Every finding on record at Joyce Eisenberg Keefer Medical Center D/P SNF

Based on interview and record review, the facility failed to ensure adequate monitoring of resident's orthostatic blood pressure (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) when taking a prescribed antipsychotic medication for one out of five residents (Resident 81) reviewed under unnecessary medications. This failure had the potential to result in Resident 81 receiving inappropriate dosage of an antipsychotic medication and experiencing symptoms of orthostatic hypotension (a significant drop in blood pressure with position change), which could lead to serious complications such as fainting and falls. Findings: During a review of Resident 81's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 81 on 6/29/2023, with diagnoses including: vascular dementia (loss of cognitive functioning-thinking, remembering, and reasoning), psychosis (a mental health symptom involving a loss of contact with reality) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During review of Resident 81's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/17/2025, the MDS indicated Resident 81 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and is dependent (helper does all the effort) for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 81's Physician Order Report, the Physician Order Report indicated Resident 81 has a physician order for Seroquel (an antipsychotic medication used to treat mental health conditions) 12.5 milligrams (mg-unit of measurement) every day at bedtime, dated 8/8/2025. The physician's order also indicated to monitor for side effects of Seroquel use: which includes headache, somnolence (state of being sleepy or drowsy), weight gain, orthostatic hypotension, anticholinergic effects (confusion, constipation, dry mouth, blurry vision, urinary retention), dizziness, hypotension (low blood pressure), and tardive dyskinesia (uncontrollable, repetitive, and abnormal body movements). Orthostatic blood pressure was ordered to be taken every Saturday evening. During a concurrent interview and record review with Registered Nurse Supervisor (RN) 3 on 3/12/2026 at 12:10 pm, Resident 81's medical record was reviewed. Resident 81's medical record did not indicate documented evidence of orthostatic blood pressure monitoring being performed from 8/1/2025 through 3/12/2026. RN 3 stated the certified nursing assistant (CNA) or licensed vocational nurse (LVN) should document why the orthostatic blood pressure could not be taken and communicate that to the physician. RN 3 stated there was no documentation on Resident 81's medical record why orthostatic blood pressures were not taken and confirmed there was no communication with the physician regarding the inability to monitor blood pressures. During an interview on 3/12/2026 at 2:00 pm with the Director of Nursing (DON), the DON stated the inability to take the orthostatic blood pressure for psychotropic monitoring should be documented in the medical record and communicated to the physician because if the nurses do not document the orthostatic blood pressures, the physician will not know if the resident is having side effects from Seroquel and cannot make adjustments to the medication or interventions if needed. During a review of facility's policy and procedures (P&P) titled, Orthostatic Blood Pressure, reviewed on 4/2025, the P&P indicated, Orthostatic vital signs shall be taken and recorded when ordered by the physician. During a review of the facility's P&P titled, Medication (Psychotherapeutic Drug Management), reviewed 4/2025, the P&P indicated the facility will monitor all psychotherapeutic medications for effectiveness and side effects like postural hypotension.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for: 1.One of two sampled residents (Resident 1) with a moisture associated damage (MASD) investigated during review of pressure ulcer/pressure injury (PU/PI - injury to the skin and underlying tissue resulting from prolonged pressure on the skin). 2. One of two sampled residents (Resident 180) whose care plan did not include all interventions agreed upon by the interdisciplinary team (IDT - a collaborative group of health care team members from different specialties who work together to address all aspects of resident's well-being) investigated for falls. These deficient practices had the potential to negatively affect the provision of care and service provided for the residents. 3. One of two sampled residents (Resident 4) to address the resident's preferred activity of listening to music investigated under activities. This deficient practice had potential for Resident 4 to not receive his preferred activity which can affect the resident`s sense of self- worth and well-being. 4. One of five sampled residents (Resident 72) on Transmission Based Precautions (TBP - extra infection control measures used in healthcare settings, beyond standard precautions, for patients known or suspected to be infected with highly infectious pathogens [virus, bacteria, fungus]) investigated during the infection control task. This deficient practice had potential for Resident 72 to not receive the necessary care and services needed to prevent the spread of infection. 5. One of five sampled residents (Resident 81) when orthostatic blood pressures (taking blood pressure measurements when lying, sitting, and standing to detect for a significant drop in blood pressure during each position change) could not be done to monitor for side effects of Seroquel (prescription medication to treat mood disorder or used as an antipsychotic). This failure had the potential to have the resident receive improper medication usage, unmonitored side effects, and incorrect dosage of Seroquel. Findings: 1. During a review of Resident 1's Face Sheet (FS - the front page of the chart that contains a summary of basic information about the resident), the FS indicated the facility admitted Resident 1 to the facility on [DATE]. The FS indicated Resident 1 was admitted with diagnosis that included bacterial pneumonia (serious lung infection caused by bacteria), chronic respiratory failure (long-term condition where the lungs cannot sufficiently transfer oxygen into the blood) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During a review of the History and Physical (H&P) report completed on 1/13/2026, the H&P indicated Resident 1 is able to make her own needs known and has the capacity to make her own medical decisions. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 1 is able to make self-understood and able to understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) with toileting hygiene and substantial/maximal assistance (helper does more than half the effort) for personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 1 was dependent for chair/bed-to-chair transfer, tub/shower transfer, and substantial/maximal assist for roll left and right (ability to roll from lying on back to left and right side and return to lying on back on the bed). During an interview on 3/11/2026 at 1:55 p.m. with Registered Nurse (RN) 6, RN 6 stated Resident 1 was initially assessed on 3/2/2026 by RN 4 on 3/2/2026 to have a pressure injury (PI – injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on right buttocks measuring 1.5cm x 1.4 cm x 0.2 cm. RN 6 stated that on the following day on 3/3/2026, she had re-assessed the right buttocks wound and determined it was a MASD, not a PI. RN 6 stated she did not make changes to Resident 1's care plan after she re-assessed the wound to ensure the care plan for Resident 1 is relevant and tailored to resident 1's specific care needs. RN 6 stated that the care plan required revision and that a dedicated care plan addressing MASD should have been established. During an interview on 3/12/2026 at 10:05 a.m. with Director of Nursing (DON), the DON stated that a care plan serves as the guide on how to care for the residents. The DON stated because Resident 1's wound was determined to be different than what was care planned, a care plan for MASD should have been created. The DON stated it is important that care plans are current and updated to reflect the plan of care for the resident's actual condition. 2. During a review of Resident 1's FS, the FS indicated the facility originally admitted Resident 180 on 01/14/2021 and was re-admitted on [DATE]. The FS indicated Resident 180 was admitted with diagnosis that included atherosclerotic heart disease (a condition where fat, cholesterol, and calcium found in the blood builds up inside the heart's arteries, causing them to narrow and harden), unspecified psychosis (a condition when a person loses clear signs of losing touch with reality but does not fully meet criteria for defined mental illness) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During review of the H&P report completed on 1/15/2021, the H&P indicated Resident 180 has impaired decision-making capacity. During a review of Resident 180's MDS, dated [DATE], the MDS indicated Resident 180's ability to express ideas and wants was limited to making concrete requests and responds adequately to simple, direct communication only for ability to understand others. The MDS indicated Resident 180 required substantial/maximum assistance with eating and dependent with all other activities of daily living. The MDS indicated that Resident 180 was dependent on all aspects of functional mobility. During a concurrent observation and interview on 3/11/2026 at 8:50 a.m. with Certified Nursing Assistant (CNA) 3 in Resident 180's room, observed Resident 180 had a unique mattress. The mattress was hollowed with cushions built in on the sides raising from the mattress. CNA 3 stated Resident 180's mattress is used to prevent resident from falls. CNA 3 could not state what the mattress is called. During an interview on 3/11/2026 at 9:24 a.m. with RN 6, RN 6 stated Resident 180 has a concave mattress. RN 6 stated that when the interdisciplinary team (IDT) identifies post- fall that sliding out of bed is the reason for the fall, providing concave mattress is part of the intervention implemented to prevent future falls. RN 6 stated a physician order is not required for the concave mattress and that the risk for fall care plan would indicate when a resident has a concave mattress. During a concurrent interview and record review on 3/11/2026 at 9:44 a.m. with Minimum Data Set Coordinator (MDSC) 3, Resident 180's care plan dated 3/11/2026 was reviewed. The care plan did not list the concave mattress as a fall prevention intervention. MDSC 3 stated it should have been in the care plan. MDSC 3 stated the MDSC would have known to add it if he had been present when the intervention was discussed during health care team meeting. MDSC 3 stated he does not know why the use of concave mattress was not in Resident 180's care plan as a as a fall prevention intervention. MDSC 3 stated he may not have been present during the meeting when it had been discussed for Resident 180 to have concave mattress and it was not communicated to him or another MDSC did not enter it when should have. During a follow-up interview with RN 6 on 3/11/2026 at 11:44 a.m., RN 6 stated she had reviewed Resident 1's records and found the concave mattress was an intervention agreed upon by IDT after Resident 130's fall on 2/5/2021. During a review of Resident 180's safety Events – Post Accident Assessment and Interventions dated 2/5/2021, the form indicated based on root cause analysis list interventions added or direct to care plan/s added includes concave mattress .IDT agreed with above interventions. During an interview with the Director of Nursing (DON) on 3/12/2026 at 10:05 a.m., the DON stated agreed upon IDT recommendations should be added to resident's care plan timely. The DON stated that not having the concave mattress in Resident 180's care plan had the potential of having the mattress removed not knowing it is part of Resident 180's plan of care. The DON stated the care plan is the guide for how the health care team takes care of the resident. Every resident should have an individualized comprehensive care plan that is current. During a review of the facility's P&P titled, Fall Reduction/Prevention Program last reviewed 4/16/2025, the P&P indicated, All residents/patients on admission, quarterly, post fall and significant change in condition, will be assessed for fall risk and when such risk is identified , the resident/patient will be noted as a fall risk with appropriate interventions placed in the medical record.Following a resident fall: The IDT, which may include the DON/designee, RN Unit Manager, Social Services, MDS Coordinator, CNA, Charge Nurse and Activities, will review the medical record, pharmacy recommendations and all other factors that may contribute to the resident fall, and create an appropriate, individualized care plan to address each resident's needs and goals with interventions specific to the root cause of the fall. During a review of the facility's P&P titled, Care Plan - Comprehensive last reviewed 4/16/2025, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetables to meet resident/patient's medical, nursing, mental, and psychological needs is developed for each resident/patient. Procedure Each resident/patient's comprehensive care plan has been designed to: a. Incorporate identified problem areas b. Incorporate risk factors associated with identified problems; c. Build on residents/patients' strengths; d. Reflect treatment goals and objectives in measurable outcomes e. Identify the professional services that are responsible for each element of care Care plans are revised as changes in the resident/patient's condition dictate.Care plan goals and objectives are defined as the desired outcome for a specific resident/patient problem. Goals and objectives are reviewed and/or revised: a. When there has been a significant change in resident/patient condition b. When the desired outcome has not been achieved. Using the Care Plan Changes in the resident/patient's condition must be reported to the MDS Assessment Coordinator so that a review of the resident/patient's assessment and care plan can be made. Documentation must be consistent with the resident/patient's care plan 3. During a review of Resident 4's FS, the FS indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and seizures (a sudden burst of electrical activity in the brain). During a review of Resident 4's MDS, dated [DATE], the MDS indicated the resident`s cognitive skills for daily decision making was severely impaired and totally dependent on staff for activities of daily living (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). The MDS also indicated that the resident's activity preferences include listening to music. During an observation on 03/09/2026 at 1:20 p.m., observed Resident 4 awake in bed and had difficulty expressing herself when spoken to. The television was observed to be off, and there was no music paying in the room. During a concurrent interview and record review on 03/11/2026 at 8:15 a.m., with Licensed Vocational Nurse 6 (LVN 6) reviewed Resident 4`s Care Plan for Activities dated 02/07/2026 and MDS dated [DATE]. LVN 6 stated that the MDS under Section F (identifies resident's preferences about daily routines and activities) indicated music is especially important to Resident 4. LVN 6 stated that the care plan should be resident specific based on the assessment and the resident's needs. LVN 6 stated that a care plan serves as communication tool among the care team to ensure everybody is aware about the resident's specific activity needs. LVN 6 stated that the care plan should have addressed the resident's preferred activity of listening to music to ensure the resident's activity needs are met. During a review of the facility`s P&P titled Resident/Patient/Person Centered Care, last reviewed on 4/16/2025, the P&P indicated that Person-Centered Care is provided or care planned to meet the resident comprehensive individual needs as established by the Physician, IDT, and resident and/or responsible party, which provides the highest reasonable and feasible psychosocial well-being and overall health of the resident. 4. During a review of Resident 72's FS, the FS indicated the facility admitted the resident on 2/17/2026 with diagnoses including unspecified severe sepsis (a life-threatening blood infection) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 72's H&P dated 12/10/2025, the H&P indicated Resident 72 speaks in full sentences, was able to make her own needs known and able to make simple medical decisions. During a review of Resident 72's MDS, the MDS indicated Resident 72 usually makes herself understood and usually understands others. The MDS further indicated Resident 72 needs substantial assistance with upper body and lower dressing, personal hygiene and putting on and taking off shoes. During a review of the facility provided matrix (A list of residents combined with a checklist that identifies who has specific care needs such as TBP) on 3/9/2026, the matrix indicated Resident 72 was identified as being placed on TBP. During a review of Resident 72's Clostridioides difficile (C.diff -a bacteria that causes severe diarrhea and intestinal inflammation) test results dated 3/6/2026, the test results indicated Resident 72 tested positive for C.diff toxins (harmful substance that C. diff produces) and required the resident to be placed on contact isolation (infection control measures to prevent the spread of germs passed by direct or indirect touch). During review of Resident 72's care plans on 3/9/2026 at 9:05 a.m., there was no care plan addressing TBP. During a concurrent interview record review on 3/12/2026 at 2:28 p.m., with the DON, the DON stated care plans are basically a manual of specific care for each individual resident. The DON stated licensed staff must create an individualized care plan when there is a change of condition such as C. Diff requiring TBP for Resident 72. The DON stated the care plan should have been completed on 3/6/2026 when the resident tested positive for C. diff so staff would know how to care for the resident and prevent the spread of infection. During a review of the facility's P&P titled, Resident/Patient/Person Centered Care, last reviewed on 4/16/2025, the P&P indicated that Person-Centered Care is provided or care planned to meet the resident comprehensive individual needs as established by the Physician, IDT and resident and/or responsible party, which provides the highest reasonable and feasible psychosocial well-being and overall health of the resident. 5. During a review of Resident 81's FS the FS indicated the facility originally admitted Resident 81 on 6/29/2023, with diagnoses including: vascular dementia (loss of cognitive functioning-thinking, remembering, and reasoning), psychosis (a mental health symptom involving a loss of contact with reality) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During review of Resident 81's MDS, dated 12/17/2025, the MDS indicated Resident 81 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and is dependent for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a concurrent interview and record review on 3/12/2026 at 12:10 pm with RN 3, Resident 81's care plan titled, Behavioral symptoms related to Seroquel, dated 8/11/2025 was reviewed. The care plan indicated to monitor side effects of Seroquel including orthostatic hypotension (a significant drop in blood pressure when measuring orthostatic blood pressures). RN 3 stated orthostatic blood pressures can be done for Resident 81. Resident 81 mostly lies in bed but can be placed in a reclining wheelchair to obtain orthostatic blood pressure. RN 3 stated there is no documentation indicating why orthostatic blood pressure could not be done and there is no care plan to indicate how to properly measure Resident 81's orthostatic blood pressure. Resident 81's further stated orthostatic blood pressure has only been measured once since the Care plan was initiated on 8/11/2025. During an interview on 3/12/2026 at 2:00 pm with the DON, the DON stated an individualized care plan for measuring orthostatic blood pressure should have been created and implemented for Resident 81. The DON stated repeated inability to measure orthostatic blood pressure should have been reported so that the care plan could be individualized and give proper interventions to monitor for orthostatic hypotension. During a review of the facility's P&P titled, Care Plans – Comprehensive, reviewed 4/2025, the P&P indicated, when goals and objectives are not achieved, the resident/patient's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. The P&P also indicates that it is the responsibility of the Certified Nursing Assistants (CNA) to report to the nurse supervisor when care plan goals and objectives have not been achieved.

