name was left off the list in error. Staff E stated she was not responsible for ensuring staff were tested for COVID-19. Staff F was on vacation and unavailable for an interview. During an interview on 06/03/2022 at 1:30 PM, with the Director of Nursing (DON) revealed facility Corporate Staff had Human Resources handle COVID-19 vaccination compliance. The DON stated she was not aware Staff B was not fully vaccinated, as the facility staff were not being kept updated on vaccination status. The DON indicated the facility process for COVID-19 testing for unvaccinated staff included keeping a list of staff who required testing and posting the list at the time clock. The DON indicated she was not aware Staff B was not being tested for COVID-19. During an interview on 06/03/2022 at 2:06 PM, the Administrator stated on 05/16/2022, the Administrator notified Human Resources that Staff B was not up to date on vaccinations; however, the Administrator was not aware Staff B had not completed a second vaccine nor that Staff B was not being tested . The Administrator stated he was under the impression that Human Resources had taken care of it, but stated it was the Administrator's responsibility to ensure testing was being completed.

Based on record review, interviews, and facility policy review, the facility failed to ensure COVID-19 Vaccination Policies and Procedures for staff included a required component whereby the facility had formulated and implemented a process to ensure all staff (except those who have been granted an exemption or have a temporary delay) were fully vaccinated for COVID-19. Specifically, the facility failed to ensure one of one staff member (Staff B, a Certified Nursing Assistant [CNA]), was fully vaccinated prior to the deadline of 03/15/2022. The facility reported a census of 51 residents. Findings included: A review of the facility policy titled, COVID-19 Staff Vaccination Policy, revised on 02/03/2022, revealed the facility did not address the facility's process to ensure all staff were fully vaccinated for COVID-19. A review of QSO-22-09-ALL CMS memorandum, dated 01/14/2022, revealed, Vaccination Enforcement - Surveying for Compliance .Within 60 days after the issuance of this memorandum, if the facility demonstrates that: Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and .Less than 100% of all staff received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC [Centers for Disease Control and Prevention], the facility is non-compliant under the rule. According to this memorandum, 100% of facility staff needed be vaccinated or have an exemption after 03/15/2022. A review of the facility's formula for Staff Vaccination Rate revealed 99.3% of facility staff members were fully vaccinated. A review of Staff B's COVID-19 Vaccination Record Card revealed that on 11/23/2021, Staff B received the first dose of a two-dose COVID-19 vaccine series. The card indicated a second dose had not been administered. A review of Staff B's Personnel Record revealed Staff B was hired by the facility on 01/19/2022. A review of Staff B's work schedule revealed the following: a. Staff B worked five days in March 2022 (four of those days were following the vaccination deadline). b. Staff B worked seven days in April 2022. c. Staff B worked eight days in May 2022. During a telephone interview on 06/02/2022 at 2:27 PM, Staff B revealed when she received her first dose of the COVID-19 vaccine, she became ill and was not sure if she was going to get the second dose. She indicated that when she was hired, the facility provided information on the medical and religious exemptions. Staff B indicated that she did not remember the facility giving her a deadline to get the second dose of the COVID-19 vaccine. Staff B indicated that she had been busy attending nursing school and was unable to come to the facility to get the second dose or get it from a Pharmacy or Doctor's Office. Staff B stated that the facility provided her with information regarding the COVID-19 vaccine. Staff B further indicated that when she worked at the facility on the weekend, she wore an N95 face mask and goggles. During an interview on 06/03/2022 at 10:30 AM, Staff A, Infection Control and Prevention Specialist, indicated that she was aware that Staff B was working and was not fully vaccinated. Staff A indicated that she contacted Staff B on 06/02/2022 to come in for the second dose of the COVID-19 vaccine. Staff A indicated that Human Resources and Employee Health were involved with making sure that the staff members were fully vaccinated. She further indicated that Employee Health tracked vaccinations. Staff A indicated that moving forward the facility would provide newly hired staff members with the first and second doses of the COVID-19 vaccine, and during that period, would do training remotely and would have no patient-care contact until two weeks following the second dose of a two-dose COVID-19 vaccine. She indicated that in the event a staff member declined to be vaccinated, the facility would provide information regarding possible COVID-19 vaccination exemption. A review of text messages revealed that Staff B was contacted on 02/24/2022 and 05/16/2022 to come into the facility to receive the second dose of the COVID-19 vaccine. During a telephone interview on 06/03/2022 at 11:40 AM, Staff D, Employee Health Nurse Manager (from the Corporate Office), indicated the Human Resource Department was responsible for tracking COVID-19 vaccination status for staff members. Staff D indicated that it was the Human Resource Department that was responsible, during the initial hiring period, to give the staff members the information regarding COVID-19 vaccines. Staff D indicated that Staff F, Office Manager/Human Resources, recently reached out to Staff B and provided places where she could get the COVID-19 vaccine, to include the local Pharmacy, medical provider, and at the facility. Staff F was on vacation during the survey and was unavailable for interview. During an interview on 06/02/2022 at 4:33 PM, the Director of Nursing (DON) indicated that moving forward all employees would be required to be fully vaccinated or have an approved exemption prior to being hired. During an interview on 06/02/2022 at 4:33 PM, the Administrator indicated that the facility would only employ staff that were fully vaccinated or have an exemption. The Administrator indicated that Staff B was scheduled to come in to get the second dose but did not show up. The Administrator further indicated that one employee was terminated due not getting the COVID-19 vaccine and/or applying for an exemption. The Administrator stated that the facility offered the COVID-19 vaccine (two-dose series) on a weekly basis.