Based on observation, interview, and record review, the facility failed to notify residents of the existence and the location of the results of the most recent standard survey (means the Statement of Deficiencies Form CMS-2567) for ten (Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 236) of 11 sampled residents in the resident council. This deficient practice had the potential for residents and their representative to not know how the facility is performing regarding resident care. Findings: a. During a review of Resident 189's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure). During a review of Resident 189's Minimum Data Set (MDS, a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 189 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. b. During a review of Resident 30's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 was cognitively intact with skills required for daily decision making. c. During a review of Resident 51's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 was cognitively intact with skills required for daily decision making. d. During a review of Resident 59's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypotension (low blood pressure). During a review of Resident 59's MDS, dated [DATE], the MDS indicated Resident 59 was cognitively intact with skills required for daily decision making. e. During a review of Resident 62's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included osteoarthritis. During a review of Resident 62's MDS, dated [DATE], the MDS indicated Resident 62 was cognitively intact with skills required for daily decision making. f. During a review of Resident 65's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 was cognitively intact with skills required for daily decision making. g. During a review of Resident 83's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83 was cognitively intact with skills required for daily decision making. h. During a review of Resident 203's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness. During a review of Resident 203's MDS, dated [DATE], the MDS indicated Resident 203 was cognitively intact with skills required for daily decision making. i. During a review of Resident 219's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 219's MDS, dated [DATE], the MDS indicated Resident 219 was cognitively intact with skills required for daily decision making. j. During a review of Resident 236's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness. During a review of Resident 236's MDS, dated [DATE], the MDS indicated Resident 236 was cognitively intact with skills required for daily decision making. During a review of the facility's Resident Council Meeting Minutes, the minutes indicated no information that residents were made aware of the survey results on the following dates: 11/26/2025, 12/17/2025, and 1/29/2026. During an observation and interview with the residents during the resident council task meeting interview on 3/09/2026 at 2:36 p.m., 10 of the 11 residents (Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 236) stated they were not aware of survey results for them to review or where the survey results were located. The 10 residents stated no one told them about survey results. During an observation on 3/11/2026 at 7:45 a.m., observed survey results binder attached to the wall in an area near the first-floor nursing station which indicated the last recertification survey was 12/20/2024. During an interview with the Activities Director (AD) on 3/11/2026 at 9:04 a.m., she stated all survey results were posted near the dining room entrance on every floor and is within reach of the residents. The AD stated she has not told residents in the resident council meetings about the existence of the survey results or where they were located. The AD stated it is important for the residents to know about past survey results and where they are located. The AD stated many of the residents are very involved and active in what occurs in the facility and knowing about the survey results should be part of their involvement. During an observation with the AD on 3/11/2026 at 9:10 a.m., the AD showed the survey team the location of the fourth-floor survey results. Observed the survey binder in a holder near the dining area entrance containing the previous recertification survey results, dated 12/20/2024. During an observation on 3/11/2026 at 9:10 a.m., observed the survey binder in a holder near the third-floor dining area entrance containing the previous recertification survey results, dated 12/20/2024. During an interview with the Director of Nursing (DON) on 3/12/2026 at 8:30 a.m., the DON stated residents should be made aware of the previous year's survey results and their location. The DON stated the residents have the right to review the survey results to remain informed. During a review of facility's policy and procedures (P&P) titled, Administrative Manual, reviewed on 4/16/2025, the P&P indicated, Most recent licensing visit report (survey)/complaint investigations, and the related follow-up plan of correction visit, in areas of the facility that are prominent and accessible to the public have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review.

Based on observation, interview, and record review, the facility failed to implement the facility's infection control policy when: 1. An incorrect sign was placed on the door of one of one resident (Resident 72) on transmission-based precautions (TBP - extra infection control measures used in healthcare settings, beyond standard precautions, for patients known or suspected to be infected with highly infectious pathogens [virus, bacteria, fungus] investigated under the infection control task. This deficient practice had the potential to increase the risk of spreading infection to other residents. 2 Licensed Vocational Nurse 3 (LVN 3) was observed leaving a resident's room during a medication pass observation while still wearing an isolation gown for one (Resident 40) of 13 residents who were on enhanced barrier precautions (EBP-a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments] to reduce the spread of pathogens between residents in skilled nursing facilities). This deficient practice had the potential to increase the risk of spreading infection to other residents. Findings: 1. During a review of Resident 72's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/17/2026 with diagnoses including unspecified severe sepsis (a life-threatening blood infection) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 72's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 72 speaks in full sentences, was able to make her own needs known and able to make simple medical decisions. During a review of Resident 72's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/13/2026, indicated Resident 72 usually makes herself understood and usually understands others. The MDS further indicated Resident 72 required substantial assistance (helper does more than half the work) with upper body and lower dressing, personal hygiene and putting on and taking off shoes. During a review of the facility provided matrix (A list of residents combined with a checklist that identifies who has specific care needs such as TBP) on 3/9/2026, Resident 72 was identified as being placed on TBP. During a review of Resident 72's Clostridioides difficile (C.diff, a bacterium that causes severe diarrhea and intestinal inflammation) test results dated 3/6/2026, the test results indicated Resident 72 was positive for C.diff toxins (harmful substance that C. diff produces) and requires contact isolation. During a concurrent observation and interview on 3/10/2026 at 9:42 a.m. outside of Resident 72's room with the Infection Preventionist (IP), the IP looked at the contact precautions (infection spread by touching) sign on the door and stated it was in fact the wrong sign. The IP stated C. diff infections require handwashing to remove the C.diff spores (the dormant, inactive, and highly resistant form that can live for months) from the hands and the current contact precaution sign instructed to use alcohol-based hand rub (ABHR - a liquid, gel, or foam antiseptic [chemical substance meant to kill germs] designed to kill the majority of germs on hands without the need for soap and water) and that sign is not enough to prevent the spread of C. diff. During an interview on 3/13/2026 at 2:28 p.m., with the Director of Nursing (DON), the DON stated licensed staff are responsible for checking and observing infection control guidelines to keep residents safe. The DON stated that for C. diff infections, the sign must include to wash the hands with soap and water after assisting the resident to ensure all the spores are washed off. During a review of the facility's policy and procedure (P&P) titled, Guideline for Isolation Precautions, last reviewed 4/16/2025, the P&P indicated there are three different kinds of transmission (mode in which the germs can infect) and contact is one of the three. The P&P stated contact transmission is when germs are transferred directly from person to person through touch. The P&P further indicated residents with C.diff will be placed on contact and spore precaution indicating the need for handwashing with soap and water. 2. During a review of Resident 40's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 40' s MDS, dated [DATE], the MDS indicated Resident 40 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 40 was dependent (helper does all the effort) on staff for eating. The MDS indicated Resident 40 has a gastrostomy tube (G-tube, a plastic tube inserted into the stomach to infuse medications for one who has problems swallowing). During a review of Resident 40's Physician's Orders, dated 12/18/2024, the physician's orders indicated EPB are to be maintained during high-contact resident care activities due to G-tube feeding. During a medication pass observation with LVN 3 on 3/11/2026 at 3:58 p.m., observed LVN 3 taking Resident 40's blood pressure in isolation gown and gloves. LVN 3 then removed their gloves and walked towards the medication cart which was placed right outside Resident 40's room at the doorway. LVN 3 was still wearing an isolation gown. When asked if his isolation gown could potentially come in contact with the medication cart, he stated he was not aware this could be an infection control issue. During an interview with the DON on 3/12/2026 at 8:15 a.m., the DON stated staff providing care for residents who are on EBP, the practice is to remove the isolation gown and gloves before leaving a resident's room. The DON stated LVN 3 should have removed the gown before exiting Resident 40's room. The DON stated this was important to prevent the spread of infection. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed 4/16/2025, the policy indicated EBP is used in conjunction with standard precautions (a set of infection control practices that are used to prevent the spread of disease in healthcare settings, such as hand washing) and expand the use of PPE during high-contact resident care activities. The policy indicated EBP are to be used for residents with indwelling medical devices, such as a G-Tube, even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs). The policy indicated the PPE: gloves and gown, are to be used in maintaining EBP.

Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of one sampled resident (Resident 72) investigated during a random observation. This deficient practice had the potential to result in Resident 72 not being able to call for facility staff assistance and delay in the provision of necessary care and services which could negatively affect the residents' comfort and well-being. Findings: During a review of Resident 72's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/17/2026 with diagnoses including unspecified severe sepsis (a life-threatening blood infection) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 72's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 72 speaks in full sentences, was able to make her own needs known and able to make simple medical decisions. During a review of Resident 72's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/13/2026, the MDS indicated Resident 72 usually makes herself understood and usually understands others. The MDS further indicated Resident 72 needs substantial assistance (helper does more than half the work) with upper body and lower dressing, personal hygiene and putting on and taking off shoes. During an observation on 3/10/2026 at 9:51 a.m. in Resident 72's room, Resident 72 was up in the wheelchair with a bedside table in front of him halfway between his bed and the entrance door. Resident 72 lifted up his empty cup and made a gesture of wanting more. Resident 72's call light located on the bed, was out of his reach. During a concurrent observation and interview on 3/10/2026 at 9:57 a.m. inside Resident 72's room with Certified Nursing Assistant (CNA 1), CNA 1 stated she forgot to place the call light next to Resident 72. CNA 1 stated the call light should be next to Resident 72 to ensure he can communicate with facility staff, including making requests for water. During an interview on 3/13/2026 at 2:15 p.m., with the Director of Nursing (DON), the DON stated all call lights should be within each resident's reach so staff would be able to attend to their needs timely at all times. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed 4/16/2025, the P&P indicated staff must answer timely to the resident's request and needs. The P&P further indicated staff must ensure the call light is accessible to the resident.

Based on observation, interview and record review, the facility failed to ensure one of four residents received the correct form of medication in accordance with the physician's order when one of four sampled residents (Resident 216), who had an order for lactobacillus acidophilus (probiotic/supplement medication) in capsule form was administered the tablet form during the medication pass observation. This deficient practice had the potential to alter the medication absorption and effectiveness, resulting in suboptimal treatment or increased risk of adverse effects (unwanted or harmful reaction to a medication or treatment).Findings: During a review of Resident 216's Face Sheet (FS), the Face Sheet indicated the facility Resident 216 was originally admitted on [DATE] and was re-admitted on [DATE] with diagnoses including acute respiratory disease (condition in which your blood does not get enough oxygen or has too much carbon dioxide), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure) and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe). During review of Resident 216's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/19/2025, the MDS indicated Resident 216 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required mostly maximal (helper does more than half the effort) assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 216's Physician Order Report, the Physician Order Report, indicated an order dated 7/29/2024 for lactobacillus acidophilus (probiotic/supplement medication) 100 milligrams (mg-unit of measurement) one capsule orally once a day. During a concurrent observation, interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 3/10/2026 at 8:43 a.m. Resident 216' s Medication Administration Record (MAR) was reviewed. Resident 216's MAR indicated to administer lactobacillus acidophilus 100 mg one capsule orally. During the medication pass observation, observed LVN 1 remove one tablet from the lactobacillus tablet medication container and administer the medication orally to Resident 216. LVN 1 stated that the facility only carried house supply of lactobacillus in tablet form and did not have the capsule form available. During an interview on 3/12/2026 at 9:20 a.m. with the Director of Nursing (DON), the DON stated that he was not aware that the facility does not carry house supply of lactobacillus in capsule form. The DON also stated that it is important to administer medication in accordance with the physician's order to ensure proper absorption and patient safety. During a review of facility's policy and procedure (P&P), titled, Medication Administration, reviewed on 4/2025, the P&P indicated, Medications will be administered in a timely manner and as prescribed by the resident's attending physician.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of five sampled residents (Residents 95 and 111) when the carpet in the residents' shared room was in disrepair. This deficient practice denied Residents 95 and 111 the right to a safe and homelike environment and had the potential to negatively impact their quality of life. Findings: During a review of Resident 95's Face Sheet, the Face Sheet indicated the facility admitted the resident on 1/1/2022 with diagnoses including, but not limited to, Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2026, the MDS indicated the resident had severely impaired cognitive (relating to or involving the processes of thinking and reasoning) skills necessary for daily decision making and never or rarely made decisions. The MDS indicated Resident 95 was dependent (helper does all of the effort) on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 111's Face Sheet, the Face Sheet indicated the facility admitted the resident on 9/18/2023 with diagnoses including, but not limited to, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 111's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognitive skills necessary for daily decision making and never or rarely made decisions. The MDS indicated Resident 111 was dependent on staff for all ADLs. During a concurrent observation and interview on 3/9/2026 at 10:32 a.m. with Resident 95's family member (FM 2) in Resident 95 and Resident 111's shared room, an area of the carpet had a linear cut in a rectangular shape with three cut sides. FM 2 stated someone had put tape over the cut area but now the tape was old and the whole area did not look nice. FM 2 put her foot in the cut area of the carpet and lifted part of the carpet up. FM 2 stated someone could trip on the carpet. FM 2 stated the carpet had been this way for at least two years. FM 2 stated someone from the facility had told her in the past it would be replaced but they never did it. During a concurrent observation and interview on 3/11/2026 at 3:10 p.m. with the Maintenance Manager (MM) in Resident 95 and Resident 111's shared room, the MM observed and validated the carpet was cut and the tape was missing over parts of the cut area. The MM observed and validated the cut area of the carpet could be lifted. The MM stated someone could trip in this area, the carpet does not look like it should, and the tape looked worn and peeling. During an interview on 3/12/2026 at 9:12 a.m. with the Director of Nursing (DON), the DON stated although the residents in the room were unable to walk, someone like a staff member could trip on that area of carpet. The DON stated the carpet does not look nice. During a concurrent observation and interview on 3/12/2026 with the MM, the MM stated the cut area in the carpet was approximately four by two-and-a-half feet. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, last reviewed 4/16/2025, the P&P indicated in order to create an individualized, homelike environment, each resident has the right to resident and receive services in the facility with reasonable accommodation or resident needs and preferences. During a review of the facility's policy and P&P titled, Work Environment, last reviewed 4/16/2025, the P&P indicated a safe and healthful work environment will be provided for all employees, residents, and visitors.

Based on observation, interview, and record review the facility failed to: a. Ensure to provide the name of the medication and its indication (reason for the use of the medication) prior to administration of the medication for one of four (Resident 59) residents observed for medication administration. This deficient practice violated Resident 59's rights to make decisions regarding her medication regimen. b. Obtain informed consent for the use of bed siderails for one of two (Resident 101) residents reviewed for restraints. This deficient practice violated Resident 101's right to be informed of and participate in the resident's treatment. Findings: a. During a review of Resident 59's admission Record (AR), the AR indicated the facility originally admitted the resident on 06/02/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure (can occur when your blood has too much carbon dioxide or not enough oxygen) and age-related osteoporosis (bones lose their ability to regrow and reform themselves). During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/12/2025, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS indicated that Resident 59 required partial/moderate (helper does less than half the effort) assistance for activities of daily living (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a concurrent observation and interview on 3/11/2026 at 4:43 p.m., with Licensed Vocational Nurse 5 (LVN 5), observed LVN 5 administering midodrine (a medication used to treat low blood pressure) 5 milligrams (mg-unit of measurement), Senokot-S (a medication used to treat constipation [infrequent and difficult bowel movements]) 8.6 mg, Trelegy Ellipta (an inhaler used to treat chronic obstructive pulmonary disease [COPD-an ongoing lung condition caused by damage to the lungs]) 200-62.5-25 micrograms (mcg-unit of measurement), Miralax (medication used to treat constipation) 17 grams (gm-unit of measurement), and Tylenol (a medication used to relive pain) 325 mg orally to Resident 59, followed by administering Systane (a medication used to lubricate [to hydrate, soothe, and protect the surface of the eyes]) to both eyes. Resident 59 was not observed informing Resident 59 of the name of each medication and its indication during administration of the medications. When LVN 5 was asked why she did not inform the resident of the names of the medications and their indication, LVN 5 stated she was not aware that it was required per facility policy. During an interview on 3/12/2026 at 09:08 a.m., with the Director of Nursing (DON), the DON stated that residents have the right to be informed about their care including their medications. The DON stated not providing information about their medication regimen restricts Resident 59 from exercising this right. During a review of the facility`s Administrative Manual, last reviewed on 04/16/2025, the administrative manual indicted that the resident has the right to: Make decisions about his/her medical condition Accept or refuse the proposed treatment. b. During a review of Resident 101's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 11/17/2025 and readmitted on [DATE] with diagnoses including hypertension (high blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 101's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated that Resident 101 required partial/moderate (helper does less than half the effort) assistance for activities of daily living (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a concurrent interview and record review on 3/12/2026 at 09:08 a.m., with the DON, reviewed Resident 101's Informed Consent for Bed Rail Use, dated 11/19/2026. The DON stated that the consent was not completed as it did not include the signature of Resident 101 or the resident's representative, the reason for the use of side rails, or the licensed nurse's signature indicating that the consent was obtained and verified. The DON stated that the resident's rights were not protected as consent was not obtained and no explanation was provided regarding the reason for the use of side rails. During a review of the facility`s policy and procedures (P&P) titled Bed Rails, last reviewed on 04/16/2026, the P&P indicated that if the IDT determines that bed rails are appropriate, they will use the Informed Consent for Bed Rail Use form prior to installation. The information will be presented to the resident, or if applicable, the resident representative, in a manner that is understood and that consent is given voluntarily, free form coercion.

Based on interview and record review, the facility failed to implement its grievance policy and procedure for one out of two residents (Resident 222) when the facility failed to assist Resident 222's family member in filing a grievance related to the care provided to Resident 222 by Certified Nursing Assistant (CNA) 5 and failed to conduct an investigation into the concerns. This deficient practice violated Resident 222's right to have a grievance addressed, had the potential to negatively affect Resident 222's care, and had the potential to cause Resident 222 to feel invalidated and disrespected. Findings: During a review of Resident 222's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), and dementia (a progressive state of decline in mental abilities). During a review of Resident 222's Minimum Data Set (MDS - a resident assessment tool), dated 1/31/2026, the MDS indicated the resident had moderate cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 222 was dependent (helper does all the effort) on staff for lower body dressing and putting on footwear. The MDS indicated Resident 222 required substantial assistance (helper does more than half of the effort) with upper body dressing and toileting. The MDS indicated Resident 222 required partial assistance (helper does less than half of the effort) with personal hygiene. The MDS indicated Resident 222 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with oral hygiene and bathing. During a review of the Tracking Log for Issues and Concerns, dated March 2025 to February 2026, the log did not indicate a grievance, issue, or concern was logged involving Resident 222. During an interview on 3/9/2026 at 11:05 a.m. with Resident 222, Resident 222 stated that CNA 5 had spoken in ways that were not nice to her in the past. Resident 222 stated a few months ago after using the bathroom she asked CNA 5 to help her pull up her brief (a high-absorbency incontinence garment). Resident 222 stated CNA 5 then told her she could do that herself and then called her lazy. Resident 222 stated her family member had reported this to the social worker. During a telephone interview on 3/9/2026 at 2:28 p.m. with Family Member (FM) 1, FM 1 stated she sent an email in September 2025 to Social Worker (SW) 1 informing her that CNA 5 was unkind to Resident 222 and had called her lazy. FM 1 stated no one from the facility had followed up with her after her email. FM 1 stated she sent another email on 3/8/2026, and today (3/9/2026) CNA 5 was no longer assigned to provide care to Resident 222. During an interview on 3/9/2026 at 3:47 p.m. with the facility administrator (ADM), the Director of Social Services (DSS), and Registered Nurse (RN) 7, the ADM stated FM 1 had emailed SW 1 about this concern in September 2025, but SW 1 was no longer employed at the facility. RN 7 stated she became aware of FM 1's concern when SW 1 told her about it in September 2025. RN 7 stated she spoke to CNA 5, and CNA 5 stated she never called Resident 222 lazy. The DSS stated she became aware of FM 1's concern this morning (did not specify time) when she read the email FM 1 sent last night. The DSS stated she was not aware of the email FM 1 sent to SW 1 in September 2025. The ADM stated there was no grievance filed in September 2025 when FM 1 sent the first email. The ADM stated the best practice would have been to file a grievance at that time. During an interview on 3/10/2026 at 4:04 p.m. with FM 1 and Resident 222, FM 1 stated when she sent the email in September 2025, she was not informed of the facility's grievance process or how to file a grievance. Resident 122 stated she was not aware of how to file a grievance. Resident 222 stated her interaction with CNA 5 was upsetting and made her feel uncomfortable. During an interview on 3/12/2026 at 2:47 p.m. with the ADM, the DSS, and RN 7, RN 7 stated after she was made aware of FM 1's concern in September 2025, she spoke to CNA 5 but did not speak to FM 1 or Resident 222. RN 7 stated she was not aware if anyone had spoken to FM 1 or Resident 222 to follow up on the concern. The ADM stated once they are aware of a concern they should go to the source, listen fully to the concern, and validate them. The ADM stated they should follow their proper process to address their concerns, make sure the resident feels safe, and ensure that they are treated in a respectful and dignified way. The ADM stated she would have expected SW 1 to forward FM 1's concern to the DSS who was her supervisor, then interview FM 1 and ask clarifying questions. The ADM stated she would then expect SW 1 to speak directly with Resident 222 to hear her experience and ask what she would like to be done and if she would like a different CNA to be assigned to her. The DSS stated all of these actions should have been documented and the facility's Issues and Concerns form should be filled out. The DSS stated when she learned of the concern on 3/9/2026 she completed an Issues and Concerns form. The ADM stated the resident could potentially have felt unheard, invalidated, not respected, or not believed. During a review of the facility's policy and procedure (P&P) titled, Issues and Concerns Process, last reviewed 4/16/2025, the P&P indicated the following: a. Grievances are referred to as Issues and Concerns for the purpose of the policy and the form associated with it. b. The facility with assist residents, their representatives, and other interested family members in filing issues or concerns when such requests are made. c. Issues and concerns can be submitted orally or in writing. d. Once a verbal or written issue or concern is received the respective department will investigate allegations and submit a written report to the administrator. e. The person filing the issue or concern will be informed of the findings of the investigation and the action that will be taken to correct any identified problems. f. If the resident or their representative is not satisfied with the result of the investigation or recommended actions they can appeal to the administrator or compliance officer. g. Records of grievances will be maintained for three years.

Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) annual assessment was transmitted to Centers for Medicare and Medicaid Services (CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to people) within the required 14 day timeframe for one of one sampled residents (Resident 87) reviewed under the resident assessment facility task. This deficiency prevents the CMS from having the most accurate information of Resident 87 and had the potential to result in delayed services for the resident. Findings: During a review of Resident 87's Face Sheet, the Face Sheet indicated the facility admitted Resident 87 on 3/23/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a progressive, long-term lung disease that makes it hard to breathe by restricting airflow), major depressive disorder (a mental health condition with persistent feelings of sadness and hopelessness.) and ileostomy (a surgical opening that lets stool pass from your body without going through your colon) During a review of Resident 87's Minimum Data Set (MDS - an assessment and care screening tool) dated 1/11/2026, the MDS indicated the Resident 87 makes himself understood and understood others. The MDS further indicated Resident 87 needed partial assistance (helper does less than half the effort) with toileting, upper body dressing, lower body dressing, putting on/taking off shoes and personal hygiene. During a review of Resident 87's Final Validation CMS Submission Report titled MDS 3.0 Final Validation Report, printed on 3/12/2026, the report indicated Resident 87's assessment was submitted and processed on 3/11/2026 at 15:08 (3:08 p.m.). The MDS was completed on 1/11/2026 but not transmitted until 59 days later on 3/11/2026. During a concurrent interview and record review on 3/11/2026 at 11:45 a.m. with Minimum Data Set Coordinator 3 (MDSC 3), MDSC 3 reviewed Resident 87's annual assessment. MDSC 3 stated once the annual assessment is complete, it must be transmitted to CMS within 14 days to ensure CMS has the most updated and accurate information on each resident. MDSC 3 stated he forgot to validate and submit Resident 87's assessment after it was completed. During an interview on 3/12/2026 at 1:32 p.m. with the Director of Nursing (DON), the DON stated MDS annual assessments must be completed on time and then submitted to CMS within 14 days. The DON stated Resident 87's annual assessment was submitted 59 days after completion and about 45 days too late. The DON stated it is important to submit the MDS annual assessments timely to ensure CMS has the most accurate information on each resident. During a review of the facility provided Policy and Procedure (P&P) titled, Transmitting MDS Data, last reviewed on 4/16/2025, the P&P indicated that after the completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. During a review of the facility provided P&P titled, Minimum Data Set - Resident Assessment Instrument, last reviewed on 4/16/2025, the P&P indicated the MDS coordinator must transmit to the state repository in accordance with CMS established record specifications and time frames.