Based on observations, interviews, record and policy reviews, the facility failed to ensure the menus were followed by not providing pureed bread to 4 of 4 residents who were on a puree diet. The facility reported a census of 46 residents. Findings include: Review of undated facility Diet Order Data Sheets, documented that Residents #13, #22, #26, and #29 diet orders included puree consistency. An observation on 1/5/21 at starting at 10:30 revealed that the above residents who had a puree consistency as part or all of their diet did not receive bread. A print out menu titled Tuesday Week 1 provided by the facility for the 1/5/21 meal observation documented for lunch that the puree diet included 1 serving of pureed home-style bread. In an interview on 1/5/21 at 11:15 a.m., Staff B, Nutritional Culinary Services Supervisor, stated that he normally does not serve pureed bread. Staff B stated that it takes away from the nutritional value and the residents could get filled up on bread and not want to eat the protein and vegetables. Furthermore, Staff B stated, the consistency of bread does not look appealing when it is pureed. An observation at this time revealed the Nutrition and Culinary Director nodding in agreement with Staff B's statements. In an interview on 1/5/21 at 4:01 p.m., the contracted Dietitian stated that her understanding was the facility pureed the bread with the meat and gravy or juices. She said that the facility was not following the menus that she had planned. When Staff B's statement was shared with this Dietitian, she stated she did not feel comfortable with them not serving bread as the menus are planned with bread being part of the carbohydrate serving for the day. The dietitian said she did not know the facility was not pureeing and serving the bread. In an interview on 1/5/21 at 4:28, the Nutrition and Culinary Director stated he talked with the Dietitian and they had agreed that the bread didn't need to be added for the same reasons that Staff B had said earlier. He said they are not following the menus as they are written and felt he had an agreement with the Dietitian that the bread could be omitted for puree diets. Furthermore, he stated that he and the Dietitian had talked about it but apparently had not reached an agreement that the bread could be omitted. The Nutrition and Culinary Director said that he had directed his staff, including Staff B, to omit the bread off of the puree consistency diets. In an interview directly following the above interview, the DON who was present during the above interview, stated that she is not a Dietitian but she would have thought the menus were being followed. A policy titled PHS Core Menu and NM Diet Manual Policy, dated 9/2020, revealed the purpose of the policy was to help design and implement nutritionally balanced menus while customizing to individual medical nutrition therapy needs and preferences. The policy directed that the menus will be prepared in advanced and followed as well as the menus were to be reviewed by a Registered Dietitian Nutritionist, a clinically qualified nutrition professional for nutritional adequacy. A policy titled PHS Care Center Diet Policy and dated 1/2020, revealed the goal of the facility was to provide nutritionally adequate and tasteful meals. The menus were to be planned and prepared in advance and reviewed by a Registered Dietitian to ensure national guidelines are met. The policy identified the Pureed diet as appropriate for individuals with dysphasia or chewing/swallowing issues.

Based on observation, pharmacy reference guide review and interviews, the facility failed to assure residents were free of significant medication errors for 1 of 5 residents sampled (Resident #15). The facility identified a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 with [DIAGNOSES REDACTED]. The MDS further revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment and required the assistance of two staff with transfers, ambulation and personal hygiene. The MDS documented Resident #15 received insulin injections 7 out of 7 last days. The Care Plan dated 10/20/20 revealed Resident #15 at risk for alteration in blood glucose levels related to [DIAGNOSES REDACTED].#15's ability to participate in activities of daily living. Review of Resident #15's Medication Administration Record [REDACTED]. The MAR further revealed an order dated 12/2/20 to inject [MEDICATION NAME] solution per sliding scale subcutaneously four times a day for diabetes. Review of Insulin and Non-Insulin Pen Quick Reference Guide provided by the facility's pharmacy instructed nurse's need to be aware of how to correctly use these devices to avoid medication errors which could lead to serious adverse events. The Insulin and Non-Insulin Pen Quick Reference Guide further revealed when using the [MEDICATION NAME] to inject the medication, hold pen in skin for an additional 6 seconds after pushing the dose button before withdrawing the needle from skin to allow sufficient time for entire dose to dispense into subcutaneous tissue. During an observation on 1/6/21 at 11:45 a.m., Staff A, Registered Nurse (RN) administered the prescribed insulin using the [MEDICATION NAME] into Resident #15's left upper arm. After injecting the insulin, Staff A failed to hold the pen in the skin for an additional 6 seconds per the manufacturer's instructions in order for the entire dose to dispense from the pen. Following the procedure, Staff A stated she removed the pen after she heard a click because in the past when she had removed the pen prior to hearing a click, insulin continued to spill out of the pen after removal. During an interview 1/6/21 at 2:16 p.m., the Director of Nursing (DON) acknowledged it would be an expectation for staff to follow the manufacturer instructions.