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT- a collaborative approach where healthcare professionals from various disciplines work together to provide comprehensive patient care) reviewed and revised a resident's care plan to include appropriate interventions addressing the resident's refusal of prescribed insulin injections for one of two (Resident 94) sampled residents. This deficient practice had the potential to result in failure to deliver the necessary care and services to Resident 94. Findings: During a review of Resident 94's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 94 on 10/01/2023 and re-admitted resident on 1/12/2025, with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), with diabetic polyneuropathy (nerve damage caused by diabetes that makes feet or hands feel numb, tingly, or painful), mild cognitive impairment(mild thinking or memory problems) of uncertain or unknow etiology (illness), and peripheral vascular disease(a condition where blood vessels outside heart and brain usually in legs become blocked or narrowed, causing poor blood flow). During a review of Resident 94's History and Physical (H & P) dated 2/27/2026, the H&P indicated Resident 94 does have the capacity to understand and make decisions on her own. During a review of Resident 94's Minimum Data Set (MDS - a resident assessment tool), dated 1/02/2026, the MDS indicated Resident 94's cognition (relating to or involving the processes of thinking and reasoning) is intact. During a review of Resident 94's Care Plan (CP) updated on 1/6/2026 titled Episodes of non-compliant with medications-insulin, the CP goal indicated the resident will participate in tasks and demonstrate a level of compliance that does not interfere with quality of care needed to maintain the safety and well-being of the resident. The CP indicated the following interventions: - Break into small steps, be patient and allow ample time or try again later. Simplify the request. Ask yes/no questions. Respect request for privacy. Reassure, comfort and distract when appropriate. Provide explanation as to benefits and risks for treatment/medication/plan of care. - Review what constitutes compliance/best interests. - Allow for time to review information given and ask if there is a better time/another day this can be reviewed again. Involve family/significant others as needed. -Accept/support decision to refuse/deny care. -Notify the primary physician of decision and review options if available. (unchecked) During a review of Resident 94's Physician Order Report dated 3/1/2026 to 3/10/2026, the Physician Order Report indicated the following order, with the start date of 3/21/2025. -Novolog(fast acting insulin) insulin 8 units; subcutaneous (under skin) for DM ; please rotate the site, hold if blood sugar less than 100 milligrams per deciliter(mg/dl, a unit of measurement to indicate how many milligrams of as glucose are present in one deciliter [100 mL] of blood ), once a day, 7:30 a.m. During a review of Resident 94's Medication Administration Record (MAR) dated 3/01/2026 to 3/10/2026, the MAR indicated the following results for the Novolog 8 units subcutaneous order administered once daily at 7:30 a.m.: 3/1/2026 at 7:20 a.m. - Not Administered: Refused 3/4/2026 at 8:35 a.m. - Not Administered: Refused 3/5/2026 at 8:22 a.m. - Not Administered: Refused 3/6/2026 at 7:15 a.m. - Not Administered: Refused 3/7/2026 at 7:58 a.m. - Not Administered: Refused 3/9/2026 at 8:04 a.m. - Not Administered: Refused During a concurrent interview and record review on 3/10/2026 at 1:02 p.m., with the Director of Nursing (DON), Resident 94's Physician Order Report dated 3/01/2026 to 3/10/2026 was reviewed. The DON stated the order indicated that Resident 94 should receive insulin Novolog 8 units every morning at 7:30 a.m. The DON stated Resident 94 has a tendency to refuse insulin injections. During a concurrent interview and record review on 3/10/2026 at 1:22 p.m., with the DON Resident 94's CP titled Episodes of non-compliant with medications-insulin, dated 1/6/2026 was reviewed. The DON stated Resident 94's care plan was not resident specific as it lacked critical information related to the resident's refusal. The DON stated the CP did not include parameters for escalation such as the number of missed doses requiring notification, the frequency for monitoring refusals, or defined blood sugar levels that would require physician notification. The DON further stated that the section indicating notify physician of decision and review options if available was unchecked, indicating this intervention had not been incorporated into the resident's CP. During a concurrent interview and record review on 3/10/2026 at 1:32 p.m., with the DON Resident 94's IDT/Care Plan with observation date of 1/6/2026 and completion date of 3/10/2026, was reviewed. The DON stated the IDT meeting care plan review did not address Resident 94 's repeated refusals of insulin administration. The DON also stated that this issue should have been discussed during the IDT/Care Planning meeting to establish appropriate interventions. During a concurrent interview and record review on 3/12/2026 at 8:22 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 94's CP titled Episodes of non-compliant with medications-insulin, dated 1/6/2026 was reviewed. LVN 4 stated that Resident 94's care plan was not resident specific, as the CP did not indicate when the physician should be notified, the number of refusals requiring notification, and acceptable blood glucose parameters. LVN 4 stated she believed the physician should be notified after three refusals. During a review of the facility's policy and procedure (P&P) titled, Inter-disciplinary Risk meeting, revised on 4/16/2025, the P&P indicated the Risk meeting is designated to bring current resident/patient care issues to the Interdisciplinary Team (IDT) for discussion, potential alterations to the plan of care, notification to all disciplines regarding current status of residents/patients, and to develop proactive approaches designed to prevent acute episodes from occurring. During a review of the facility's P&P titled, Care Plans, Comprehensive, revised on 4/16/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient's medical, nursing, mental and psychological needs is developed for each resident/patient. Our facility's care planning/interdisciplinary team, in coordination with the resident/patient his/her family or representative (sponsor), develops and maintains a comprehensive car plan for each resident. Each resident/patient's comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident/ patient's strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care;

Based on observation, interview, and record review, the facility failed to: 1.Clarify with the physician the basis for determining the appropriate setting for a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) in accordance with the facility policy for one (Resident 4) out of two sampled resident investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body). 2. Complete a skin assessment for one of two sampled residents (Resident 1) reviewed for pressure ulcer/injury when Resident 1's skin impairment was re-classified from Stage 2 pressure injury (PI - injury to the skin and underlying tissue resulting from prolonged pressure on the skin) to Moisture Associate Skin Damage (MASD - skin erosion caused by prolonged exposure to source of moisture such as urine, stool, seat, wound drainage, saliva or mucus). This deficient practice had the potential to place Resident 1 at risk for inappropriate interventions, incorrect treatment, and potential worsening of skin integrity. Findings: 1.During a review of Resident 4's Face Sheet, the Face Sheet indicated the facility originally the resident to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia ( a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and seizures (a sudden burst of electrical activity in the brain). During a review of Resident 4`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/06/2026, indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and totally dependent on staff for activities of daily living (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During an observation on 03/09/2026 at10:49 a.m., observed Resident 4 in bed sleeping on a low air loss mattress set at 210 pounds. During a concurrent interview and record review on 03/11/2026 at 8:32 a.m., with Licensed Vocational Nurse 6 (LVN 6), Resident 4`s physician`s order and current weight was reviewed. The review indicated that there was an order for a LALM for wound prevention on 3/6/2026, however it did not specify the basis for determining the setting for the LALM. LVN 6 stated Resident 4's current weight is 171 pounds (lbs.-unit of weight). LVN 6 stated that the LALM is used for skin management and to prevent skin breakdown for resident that are always in bed. LVN 6 stated a LALM is set according to the resident`s weight and the higher the setting the harder and firmer the mattress becomes, which can potentially result in the development of a wound. During a concurrent observation and interview on 3/11/2026 at 8:45 a.m., in Resident 4's room with LVN 6, observed Resident 4 lying on a LALM set at 210 lbs. LVN 6 stated that the setting of 210 lbs. is not accurate and she will obtain a physician order to determine the appropriate setting for Resident 4's LALM. During an interview on 03/12/2026 at 9:08 a.m., with the DON stated the use of air loss mattress can prevent the development of skin impairment and if the setting is incorrect, it will not achieve the intended therapeutic effect but rather can be the cause of the pressure ulcer. During a review of the facility`s policy and procedure (P&P) titled Patient/Resident Pressure Redistribution Devices-Air Loss Mattress, last reviewed on 4/16/2025, the P&P indicated that it is the policy of this facility that all residents/patients utilizing an air loss mattress will be monitored appropriately to ensure pertinent and effective use and cleaning. During a review of the Air Loss Mattress Operation Manual (OM) provided by the facility, the OM indicated that users can adjust air mattress to a desired firmness according to patient`s weight or the suggestion from a health care professional. 2. During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 to the facility on 01/10/2026, with diagnoses including bacterial pneumonia (serious lung infection caused by bacteria), chronic respiratory failure (long-term condition where the lungs cannot sufficiently transfer oxygen into the blood) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). During review of the History and Physical (H&P) report completed on 1/13/2026, the H&P indicated Resident 1 is able to make her own needs known and has the capacity to make her own medical decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 is able to make self-understood and able to understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) with toileting hygiene and substantial maximal assistance (helper does more than half the effort) for personal hygiene, shower/bathe self, upper and lower body dressing. The MDS indicated that Resident 1 is dependent for chair/bed-to-chair transfer, tub/shower transfer, and substantial/maximal assist for roll left and right (ability to roll from laying on back to left and right side and return to laying on back on the bed). During an interview on 3/9/2026 at 9:46 a.m. with Resident 1, Resident 1 stated she has bowel and bladder incontinence (losing control over passing stool or urine, leading to accidental leakage). Resident 1 stated that her medication makes her urinate often, and she had several days of diarrhea. Resident 1 stated that the frequent urination and recent loose stools have caused her to have sores on her buttocks. During a concurrent interview and record review on 3/11/2026 at 12:50 p.m., with the Minimum Data Set Coordinator (MDSC) 1, Resident 1's Wound Management dated 3/2/2026, Progress Notes dated 3/2/2026-3/3/2026, and Physician Orders dated 3/11/2026 were reviewed. MDSC 1 stated that it is the Registered Nurse's (RN) responsibility to perform a comprehensive skin assessment during admission and as needed, such as when a resident develops impaired skin integrity. During review of the Wound Management form dated 3/11/2026, the form indicated Resident 1 had a pressure injury to right buttocks measuring 1.5 centimeters (cm-unit of measurement) x 1.4 cm x 0.2 cm. During review of Resident 1's current treatment orders, the physician's orders dated 3/3/2026 indicated treatment orders for MASD to the right buttocks. MDSC 1 stated that the wound was likely re-assessed and determined to be MASD and not a PI. MDSC1 stated that there was no documented evidence that an assessment was completed by an RN on the Wound Management or on the progress notes from 3/2/2026-3/3/2026 indicating presence of right buttocks MASD. During an interview on 3/11/2026 at 1:55 p.m. with RN 6, RN 6 stated she had re-assessed Resident 1's right buttocks wound on 3/3/2026 and determined the wound was MASD, not PI. RN 6 stated she did not document her assessment when she re-evaluated the wound. RN 6 stated she should have documented the assessment because if she did not document it, there is no way that it can be validated the re-assessment was performed. During an interview on 3/12/2026 at 10:05 a.m. with the Director of Nursing (DON), the DON stated that newly identified skin impairment may be at times be re-assessed the following day by another RN with greater wound care experience. The DON stated that the RN who conducted the reassessment is responsible for documenting their findings. The DON stated that if the re-assessment is not documented, it is considered as though it was not performed. The DON stated that because Resident 1's wound re-assessment was not recorded, the health care team lacked awareness of any changes from the initial evaluation of the right buttocks wound dated 3/2/2026 to 3/3/2026. Without documentation confirming the wound was MASD, the prescribed treatment did not align with the skin assessment. The DON stated discrepancy between assessment and treatment can potentially result in delaying appropriate wound healing due to the absence of appropriate intervention. During a concurrent observation and interview on 3/13/2026 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's buttocks was observed to have irregular areas of skin epidermal skin erosion on the buttocks. LVN 1 stated that Resident 1's skin impairment is MASD and treatment orders for Resident 1's buttocks is for MASD. During a review of the facility's P&P titled, Wound and Skin Management last reviewed 4/16/2026, the P&P indicated: 1. Licensed nurse/treatment nurse will document injury status and other skin conditions at least every seven (7) days and prn and should cover each of the following areas: Licensed nurse shall differentiate the type of injury (pressure-related or non-pressure related) Licensed nurse/treatment nurse shall document status of the injury sites, treatments administered, status of dressing if ordered, and effectiveness of treatment and signs and symptoms of infection Describe injury edges and wound bed, share, surrounding tissues, drainage (color and odor) Size: be sure to include length, width, and depth measurements in centimeter Stage the pressure injury/sore Drainage Undermining/tunneling Character of wound Pain assessment and changes in condition e.g. infection or other possible complications During a review of the facility's Health Information Record Manual titled, Chapter III 3025 Documentation Guidelines last reviewed 4/16/2025, the record indicated, 3. Documentation in the legal health record will follow these basic rules: .Record applicable observations, psychosocial and physical manifestations, incidents, unusual occurrences, and abnormal behavior.Promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident.

Based on observation, interview, and record review, the facility failed to: 1.Ensure one of five sampled residents (Resident 40) reviewed for accidents, was safely transferred from bed to wheelchair using the sit-to-stand lift (Sara lift, a mechanical device that helps lift a resident to rise from a seated position. This requires a resident to be able to support at least partial body weight while standing) with a two-person assist in accordance with the facility policy. This deficient practice had the potential to place Resident 40 at risk for fall. 2. Ensure prepared medication was not left unattended on one of five medication carts (Medication Cart 2). This deficient practice had the potential to result in accidental ingestion of medication and can lead to adverse reactions (any unexpected or dangerous reaction to a drug). Findings: 1. During a review of Resident 40's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 40' s Minimum Data Set (MDS, a resident assessment tool), dated 1/01/2026, the MDS indicated Resident 40 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 40 was dependent (helper does all the effort) on staff for chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). During a review of Resident 40's Physician's Orders, the orders indicated: Sara lift with two-person assist (sic) [a Latin adverb that is used to note when a quotation may not be correct in terms of spelling or grammar] on all transfers, dated 11/20/2024. During a review of Resident 40's Care Plan for Falls, initiated 3/19/2021, the care plan indicated a goal that there will be a reduced risk for falls daily for 90 days. The care plan indicated an intervention for Sara lift with two-person assist on all transfers. During a review of Resident 40's Falls Risk Assessment, dated 12/31/2025, the assessment indicated the resident was at a high risk for falls. During an observation on 3/12/2026 at 7:30 a.m., observed CNA 4 opening Resident 40's room door and exiting pushing a Sara lift. CNA 4 stated she moved Resident 40 from bed to wheelchair with the Sara lift. When asked if she had assistance with the transfer from another staff member, she stated Registered Nurse 5 (RN 5) assisted her. During an interview with RN 5 on 3/12/2026 at 7:37 a.m., she stated she did not help CNA 4 with any task that morning as she walked in the hallway and stopped in front of Resident 40's room. CNA 4 stated RN 5 assisted her with the Sara lift and RN 5 stated she did assist CNA 4. When asked why RN 5 stated she had helped CNA 4 when a moment ago she said she did not help her, RN 5 stated she did not help CNA 4 to transfer Resident 40 from bed to wheelchair using the Sara lift. Then CNA 4 stated she used the Sara lift by herself without help from any staff. CNA 4 stated she should have asked another staff member to help her because it is important for someone to be standing by to ensure the Sara lift is locked and the wheelchair does not move. RN 5 stated two staff should operate the Sara lift, to ensure the safety of the move and to prevent injury. RN 5 stated one person transfer with the Sara lift could place a resident at risk for fall. During a concurrent interview and record review with the Director of Nursing (DON) on 3/12/2026 at 8:15 a.m., the DON reviewed the facility's policy and procedure titled, Moving/Positioning a resident/patient, last reviewed 4/16/2025. The DON referred to the portion of the policy that indicated: to ensure that there is a second person to assist in the use of Hoyer lifts (electric medical device designed to safely transfer individuals with limited mobility between beds, chairs, and wheelchairs, which would include Sara lift). The DON stated this referred to a Sara lift also. The DON stated the Sara lift should always have two staff members present for resident transfer. The DON stated it is their policy, for safety, to prevent any possible injury. During a review of the facility's policy and procedure titled, Moving/Positioning a resident/patient, last reviewed 4/16/2025, the policy indicated in the section titled, Hoyer/Sara lifts: Ensure that you have a second person to assist in the use of Hoyer lifts. 2. During an observation on 3/9/2026 at 9:19 a.m. in between the nursing station and main dining room on the second floor of the facility, a medication cup filled with pasty substance and a spoon inside the cup was observed resting on the unattended Medication Cart 2. During an interview on 3/9/2026 at 9:30 a.m. with Licensed Vocational Nurse 8 (LVN 8), LVN 8 stated she prepared the medication for a resident and left it on the medication cart when she went to another resident's room. LVN 8 stated she left the medication on the cart so she could inform another resident about their upcoming beauty salon visit later that day. LVN 8 stated there was no urgent need to let the resident know about her visit to the beauty salon. LVN 8 stated she should not have allowed herself to get distracted and be interrupted from administering the medication she had prepared for the resident. LVN 8 stated I know my mistake. We have to only be doing medications when doing medications. LVN 8 stated she was multi-tasking when she should be concentrated on medication pass (a structure process used in long-term facilities to ensure residents receive their medication safely and accurately). LVN 8 stated medication should be administered immediately after preparation. LVN 8 stated that if there was a valid reason that interrupts her during medication pass such as an emergency, the medication must be stored securely to prevent access by other residents for safety reasons. During an interview on 3/12/2026 at 10:05 a.m. with the DON, the DON stated medication should never be left unattended due to the potential risk of other residents ingesting medication not prescribed for them. The DON stated medications must be securely maintained to protect resident safety. During a review of the facility's P&P titled, Medication Administration last reviewed 4/16/2026, the P&P indicated Security of medication care during medication pass: No medication are kept on top of the cart. During a review of the facility's P&P titled, Drug Storage/Inventory Inspection last reviewed 4/16/2026, the P&P indicated Drugs on the unit will be kept in locked medication carts or in locked medication rooms with access to licensed nursing and pharmacy personnel only.Drugs shall be accessible only to licensed personnel designated by the medical center. During a review of the facility's P&P titled, Accident and Resident Safety Reporting last reviewed 4/16/2026, the P&P indicated The facility provides management to support environment, training, assessment and action(s) planned as needed to keep residents as free as possible from accidents, hazards, breaches of personal identified information, infections, communicable/pandemic diseases over which the facility has control.Hazards refer to elements of the residents environment that have the potential to cause injury or illness.Free of accidents hazards as is possible refers to being free of accident hazards over the facility has control.Resident environment includes the physical surrounding to which the resident has access (e.g. room, unit, common areas, and facility grounds, etc.).

Based on interview and record review the facility failed to complete a resident's Hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) Record with information including assessment of the arteriovenous fistula (AVF- a surgically created connection, typically between an artery and a vein in the forearm or upper arm, with the non-dominant arm preferred) for bruit and thrill (you can feel for a thrill at the fistula incision site. A thrill feels like buzzing under your skin. The bruit and thrill tell you that your fistula is working) for one of one (Resident 16) resident investigated under the Dialysis care area. This deficient practice placed the resident at risk for complications such as thrombosis (blood clot), stenosis (narrowing), or reduced blood flow, resulting in loss of access, infection, and inadequate dialysis treatment. Findings: During a review of Resident 16's Face Sheet, the Face Sheet indicated the facility originally admitted the resident to the facility on [DATE] with diagnoses including end stage renal disease (when kidneys no longer function well enough to meet a body's needs) and type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 16`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/25/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and the resident required supervision and touching assistance (helper provides verbal cues) for oral hygiene, upper body dressing, personal hygiene and substantial/maximal assistance (helper does more than half the effort for toileting hygiene and shower. During a review of Resident 16's Physician Order dated 02/11/2025 to 03/11/02025, the Physician Order indicated an order for dialysis every Tuesday-Thursday-Saturday at 11:30 a.m. chair time (refers to the time spent sitting in a dialysis chair during a dialysis treatment, which typically lasts around 3-4 hours). During a review of Resident 16`s Hemodialysis Record on 03/11/2026 at 10:11 a.m. with Licensed Vocational Nurse 6 (LVN 6), the record did not have documented evidence that an assessment for the presence of bruit and thrill was conducted on the following dates: 02/03/2026 02/05/2026 02/07/2026 02/09/2026 02/12/2026 02/14/2026 02/17/2026 02/19/2026 02/21/2026 02/24/2026 02/26/2026 02/28/2026 LVN 6 stated that the AVF must be assessed before and after dialysis treatments to ensure that the fistula is patent and not clotted and to monitor for signs and symptoms of infection. LVN 4 further stated that routine pre and post dialysis assessments are necessary to promptly identify concerns, such as absence of bruit or thrill or signs of infection, and to ensure timely notification of the physician to prevent missed dialysis treatments. LVN 4 also stated the hemodialysis record serves as a communication tool between nursing staff and the dialysis provider, including documentation of the AVF status to ensure continuity of care. During a review of the facility policy and procedure (P&P) titled, Dialysis Care, last reviewed 4/16/2025, the P&P indicated that the facility shall facilitate arrangements for ongoing dialysis care as ordered by the physician.IDT [An Interdisciplinary Team (IDT) in nursing is a collaborative group of healthcare professionals-including nurses, physicians, social workers, and therapists-who work together to create and implement a comprehensive care plan for patients] shall assure that the resident`s/patient`s treatment plan includes resident`s/patient`s renal condition and necessary precautions i.e. shunt site, weights, dietary and fluid restrictions.observe for signs and symptoms of infection.

Based on observation, interview and record review the facility failed to ensure that staffing information, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted daily for two of two days (3/9/2026 and 3/10/2026), in accordance with the facility's policy and procedure (P&P) on Administrative Manual. This deficient practice resulted in the total number of staff and the actual hours worked by the staff in the facility were not readily accessible to residents, staff and visitors. Findings: During an observation on 3/10/2026 at 2:30 p.m., a nurse staffing information posted near the lobby nursing station was dated 3/9/2026, and did not indicate the resident census, the total number and the actual hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistant s from 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. During a concurrent observation and an interview with Registered Nurse 2 (RN 2) on 3/10/2026 at 2:33 p.m., observed nurse staffing information posted near the lobby nursing station. RN 2 stated that the nurse staffing information posting was dated 3/9/2026. RN 2 stated the staffing information was missing the actual resident census and the actual total hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants from 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. RN 2 stated that the nursing staffing information should be posted daily and updated every shift so residents, family members, and staff can see the number of hours available for resident care. During an interview and record review on 3/10/2026 at 3:35 p.m., with the Executive Administrative Assistant (EEA), JEKMC Nursing Census dated 3/9/2026 and timed 3:47 p.m.; signed on 3/10/2026 at 3:47 p.m. was reviewed. The EEA stated that the facility's nursing staffing information should be posted and updated daily at the beginning of each shift to inform the public the total number and actual hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistant every shift. The EAA stated that the nursing staffing information for 3/10/2026 should have been posted by the night shift charge nurse to ensure the staffing information was visible to all staff, residents and visitors prior to the to the start of the morning shift (7 a.m.-3 p.m.). During an interview and record review on 3/11/2026 at 8:33 a.m., with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Administrative Manual was reviewed. The DON stated that the nurse staffing data should be posted daily at the beginning of each shift, including resident census and the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. The DON stated that facility policy was not followed, resulting in residents, staff and visitors being unable to determine how many staff worked on 3/9/2026 or who was scheduled to work on 3/10/2026. During a review of facility's (P&P) titled, Administrative Manual, revised on 4/16/2025, the P&P indicated the facility will post the nurse staffing data daily at the beginning of each shift. Data will be posted clear and red able format and in a prominent place readily accessible to residents and visitors the posting will include the total number and actual hours worked by the following categories of licensed and licensed nursing staff directly responsible for resident care per shift Registered nurse, License practical nurse, certified nurse assistant and resident census.