Based on record review and staff interview, the facility failed to revise Resident #1's care plan to ensure he/she received adequate supervision to prevent against hazards. Record review and staff interviews revealed the resident developed a urinary tract infection on 7/4/13 with constant need for toileting. The evening shift on 7/7/13 documented the resident had been very confused and used the bathroom seven times that night until he/she fell and sustained an acute subdural hematoma which subsequently lead to his/her death. The care plan lacked any directives to address the resident's noncompliance with the call light. The facility reported a census of 55 residents, with four residents reviewed. Findings include: The Minimum (MDS) data set [DATE] identified Resident #1 with the following Diagnoses: [REDACTED]. The assessment identified the resident weighed 95 pounds had problems of inattention and required staff assistance with most activities of daily living. The resident scored 12 on the Brief Interview for Mental Status (BIMS) cognitive test (a score of 8 to 12 indicates the individual had moderate cognitive impairments). The test for balance revealed the resident not steady and only able to stabilize with staff assistance when moving from seated to standing position; when walking; when turning around; moving from on and off the toilet; and during surface to surface transfers. The assessment did not identify the resident had two falls since admission to the facility. A review of the fall log for the resident which the director of nursing (DON) verified the resident fell on : 4/18/13 at 10:30 a.m. found by family on knees beside the bed 4/19/13 at 6:40 a.m. found lying on the floor beside the bed 7/7/13 at 10:30 p.m. found on floor leaning against the wall The care plan revealed on 5/6/13 identified the resident at risk for falls due to impaired mobility and generalized weakness and directed staff to: Ensure both hearing aides were in place daily Ensure glasses were clean and in place daily Transfer and ambulate with walker and assist of one staff Keep walker garage by the bed Keep the bed at the height marked on the wall Refer to physical therapy and occupational therapy as needed Toilet the resident on overnight rounds. 7/7/13 have the resident assessed by a physician. 7/8/13 contact the hospice nurse with any concerns. A review of the nurse's notes revealed the following: 6/1/13 at 9:26 p.m. skilled physical and occupational therapy provided for congestive heart failure 6/3/13 at 12:41 p.m. resident had been discharged from occupational therapy. 6/4/13 at 1:01 p.m. resident had been discharged from physical therapy. 7/7/13 at 8:54 p.m. restarted antibiotics, resident complained of urinary frequency "I feel awful". 7/7/13 at 10:30 p.m. got up from bed, walker not in garage, tripped over personal side table, said repeatedly "I have to go to the bathroom". No documentation that resident had been non-compliant with use of the call light. A review of the physician orders [REDACTED]. 6/20/13 obtain a urinalysis with culture and sensitivity (UA C&S) if the white blood count greater than 10. 6/20/13 a copy of the urinalysis with an order for [REDACTED]. 6/20/13 a copy of the UA C&S report with Escherichia Coli (E. coli: a bacteria commonly found in the intestines) and showed the Cipro as effective in treatment of [REDACTED]. 7/5/13 obtained a UA C&S. The nursing staff informed the physician the resident had an increase in confusion that morning and the day prior (7/4/13). 7/6/13 an order for [REDACTED]. Call the physician with C & S results. 7/6/13 a copy of the UA C&S report with Staphylococcus warneri (a bacteria which can cause serious infection in those with a compromise in the immune system) showed the organism as resistant if treated with Cipro. The report had a facsimile transmission date and time of 7/8/13 at 8:48.m. and did not have new orders. 7/7/13 a fax physician order [REDACTED]. Neurological checks for head injury (hand grips stronger on right side than left, resident's pupils equal of response to light and moves all extremities freely without discomfort). 7/8/13 at 11:20 a.m. transport to the hospital 7/8/13 at 9:45 p.m. admit to hospice and discontinue all oral medication. 7/10/13 release body to the funeral home. The call light record for the resident's bed showed the last entry dated and timed on second shift for 7/7/13 at 7:18 p.m. and the record for the resident's bathroom showed the last entry dated and timed on second shift for 7/7/13 at 7:46 p.m. A review of the staff communication sheets from 7/1/13 through 7/7/13 revealed the resident displayed signs and symptoms of a urinary tract infection on 7/4/13 with frequency and constant need for toileting without documentation of resident's non-compliance with use of the call light. The evening shift on 7/7/13 documented the resident used the bathroom seven times that night, had been very confused and felt he/she had been annoying the staff. The night shift on 7/7/13 documented the resident to be found on the floor with a skin