Based on interview and record review, the facility failed to ensure the physician was notified when one of two sampled residents (Resident 94) repeatedly refused insulin (medication to lower blood sugar) injection. This deficient practice placed Resident 94 at risk for delayed care and poor blood glucose management, placing the resident at risk for health complications. Findings: During a review of Resident 94's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 94 on 10/01/2023 and re-admitted the resident on 1/12/2025, with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), with diabetic polyneuropathy (nerve damage caused by diabetes that makes feet or hands feel numb, tingly, or painful), and peripheral vascular disease(a condition where blood vessels outside heart and brain usually in legs become blocked or narrowed, causing poor blood flow). During a review of Resident 94's History and Physical (H & P) dated 2/27/2026, the H&P indicated Resident 94 does have the capacity to understand and make decisions on her own. The H&P indicated the Hemoglobin A1c (HbA1c, a blood test that shows your average blood sugar level over the past 2-3 months. The normal range is below 5.7 percent [%]) dated 8/21/2025 was 8.9%. The H&P indicated the HbA1c remains above goal, and the goal is less than 8%. During a review of Resident 94's Minimum Data Set (MDS - a resident assessment tool), dated 1/02/2026, the MDS indicated Resident 94 has intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision. During a review of Resident 94's Physician Order Report dated 3/1/2026 to 3/10/2026, the Physician Order Report indicated the following order, with the start date of 3/21/2025. -Novolog(fast acting insulin) insulin 8 units; subcutaneous (under skin) for DM ; please rotate the site, hold if blood sugar less than 100 milligrams per deciliter(mg/dl, a unit of measurement to indicate how many milligrams of as glucose are present in one deciliter [100 mL] of blood ), once a day, 7:30 a.m. During a review of Resident 94's Medication Administration Record (MAR) dated 3/01/2026 to 3/10/2026, the MAR indicated the following results for the Novolog 8 units subcutaneous order administered once daily at 7:30 a.m.: 3/1/2026 at 7:20 a.m. - Not Administered: Refused 3/4/2026 at 8:35 a.m. - Not Administered: Refused 3/5/2026 at 8:22 a.m. - Not Administered: Refused 3/6/2026 at 7:15 a.m. - Not Administered: Refused 3/7/2026 at 7:58 a.m. - Not Administered: Refused 3/9/2026 at 8:04 a.m. - Not Administered: Refused During a concurrent interview and record review on 3/10/2026 at 1:02 p.m., with the Director of Nursing (DON), Resident 94's Physician Order Report dated 3/01/2026 to 3/10/2026 was reviewed. The DON stated the order indicated that Resident 94 should receive insulin Novolog 8 units every morning at 7:30 a.m. The DON stated Resident 94 has a tendency to refuse insulin injections. During a concurrent interview and record review on 3/10/2026 at 1:10 p.m., with the DON Resident 94's MAR dated 3/01/2026 to 3/10/2026 was reviewed. The DON stated the MAR indicated that Resident 94 refused the scheduled Novolog injections at 7:30 a.m. on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. The DON stated licensed nurses should have informed the physician that Resident 94 refused scheduled Novolog injections at 7:30 a.m. on those dates. The DON stated that it important to inform the physician when a resident refuses insulin so the physician can adjust the dose and help prevent complications such as high blood sugar or low blood sugar. During a concurrent interview and record review on 3/10/2026 at 1:17 p.m., with the DON, Resident 94's progress notes dated 3/1/2026 to 3/10/2026 was reviewed. The DON stated he was unable to find documented evidence that licensed nurses informed the physician that Resident 94 refused the scheduled 7:30 a.m. insulin injection on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. During a concurrent interview and record review on 3/12/2026 at 8:18 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 94's MAR and progress notes dated 3/01/2026 to 3/10/2026 were reviewed. LVN 4 stated that Resident 94 refused the scheduled 7:30 am insulin injection on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. LVN 4 stated she is unable to find any documentation in the progress notes indicating the physician was informed of Resident 94's repeated refusal of insulin for 3/2026 .LVN 4 stated not notifying the physician had the potential to result in Resident 94 not receiving the right amount of medication which can lead to complications such as high blood sugar which could result in the resident experiencing increased thirst, headaches, blurred vision or low blood which could result in coma (deep state of unconsciousness where a person is not awake and cannot respond to their surroundings, including voice, touch, or pain), confusion or shakiness. LVN 4 further stated that notifying the physician will allow the physician to adjust the dose accordingly and determine an appropriate plan. During a concurrent interview and record review on 3/11/2026 at 8:38 a.m., with the DON, the facility's policy and procedure (P&P) titled, Medication Administration was reviewed. The Medication Administration, revised on 4/16/2025, indicated the DON and the attending physician must be notified when two consecutive doses of medication are refused or withheld. The DON stated that the licensed nurses should have notified the physician when Resident 94 refused insulin injection on 3/4/2026, 3/5/2026, 3/6/2026, and 3/7/2026 since the refusal occurred on consecutive days. The DON stated licensed nurses did not notify the physician and facility policy was not followed. The DON stated failure to notify the physician could result in the physician being unable to adjust the insulin accurately and the resident may not receive the right amount of insulin in the body. During a review of the facility's P&P titled, Medication Administration, revised on 4/16/2025, the P&P indicated medications will be administered in a timely manner and as prescribed by the resident's/patient's attending physician or the facility's medical director. Charting Withholding/ Refusal of Medication on the MAR. Should a drug be withheld, refused, or given other than the schedules time, the individual administering the medication must initial and circle the MAR space provided for that particular drug. The Director of Nursing services and attending physician must be notified when two consecutive doses of medication are refused or withheld.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for one out of ten residents (Resident 3) observed while dining when Resident 3 was served a sandwich made with softened bread with the crusts left on while on a soft and bite-sized diet (foods that are soft, tender, moist, and easy to chew and swallow). This deficient practice had the potential to result in Resident 3 having difficulty with chewing and swallowing leading to a potential decrease in food intake and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the admitted the resident on 2/8/2024 with diagnoses including, but not limited to, chronic (long-term) atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 1/1/2026, the MDS indicated the resident had severe cognitive impairment (trouble with thinking, learning, and remembering clearly). The MDS indicated Resident 3 was dependent (helper does all of the effort) on staff for toileting, bathing, and personal hygiene. The MDS indicated Resident 3 required substantial assistance (helper does more than half of the effort) with eating, oral hygiene, and dressing. During a review of Resident 3's Physician Order Report, the Physician Order Report indicated an order for a fortified (adding additional nutrients), soft and bite-sized diet, dated 6/4/2025. During a review of the facility's Menu and Diet Guidelines Manual titled, Summary of Diets, last reviewed April 2025, the manual indicated a soft and bite-sized diet follows the guidelines for International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 6 with a texture modification of soft foods that are easy to chew and swallow. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive), titled Spread Sheet Week 8 Winter 2026, dated 3/10/2026, the spreadsheet indicated residents on a soft and bite-sized diet would include a krab (imitation crab meat) salad roll and a soaked soft bun. During a concurrent observation and interview on 3/10/2026 at 12:19 p.m. with Certified Nursing Assistant (CNA) 3 and Resident 3, CNA 3 assisted Resident 3 to eat lunch. Observed the krab salad roll was served in bread which had the crusts on. CNA 3 stated the crust was still on the bread, but the bread was moistened so the resident can chew it more easily since she is on a soft and bite-sized diet. During an interview on 3/12/2026 at 10:34 a.m. with the Registered Dietician (RD), the RD stated the sandwich bread for a soft and bite-sized diet should be prepared following the IDDSI standards. The RD stated per the IDDSI standards the crusts on the bread should be removed then the bread should be soaked with liquid. The RD stated the IDDSI standards should be followed so that they can provide a safe diet texture to the residents and minimize the risk of choking. During a review of the IDDSI guidelines provided by the facility titled Level 6 Soft and Bite-Sized for Adults, dated January 2019, the guidelines indicated to avoid any crust which is formed during cooking or heating as it poses a choking risk.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance and flavor for lunch when chicken was served with some of the quills (the hollow central part of a feather) still in the skin for one of three residents (Resident 172) during dining observation. This failure had the potential to result in the resident not consuming meals or having poor food intake, which could lead to unintended weight loss. Findings: During a review of Resident 172's Face Sheet, the Face Sheet indicated the facility admitted Resident 87 on 1/7/2026 with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and gastro-esophageal reflux disease (a chronic condition where stomach acid frequently flows back up into the esophagus [food pipe]). During a review of Resident 172's History and Physical (H&P) dated 3/2/2026, the H&P indicated Resident 172 speaks in full sentences, was able to make her own needs known and able to make her own medical decisions. During a review of Resident 172's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/13/2026, the MDS indicated the Resident 172 makes himself understood and understood others. The MDS further indicated Resident 172 needed supervision (helper provides verbal cues and/or touching assistance) for eating and oral hygiene and substantial assistance (helper does more than half the effort) with toileting, upper body dressing, lower body dressing, putting on/taking off shoes and personal hygiene. During an initial pool interview on 3/9/2026 at 9:39 a.m. with Resident 172 in her room, Resident 172 was sitting up in her wheelchair eating a snack. Resident 172 stated she was a caterer in the past and food along with its presentation is important to her. Resident 172 stated she loves chicken on the bone, and the skin is her favorite part and the chicken the facility uses gets served with quills in the skin and she cannot eat it. Resident 172 stated the facility follows Kosher food laws (a set of Jewish [religion, culture and shared ancestry] dietary regulations to determine which foods are ok to eat) and although they state that they burn them off, there are still lots of [NAME] tips in the skin. During a concurrent observation and interview on 3/9/2026 at 12:11 p.m. in the fifth-floor bistro, Resident 172 was eating her lunch and asked the surveyor to come over. Resident 172 was eating the leg and thigh quarter of a chicken and stated there were quills in the skin. Resident 172 then pulled out several small quills, stated she was disgusted and removed all of the skin and set it aside. During a concurrent observation and interview on 3/9/2026 at 12:16 p.m. in the fifth-floor bistro with Certified Nursing Assistant (CNA 2), CNA 2 looked at Resident 172's chicken skin and stated she has seen quills in the chicken skin before and the kitchen is aware. CNA 2 stated Resident 172 enjoys her food less and does not finish her meal when there are quills left in her chicken. During an interview on 3/9/2026 at 1:02 p.m. with the Dietary Supervisor (DS), the DS stated the chicken source must be Kosher and often times the chicken on the bone with skin usually have some quills and the kitchen staff uses a torch to burn the quills. The DS stated he was made aware of the quills and is looking for a new source that is Kosher to purchase from so the chicken can be appetizing for all the residents. During a review of the facility's Policy and Procedure (P&P) titled Food Presentation, last reviewed 4/16/2025, the P&P indicated meals served to residents shall be presented in an attractive, appetizing and sanitary manner that promote adequate nutrition and resident satisfaction. During a review of the facility's P&P titled Meal Delivery Service, last reviewed 4/16/2025, the P&P indicated the meals shall be delivered to the residents in an attractive manner .and will meet the diets, consistency and personal preferences. During a review of the facility's P&P titled Standardized Recipes, last reviewed 4/16/2025, the P&P indicated the facility cooks shall follow recipes including the proper cutting, slicing and other preparations of ingredients.

Based on observation, interview, and record review, the facility failed to: 1. Remove Resident 72's discontinued medication from the medication cart after the physician discontinued the order in one (1) of five (5) inspected medication carts (Medication Cart 2). 2. Label an over the counter (OTC-medications available to consumers without a prescription) medication in one of three sampled medication storage rooms (Medication Storage Room C) These deficient practices had the potential to result in a medication error by allowing discontinued medication to remain in the cart and creating the risk of administering medication to the wrong resident, lost medication, or delayed treatment. Findings: 1. During a review of Resident 72's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 72 on [DATE] and was re-admitted on [DATE] with diagnoses including sepsis a serious infection that is already affecting their organs, chronic kidney disease (CKD-a longstanding disease of the kidneys leading to kidney failure) and hypertension (high blood pressure ). During a record review of Resident 72's History and Physical (H & P) dated [DATE], the H&P indicated Resident 72 able to make simple medical decisions. During a review of Resident 72's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated the resident 72 cognition (relating to or involving the processes of thinking and reasoning) was severely impaired. During a review of Resident 72's Physician Order Report (POR), dated [DATE] to [DATE], the Physician Order Report indicated that the physician's order dated [DATE], for Cipro (Ciprofloxacin HCL) (a medication classified as an antibiotic used to treat infections) 500 milligrams(mg-unit of measurement) for urinary tract infection (UTI-infection caused bacteria entering the urinary system, commonly affecting the bladder) twice a day by mouth was discontinued on [DATE]. During an observation on [DATE] at 10:12 a.m., with Licensed Vocational Nurse (LVN ) 7, of the Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances {CS}) drawer of Medication Cart 2 there were two medication bubble packs (medication cards that contain individual doses sealed in clear plastic bubbles with a foil backing), each with 5 doses of Cipro 500 mg. During a concurrent interview and record of Physician Order Record on [DATE] at 10:10 a.m. with LVN 7, LVN 7 stated there was an order for Cipro to be discontinued on [DATE]. LVN 7 stated that when a non-controlled medication order is discontinued, the standard practice is for nursing staff to place the discontinued medication in the medication room in the designated container, and if not used at all to return to the pharmacy. LVN 7 stated it is important to follow the facility policy of removing discontinued medications from the CM drawer to prevent medication error. LVN 7 stated the CM drawer was designed the storage of controlled medications, however, discontinued medications were also in the drawer. During a concurrent interview and review record of the Physician Order Report on [DATE] at 10:23 a.m. with the Director of Nursing (DON), the DON stated based on their facility policy, when a non-controlled medication is discontinued the medication should be removed from the medication cart and placed in a secured medication room in the designated containers for disposition (facility's process for properly handling, removing, storing, returning, or destroying medications that are discontinued, expired, unused, or no longer required for the resident). The DON stated discounted medications should not be placed in the CM drawer to prevent medication error. 2. During a concurrent observation and interview on [DATE] at 10:48 am with Registered Nurse Supervisor (RN) 2 in Medication Storage Room C, a 36-count box of lozenges (medicated tablet designed to dissolve slowly in the mouth, providing temporary relief for sore throats, minor mouth irritations, and cough suppression) was stored without a label indicating a resident's name or expiration date. RN 2 stated the medication box did not have an expiration date or the resident's name indicated. During an interview on [DATE] at 1:45 pm with the Pharmacist (Pharm), the Pharm stated the box of lozenges was not provided by the pharmacy and was an over-the-counter box of lozenge provided by a resident's family and the manufacturer did not provide an expiration date for the lozenges. During an interview on [DATE] at 1:50 pm with RN 2, RN 2 stated over-the-counter lozenges should have had the resident's name written on the box because without a name, licensed nurses would not know who the lozenges belonged to. During an interview on [DATE] at 2:00 pm with the Director of Nursing (DON), the DON stated all medications in the medication storage rooms should be labeled. The DON further stated it is important to label resident's own medications and over the counter medications with the resident's name and room number to ensure accurate identification, prevent administration to the wrong resident, and avoid causing distress to the resident. During a review of facility's policy and procedure (P&P) titled, Disposition of Controlled and Non-Controlled Medication, revised on [DATE], the P&P indicated when a non-controlled medication is discontinued or expired the medication shall be removed from the medication cart and placed in a secured medication room in the designated containers for disposition. The licensed nurse shall complete the Medication Disposition log. During a review of the facility's (P&P) titled, Medication Labeling, revised 08/ 2019, the P&P indicated, resident's own over-the-counter medications should be labeled with resident's name and room number.