tear to the left elbow, bump on the head, laceration by the left ear and abrasion to the right shoulder. The urine culture report dated 7/6/13 and facsimile date and time of 7/8/13 at 10:56 a.m. showed the organism to be resistant to Cipro and the physician's signature and date of 7/9/13. The resident occurrence report dated and timed 7/7/13 at 10:30 p.m. revealed the resident had been found on the floor, apparently tripped over clutter of objects after he/she got out of bed. The emergency department physician's progress note dated and timed 7/8/13 at 12:40 p.m. identified the resident on Coumadin, with left-sided weakness and left hemi-neglect and had a traumatic fall with traumatic head bleeding. The CT (computerized tomography) showed a large hematoma (a solid swelling of clotted blood in the tissues). The physician's progress note dated 7/9/13 revealed the resident as unresponsive, suffered a subdural hematoma from a fall with left facial droop and unable to speak or swallow and all oral medications discontinued. The death record dated 7/10/13 at 10:58 p.m. revealed the cause of death as subdural hematoma/CVA (stroke) and fall with head injury. In an interview on 7/22/13 at 3:08 p.m., the director of nursing (DON) reported the resident had a history of [REDACTED]. One the day of the resident's fall, he/she had walked over to the bathroom without assist as he/she did not want to annoy the staff. The staff reminded the resident to use the call light. Interventions in place prior to the fall were to have the walker garage (strips of tape on the carpet to show staff where the walker should be placed beside the bed), tape on the wall which measured where the height of the bed should be and to toilet the resident on the night shift on rounds at 1:00 a.m. and 4:00 a.m. Interventions had been placed, however, the resident got up without calling for help. In an interview on 7/22/13 at 3:29 p.m., Staff A, RN, reported the resident had been a little impulsive and did not wait for staff to assist (after the resident used the call light) due to the urinary urgency which Staff A felt contributed to the fall. She could not recall what interventions were in place to prevent falls. In an interview on 7/22/13 at 3:43 p.m., Staff B, RN reported the resident had a urinary tract infection (UTI), became more confused, got up and called a lot more the last few days prior to the fall and required to be transferred and ambulated with the assist of one staff member with use of the walker. Staff B reported Staff C, CNA found the resident on the floor on 7/7/13 at 110:30 p.m. and when she assessed the resident, found the overbed table tipped over with clutter on the floor, the cord to the phone wrapped around the resident's waist and the resident with an abrasion to the back of the head, minimal amount of bleeding from the back of the head and did not notice any bumps on the resident's head. In an interview on 7/23/13 at 1:00 p.m., Staff C, CNA, reported the resident became more confused after the urinary tract infection and got up without assist and did not use the call light. Interventions in place to prevent falls prior to the fall on 7/7/13 were to place the walker in the walker garage and transfer with assist of one with the gait belt and walker. On the night of the fall, Staff D, CNA (who cared for the resident on second shift) had already left the facility when Staff C found the resident on the floor at 10:30 p.m. Staff C could not recall what Staff B reported about the resident at shift change, however, felt the fall could have been avoided if the resident received the proper antibiotic for the UTI. In an interview on 7/24/13 at 9:30 a.m., the DON reported the facility call light splits off from the wall to allow one call light to be placed on the resident's bed and one to be placed on the chair which beside the resident ' s bed prior to the fall on 7/7/13. The aides chart only once a shift in the computerized record and the time of the entry made, not necessarily the times that care had been provided. In an interview on 7/24/13 at 10:00 a.m., Staff D, CNA, reported the resident would get up without the walker as the resident became forgetful with the UTI, that she was informed the resident was resistant to the antibiotic ordered and frequency increased. Interventions in place prior to the fall on 7/7/13 were to transfer and ambulate the resident with assist of one staff member with use of the gait belt and walker. She reported she saw the resident last at 8:00 p.m. after she toileted the resident and assisted the resident to bed. In an interview on 7/24/13 at 10:42 a.m., the DON reported she had not been made aware the resident had been non-compliant with use of the call light and had been up frequently without assist, that she would have expected the staff to inform her of this. The aides had a communication book to inform the next shift of issues to be followed up on. After Staff D, CNA, assisted the resident to bed at 8:00 p.m., would have expected her to make rounds again on the resident at 10:00 p.m.