Based on observation, interview, and record review, the facility failed to safeguard resident confidentiality and privacy when a medication cart computer screen was left open and unattended on one of five medication carts (Medication Cart 3). This deficient practice had the potential to result in unauthorized disclosure of residents' personal information. Findings: During an observation on 3/9/2026 at 9:19 a.m. in between the nursing station and main dining room on the second floor of the facility, observed Team B medication cart unattended with the computer screen open to a resident's electronic Medication Administration Record (eMAR - a digital system to track and manage medication administration for resident). Registered Nurse (RN) 6 was observed calling out a name while approaching the medication cart, took steps to remove the eMAR from view on the screen and walked away from the medication cart. During an interview on 3/9/2026 at 922 a.m. with Registered Nurse (RN) 6, RN 6 stated she observed that the computer screen was left open displaying resident information and minimized the window screen (hide the screen) because of Health Insurance Portability and Accountability Act (HIPPA - US federal law designed to protect sensitive patient health information from disclosure without consent). RN 6 stated leaving the window open leaves residents' information to be seen by others. RN 6 stated she left the medication cart after minimizing the window screen to let the charge nurse know of the incident. During an interview on 3/9/2026 at 9:30 a.m. with Licensed Vocational Nurse (RN) 8, LVN 8 stated RN 6 informed her right away of her mistake of leaving the medication cart computer screen open. LVN 8 stated she should not have left the screen open displaying resident information because of HIPPA. LVN 8 stated that leaving the screen open had the potential for residents' personal information to be exposed and their privacy unprotected. During an interview on 3/12/2026 at 10:05 a.m. with the Director of Nursing (DON), the DON stated leaving a computer screen open to resident's medical record is a HIPPA concern. The DON stated leaving a computer screen open to a resident's medical record compromises privacy and confidentiality. During a review of the facility's policy and procedure (P&P) titled, Medication Administration last reviewed 4/16/2026, the P&P indicated, The MAR should be closed or covered when not attended to protect resident/patient confidentiality. During a review of the facility's P&P titled, Patient Protected Health Information last reviewed 4/16/2026, the P&P indicated, It is the policy of Los Angeles Jewish Health (LAJH) that all LAJH employees take every reasonable precaution in order to assure that patient protected information (PHI) is secure and will not be open to unwarranted exposure.LAJH employees using electronic devices will not leave them open for viewing and unattended should they be temporarily distracted by another duty. They will close the document and sign out of the software program. Screens should not be left open and unattended.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse, after a certified nurse assistant (CNA 1) kicked Resident 1 in the shin and attempted to punch him in the face. This failure had the potential to cause Resident 1 mental distress and anxiety due to the abuse. This failure resulted in a small purple discoloration to Resident 1's left shin. Findings: A review of Resident 1's Face Sheet (admission record), dated 9/29/20, indicated the facility admitted Resident 1 to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History & Physical (H&P), dated 10/6/20, indicated that the resident also has anxiety (excessive worrying or fear that interferes with daily life) and depression disorder (a mood disorder that causes feeling sadness or loss of interest in activities that interferes with daily life). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/9/20, indicated a Brief Interview for Mental Status (used to assess cognitive status in the elderly) score of nine, indicating moderate cognitive impairment (having a hard time remembering things, making decisions, concentrating, or learning). Resident 1 required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's care plan, dated 10/8/20, indicated Resident 1 had behavioral symptoms of striking out, punching, kicking towards staff during ADL (activities of daily living) care. The goal was to resolve Resident 1's aggression and prevent injury to the resident and the staff. An approach implemented to attain the care plan's goal was to give care at a later time when calm, if agitated. A review of Resident 1's Progress Notes, dated 11/19/20, indicated, Resident (1) was physically combative with his CNAs this morning when they attempted to assist him to the bathroom. A review of Resident 1's Progress Notes, dated 11/19/20, indicated Resident 1 had a small purple discoloration on the left shin. During an interview on 11/25/20, at 12:37 p.m., with CNA 2, CNA 2 stated, When I came to work on November 19, the CNA asked me for help. I went to help her because the resident is combative . (Resident 1) started to kick. I said that maybe we need to stop. (CNA 1) said no, let's do it. He kicked again, I moved fast to go between them, and she kicked him. I told her, 'You need to relax.' She did punch him and kick him. He moved his face, so the fist went past and hit him on the shoulder, but she did hit him on the leg. I went fast to my supervisor, I can't be quiet about those things. I reported it immediately. During a telephone interview on 12/7/20, at 7:28 a.m., with CNA 3, CNA 3 stated, There were 4 of us helping the resident that morning: me, (CNA 1), (CNA 2), and (CNA 4). Then (Resident 1) hit (CNA 1) on the face, but then she was angry, and she hit him. I saw she punched him on his face. During a telephone interview on 12/8/20, at 4:10 p.m., with CNA 4, CNA 4 stated, In the morning, (CNA 1) asked me for help. She said, 'Can you please help me with this resident because he's a very fighting resident?' I went to the room with other people, a total of 4 people with this resident. The resident started fighting . He was moving so fast, and when I saw (Resident 1) kick (CNA 1)'s face, (CNA 1) got so upset. She started hitting him. I put myself in front of her, I said, 'Don't do that. This is bad. Don't do that. He doesn't know what he's doing.' She was very upset, she tried to go to the other side and start kicking him. She gave a really hard kick to him . She was very mad. She slapped him, and (CNA 2) left the room and said, 'I'm going to report you.' During a telephone interview on 12/4/20, at 2:05 p.m., with the Registered Nurse (RN) Unit Manager, the RN Unit Manager stated, (CNA 1) started to tell me, 'I wanted to help him to the bathroom, he hit me, and I lost it and I kicked him. I know I lost it and I shouldn't have done that.' The RN Supervisor further stated that she assessed and interviewed the resident after speaking to CNA 1. Resident 1 stated to her that CNA 1 had kicked him earlier in the morning. The RN Unit Manager stated, I said, 'Where did she kick you?' He showed me on this leg, there was a little ecchymotic (Blood or bleeding under the skin due to trauma of any kind; typically black and blue at first, with color changes as healing progresses) area. I checked both legs and I checked his arms and face and there was no other evidence of any other injury and he denied pain from that incident. During a concurrent interview on 11/25/20, at 11:40 a.m., with the Administrator and Director of Nursing (DON), the Administrator and DON stated CNA 1 was suspended pending further investigation the morning of the incident, and then her employment was terminated the next day. During an interview on 12/21/20, at 8:11 a.m., with the Administrator, when asked if the staff followed the resident's care plan to provide care when he was calm, the Administrator stated, The care plan was followed by the staff until the point where he hit the CNA and then she, in my interpretation, had basic human instinct to protect herself and she reacted. Up to the point she reacted, the care plan was followed. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Reporting, revised January 2017, the P&P indicated that the purpose is to ensure that resident rights are protected from abuse, neglect, misappropriation of property, exploitation, and crime, and proper reporting processes are followed.

Based on observation, interview, and record review, the facility failed to: 1. Provide adequate supervision for two of two sampled residents (Resident 1 and 2), while they sat, alone and unsupervised, in the dining room. 2. Implement Resident 1's care plan by failing to provide a grabber (a device that extends a patients reach, relieving the need for a patient to bend over to pick up something dropped) while Resident 1 was in the dining room. The new intervention was developed after Resident 1's fall on 6/24/19. The facility's failure to provide adequate supervision and a grabber resulted in a fall for Resident 1, on 6/27/19, as Resident 1 bent over to pick something off the floor causing Resident 1 to fall off the wheel chair. Resident 1 sustained a [MEDICAL CONDITION] hip that required surgical repair. The facility's failure to provide adequate supervision had the potential to result in a fall or injury for Resident 2. Findings: On 7/10/19, an unannounced visit was conducted at the facility to investigate a facility-reported incident (FRI) regarding Resident 1's fall that occurred on 6/27/19, at 6:50 AM. 1. On 7/10/19, at 7:45 AM, during a concurrent observation and interview, Resident 1 was observed in the main dining room on the second floor. Resident 1 was awake and alert. Resident 1 was sitting on the wheelchair with a seat cushion and the foot rest in place. Resident 1 was not observed with a grabber at this time. Resident 1 was asked how he broke his left hip. Resident 1 stated he bent over too far and fell off the wheelchair, in the dining room. Resident 1 stated nobody was in the dining room when he fell and does not remember how long it took for somebody to find him. Resident 1 stated he broke his hip and had surgery. On 7/10/19, at 8:25 PM, during an interview, the director of nursing (DON) stated Resident 1 had a history of [REDACTED]. The DON learned about Resident 1's fall on 6/27/19, at 7:15 AM. The DON stated he assessed Resident 1 and investigated Resident 1's fall. The DON stated Resident 1 bent over to pick something up off the floor, although, nothing was on the floor. The DON stated that Resident 1 complained of pain to the left hip, an x-ray was taken which confirmed Resident 1 fractured the left hip. The DON stated Resident 1 was taken to an acute care hospital for surgical repair of the left hip. The DON stated nobody was in the dining room during the fall. The DON stated the certified nurse assistant (CNA 2),who was supervising the dining room, was pulled to help out with another resident who was very agitated. The DON stated the facility's practice was to have a staff member in the dining room, when residents were present, for the safety of the residents. The DON stated a staff member should have been there. The DON stated there needed to be a back up plan if the CNA gets pulled from the dining room. On 7/10/19 at 3:57 PM, during a telephone interview, CNA 1 stated she took care of Resident 1 on 6/27/19, the day of the fall. CNA 1 stated Resident 1 was alert, oriented, and had a history of [REDACTED]. CNA 1 stated that on 6/27/19, at 6:40 AM, she took Resident 1 to the dining room, and left him sitting on the wheelchair. CNA 1 stated there was a CNA (CNA 2) monitoring the dining room at that time. CNA 1 stated she went to the nearby nursing station to give report to the oncoming CN[NAME] CNA 1 stated that at 6:43 AM, she observed Resident 1 in the dining room, and he was okay. CNA 1 stated that the CNA 2, who was monitoring the dining room, left the dining room for two minutes. CNA 1 stated that at 6:45 AM, another resident yelled for help, so CNA 1 came back to the dining room and found Resident 1 on the floor. CNA 1 stated there was no CNA in the dining room when she found Resident 1 on the floor. CNA 1 stated she contacted the charge nurse. CNA 1 stated Resident 1 denied any pain initially, but complained of hip pain at 7:15 AM. On 7/30/19, at 9:30 AM, during a telephone conference, the administrator stated that Resident 1 had previously fallen on 6/26/19 while trying to pick up his phone charger from the floor and had been provided a grabber on 6/27/19. The administrator stated that on 6/27/19 Resident 1 had been placed in the dining room with his phone, and devices, and non-skid pad, and had everything he needed. The administrator stated Resident 1 had not been provided with the grabber, stating it was only for his room. A review of Resident 1's medical record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], following a hospitalization for surgical repair of a fractured left hip that was the result of a fall experienced on 6/27/19. Resident 1's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/18/19, indicated Resident 1 was interviewable. Resident 1 required extensive assistance with transfer and walking. A review of a document titled, Fall Risk Predictive Factors Assessment, dated 5/20/19, indicated Resident 1 was at high risk for falls. A review of Resident 1's care plan titled, initiated on 8/6/16, indicated Resident 1 was at risk for falls/injuries related to a history of falls prior to admission, and conditions including, ataxia (impaired coordination causing abnormal gait), muscle weakness, [MEDICAL CONDITION], impaired gait and balance, and [MEDICAL CONDITION]. Interventions included, use of a non-skid mat on the wheelchair cushion, use of foot rest while being pushing in the wheelchair, no foot rest while resident self-propels in the wheelchair, resident education to ask for help, and observation of the resident during ADLs (activities of daily living) care, activities, meals, medication pass, mobility, and hydration. On 6/26/19, new interventions were added to the care plan, after the fall that occured on 6/24/19. The interviews were for the CNA to charge IPOD when not in use, to provide a grabber, and to provide a hook to hang the charger. A review of Resident 1's nurse's note, dated 6/24/19, at 6:03 AM, indicated that nursing went to Resident 1's room and found Resident 1 lying on the right side, at the bottom of the bed. Resident 1 was alert and oriented. The call light was not on. Resident 1 stated he was plugging the computer to the outlet, lost his balance along the way. Vital signs were done and x-ray of righr shoulder was ordered. Started nuerocheck. Inform family in AM. A review of Resident 1's nurse's note, dated 6/27/19, at 6:50 AM, indicated a call was received about a resident found laying on the floor, near his wheelchair, in the dining room. Resident was alert and oriented to name and situation but forgetful at times. Resident 1 stated he was trying to pick something up from the floor, then he slid off the wheelchair, landing on his left side. Resident 1 was assessed, there were no signs of injury. Resident 1 denied any pain. Resident 1 was in no apparent distress at the time. Resident 1 stated he did not break anything and felt ok. A review of Resident 1's nurse's note, dated 6/27/19, at 7:15 AM, indicated report was received by night shift nurse regarding Resident 1's fall. Resident 1 was assessed and asked if he had any pain. Resident 1 stated he had pain to the left hip. Resident 1 stated he was just bending down to pick-up stuff on the floor and slide off the wheelchair. Resident 1 was informed that the physician had ordered an immediate (STAT) x-ray of the left hip and a technician would come by to do the x-ray. A review of Resident 1's nurse's note, dated 6/27/19, at 11:45 AM, indicated that the diagnostic x-ray technician was at the bedside, and the x-ray showed possible dislocation or fracture. Resident 1 was assessed in bed, noted with shortening of the left leg and Resident 1 complained of 10/10 pain. At 11:30 AM, the physician ordered to transfer Resident via 911 to an acute care hospital. At 11:45 AM, Resident 1 was transferred to an outside acute care hospital. At 11:55 AM, received result of x-ray of left hip with acute intertrochanteric fracture. A review of Resident 1's radiology results, date of service 6/27/19, indicated Resident 1 had a x-ray of the hip. The findings indicated there was an acute intertrochanteric (between the bony protrusions of the thighbone, where the thigh and hip attach) fracture. A review of discharge summary from the acute care hospital, dated 6/30/19, indicated Resident 1 presented with a left [MEDICAL CONDITION], underwent surgical intervention, and was stable postoperatively. Plan for discharge back to facility with outpatient follow-up within two weeks. Resident was agreeable for discharge at present time. Discharge [DIAGNOSES REDACTED]. 2. On 7/10/19, at 7:37 AM, during a concurrent observation and interview, accompanied by the administrative assistant (ADM Asst), Resident 2 was observed in the second floor dining room labeled as the Bistro. Resident 2 was observed sitting at the table, on a wheelchair. No other staff members or residents were observed in the dining room. Resident 2 was awake and alert. Resident 2 stated she did not know where the staff members were. A review of Resident 2's medical record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was not interviewable. Resident 2 required extensive assistance with ADLs. A review of a document titled, Fall Risk Predictive Factors Assessment, dated 7/2/19, indicated Resident 2 was at high risk for falls. A review of Resident 2's care plan titled, Falls Management, initiated on 4/12/19, indicated Resident 2 had conditions including, a history of falls, poor safety awareness, impaired cognition and dementia (a general term for decline in mental ability severe enough to interfere with daily life). A review of the facility's policy and procedure titled, Fall Reduction/Prevention Program, revised date 3/2019, indicated the purpose of the policy is to provide an environment that is free from accidental hazards, to provide supervision and assistive to each resident through a program of continuous rounds by all staff members in an effort to anticipate the needs of the resident by utilizing the 5 P's (positioning for comfort, personal needs, pain, location of personal items, and proper sleep), as well as assessment, risk identification and application of interventions. The inter-disciplinary team (IDT) will determine the type and frequency of supervision and assistive devices, and this will be included in the care plan and communicated to the rest of the relevant staff.

Based on observation, interview, and record review, the facility failed provide supervision to prevent accidents for two of three residents (Resident 110 and Resident 4) who had a history of falls or were at risk for falls by: 1. Failing to develop and implement a care plan to address the falls, not initiated a fall care plan within 48 hours of admission on 8/24/18, but initiated later on 9/13/18, after Resident 110's first fall (which was 9/11/18). 2. Failing to implement facility's policy and procedure titled, Fall Reduction/Prevention Program, for the pharmacist to review Resident 110's medications that may increase fall risk and can lead to injuries. 3. Failing to ensure Resident 110 who was identified as not using her call light and goes to the bathroom by herself, had an alternative plan of care to include how the staff would be alerted when the resident was attempting to go to the bathroom, in order to provide the required one person physical assistance with toileting. 4. Failing to follow the Minimum Data Set (MDS, a standardized assessment and care-screening tool) to provide Resident 4 with two- person physical support during transfer. These deficient practices resulted in Resident 110 having five-fall incidents from 9/11/18 to 1/7/19, including a fall with fracture on 9/18/18. Resident 110 was transferred to a General Acute Care Hospital (GACH) on 9/18/18, for angulated (displaced) right proximal humeral shaft (upper arm) fracture (break in the bone) and returned to the facility with a right arm sling. This deficient practice resulted in a distal left femur (thighbone) fracture for Resident 4. Findings: a. A review of Resident 110's admission record indicated the resident was admitted to the facility on [DATE]. Resident 110 diagnoses included visual hallucinations (seeing people or things that are not actually present), anxiety disorder (feelings of uneasiness), unspecified neuropathic pain (or nerve pain, is one of the most intense types of chronic pain, often described as sharp, stinging, or burning), chronic obstructive pulmonary disease ([CONDITION(S)], a type of obstructive lung disease characterized by long-term breathing problems and poor airflow), and stroke. A review of Resident 110's History and Physical, dated August 24, 2018, indicated resident had history of falls, unsteadiness of feet, and [CONDITION(S)] (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). A review of Resident 110's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated September 2, 2018, indicated the resident had intact cognitive skills (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision-making. The MDS indicated the resident required one-person extensive assistance for locomotion in a wheelchair, walking in room and corridor did not occur at the assessment time. Moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer (transfer between bed and chair or wheelchair) were assessed as not steady, and was only able to stabilize with staff assistance. A review of Resident 110's Fall Risk Predictive Factors Admission Assessment, dated August 24, 2018, indicated the resident had a score of 16. If the total score is 10 or greater, the resident may be considered high risk for potential falls. The document indicated there were 1-2 falls in the past 3 months before admission to the facility. The document indicated Resident 110 takes 3-4 of these types of medications in the last 7 days: Antihypertensive (medication to keep blood pressure normal), benzodiazepines (a class of drugs that act as tranquilizers and can cause drowsiness, used to treat anxiety), narcotics (strong pain medication), and [CONDITION(S)] (any drug capable of affecting the mind, emotions, and behavior). A review of Resident 110's Physician Orders included the following: 1. [MEDICATION(S)] (a benzodiazepine, -used to treat anxiety) 1 milligram (mg) as needed (PRN) every 2 hours (Q2H) for severe anxiety manifested by (M/B) agitation leading to hyperventilation (a condition in which you start to breathe very fast), ordered on 8/24/18 and was discontinued on 9/28/18. - [MEDICATION(S)] 0.5 mg PRN every two hours for anxiety M/B agitation leading to shortness of breath, ordered 8/24/18 and was discontinued on 9/4/18. - [MEDICATION(S)] 0.5 mg PRN every two hours for anxiety M/B hyperventilation, ordered 9/28/18 and was discontinued on 2/1/19. - [MEDICATION(S)] 0.5 mg PRN every two hours for anxiety M/B hyperventilation, ordered on 2/1/19 and will continue to 8/1/19. 2. [MEDICATION(S)] (a narcotic pain medication combination of [MEDICATION(S)] 10 mg/acetaminophen 325 mg) one tablet for moderate pain (pain scale 4-6/10 moderate pain (on a pain scale of zero being no pain, and 10 being the worst pain possible) every 4 hours (Q4H) PRN ordered on 8/24/18 and was discontinued on 12/5/18. - [MEDICATION(S)] 10/325 mg 2 tablets for severe pain (pain scale 7-10/10) Q4H PRN ordered on 8/24/18 and was discontinued on 10/2/18. - [MEDICATION(S)] 10/325 mg three times a day (TID) for severe generalized pain ordered on 9/2/18 and was discontinued on 10/4/18. - [MEDICATION(S)] 5/325 mg one tablet four times a day (QID) for general pain or shortness of breath ordered on 10/3/18 and was discontinued on 12/27/18. - [MEDICATION(S)] 10/325 mg one tablet for moderate pain (pain scale 4-6/10) Q4H PRN ordered on 12/5/18 and was discontinued on 1/9/19. - [MEDICATION(S)] 5/325 mg one tablet for generalized pain or shortness of breath PRN Q4H ordered on 1/9/19. 3. [MEDICATION(S)] (a narcotic pain medication) 20 mg by mouth (PO) Q12H for shortness of breath ordered on 12/27/18 and was discontinued on 1/3/19 - [MEDICATION(S)] 20 mg PO Q12H ordered on 1/3/19 and was discontinued on 1/7/19. 4. [MEDICATION(S)] (a benzodiazepine, used to treat panic attacks) 0.5 mg twice a day for anxiety related to shortness of breath ordered on 9/6/18 and was discontinued on 9/11/18. - [MEDICATION(S)] 1 mg twice a day p.o. for anxiety related to shortness of breath ordered on 9/11/18. 5. [MEDICATION(S)] (an antipsychotic, used to treat certain mental/mood conditions) 50 mg at bedtime for visual hallucinations (when you see things that are not there), psychotic features manifested by agitation leading to screaming, ordered 8/24/18 through 8/31/18. -[MEDICATION(S)] 25 mg at bedtime for visual hallucinations, psychotic features manifested by agitation leading to screaming ordered 9/1/18 through 9/17/18. On February 7, 2019 at 10:07 a.m. during an interview and concurrent review of the Falls Risk Predictive Factors dated August 24, 2018, with the licensed vocational nurse (MDS 2), she stated Resident 110 was identified as a high risk for fall upon admission on 8/24/18. MDS 2 stated the fall prevention care plan should have been done but was not. A review of Resident 110's Falls Risk Predictive Factors, indicated the resident's fall risk had increased from August 24, 2018, when the resident's score was 16, to September 11, 2018, when the resident's score was 19. A review of Resident 110's medical record revealed the resident had five-fall incidents within four months from September 11, to January 7, 2019, as follows: 1. On September 11, 2018, at 3:40 p.m., (first fall) the Situation-Background-Assessment-Recommendation (SBAR, technique provides a framework for communication between members of the health care team about a resident's condition) completed the day the resident fell , indicated a registered nurse (RN) was called to the room for a fall. Resident 110 was sitting on the floor, her body leaning on the side of the bed, her right leg in flexed position and the left leg in straight position facing the door. The resident is alert/oriented, and was asked what she was trying to do and Resident 110 stated, I sat on the edge of the bed trying to reach the paper that was on my front wheeled walker but I slid to the floor because the mattress cover is slippery. There was no injury. A review of Resident 110's Falls Care Plan initiated on September 13, 2018, indicated the resident was at risk for falls/injuries related to weakness, heart condition, on hospice care (supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure), using pain medications, [CONDITION(S)] medications, requires assistance with activities of daily living (ADLs), hypertension (high blood pressure), [CONDITION(S)], [CONDITION(S)] (irregular heartbeat), stroke, anxiety disorder, [CONDITION(S)], advanced age, and episodes of getting out of bed unattended. The care plan goal indicated any injuries related to fall will be identified and intervened appropriately. The interventions included neurological check (when nursing assess a resident for any neurological problems such as level of consciousness, motor, and sensory functions) for 72 hours, to discontinue LAL (low air loss) mattress per resident's request because it is slippery and uncomfortable, and to assist as needed with ADLs. A review of Resident 110's Falls Risk Predictive Factors, dated September 11, 2018, indicated a score of 19. On September 11, 2018, Resident 110's [MEDICATION(S)] 0.5 mg twice a day was increased to 1 mg twice a day for anxiety. 2. On September 18, 2018 at 4:20 a.m., (second fall), the day of the second fall, the Nursing Progress Note indicated the RN (RN 5) was called at 4 a.m., to resident's room. Resident 110 was lying in bed in severe pain 10/10, pointing over her right shoulder, right upper arm is swollen and internally rotated (referring to rotation towards the center of the body). The note indicated the resident had a weak handgrip on right hand compared to left hand and has skin tear over right upper arm measured 3 centimeters (cm- a unit of measure) by 2 cm, right upper inner forearm measured 3 cm by 1 cm right inner mid forearm and skin scratch on left elbow. The resident is alert, and oriented, verbally responsive, and answer questions appropriately. She stated she went by herself to the bathroom, on her way out from the bathroom she felt dizzy, and lost her balance. A review of Resident 110's right shoulder x-ray report dated 9/18/18 at 9:31 a.m., indicated there was angulated (displaced) right proximal humeral shaft (upper arm) fracture (break). The resident was transferred to GACH and return to the facility with a right arm sling. A review of Resident 110's Falls Care Plan initiated on 9/13/18 and updated on 9/18/18, the intervention included bed side commode, educated resident to ask for help when want to go to the toilet, increased help with ADLs, assist with transfer - one-person assistance, maintain safe environment free from clutter, adequate lighting, remove or identify safety hazards. A review of Resident 110's Hospice Social Worker Note on September 20, 2018, at 3:53 p.m., indicated the social worker (SW) had a discussion with the resident and one of Resident 110's licensed vocational nurses (LVN) about pain medications, and the timing. The Hospice Social Worker Note indicated the LVN is concerned that Resident 110's medications are sedating and it interferes with her meals. If the medication timing is changed according to the suggestion, then Resident 110 may not be sedated at meal times, but leaves the possibility of being sedated at another time. (The resident was administered [MEDICATION(S)] 10/325 mg three times a day from 9/2/18, to 10/4/18, for severe generalized pain, [MEDICATION(S)] can have side effects including sedation). A review of Resident 110's Nursing Progress Note, dated September 21, 2018, at 11:59 a.m., indicated during Hospice Registered Nurse (HRN 1) visit, the LVN told her Resident 110's level of consciousness was altered and decreased and she had a dazed look but still managed to ask for [MEDICATION(S)]. When the Hospice Registered Nurse went to Resident 110's room, Resident 110 was very lethargic (sluggish) and speech was unintelligible due to lethargy. The note indicated throughout the next hour Resident 110 became more awake and her speech clearer, but was initially confused. A review of Resident 110's Nursing Progress Note, dated September 25, 2018, at 2:26 p.m., indicated HRN 1's routine visit. Resident 110 was up in a wheelchair by nursing station, lethargic, eyes closed, and head leaning to the right. 3. On September 26, 2018, at 9:50 p.m., (third fall) the SBAR indicated Registered Nurse 6 (RN 6) was called to go to the room of the resident for a fall. Resident 110 was in bathroom floor in lying position in between the door and toilet bowl, her both legs facing the bathroom door. Resident 110 is alert and speech is coherent. Resident 110 stated, I walked to the bathroom but was outbalanced and I fell . Resident 110 stated, I fell in sitting position on the floor then I crawled to stand up holding the bar but I cannot make it. The note indicated skin tear to left elbow measured 2 cm by 2 cm with minimal bleeding. No injury. Resident was wearing socks that had no grips at the time of fall. A review of Resident 110's Falls Care Plan initiated 9/13/18 and updated on 9/27/18, indicated a goal of any injuries related to fall will be identified and intervened appropriately. The interventions included offer Resident 110 to use the bathroom or commode around 9:30 p.m., Interdisciplinary Team (IDT, when different disciplines meet to address resident's problem) met and recommended medication regimen review (MRR) by pharmacist, hospice to review medications that may be related to hallucination, remove socks at night, and encouraged to use call light when in need. The care plan did not indicate when the MRR would be done by the pharmacist and or specify the medication to review or the reason for the review. A review of Resident 110's Nursing Progress Note, dated September 27, 2018, at 2:42 p.m. indicated: Monitoring for safety. Resident 110 was found in the bathroom in lying position, gets lethargic after taking her medications after breakfast and lunch, but then comes out of it after like an hour. A review of Resident 110's Nursing Progress Note, dated September 28, 2018, at 2:12 p.m., indicated Resident 110 issue with drowsiness and falls. Has [MEDICATION(S)] 1 mg BID. Received [MEDICATION(S)] at 9 a.m. Takes routine Oxymoron three times daily. Resident 110 asked for her PRN [MEDICATION(S)] which is 1 mg q2h PRN at 10 a.m. She received a breathing treatment instead in an attempt to avoid resident becoming sedated and risk of fall. Breathing treatment was effective for relieving resident's shortness of breath. Resident did not ask for [MEDICATION(S)] again until 1:15 p.m. 4. On October 6, 2018, at 4:30 p.m., (fourth fall) the SBAR indicated the RN when to resident's room; the resident's family member stated her mother slipped from wheelchair to the floor in sitting position in front of us. I asked what she was trying to do and she said she was reaching for the garbage can to throw something but she slipped. No injury. A review of Resident 110's Falls Care Plan initiated September 13, 2018, updated on October 8, 2018, the interventions included automatic wheel chair break, non-skid mat above the wheelchair cushion. A review of Resident 110's Nursing Progress Note, dated October 7, 2018 at 7:21 a.m., indicated still noted resident trying to get out of bed. Safety measure put into effect explained to resident to use call light at all times. However, there was no indication of Resident 110's response to that instruction. A review of Resident 110's Hospice Nursing Progress Note, dated October 9, 2018, at 2 p.m., indicated Resident 110 seemed sleepy during the visit. 5. On January 7, 2019 at 3:04 p.m., (fifth fall) the Nursing Progress Note, indicated staff told the RN that Resident 110 was on the floor in her room. The note indicated Resident 110 stated she had to go to the bathroom and was feeling strong and thought she could get herself to the bathroom, but upon getting up from bed realized that even though she had no increase in shortness of breath, she was too weak to make it to bathroom and so she sat down where she was and would just have to go in her pants. No skin injury noted. A review of Resident 110's Falls Care Plan initiated September 13, 2018, updated January 10, 2019; the intervention included discontinued routine [MEDICATION(S)], MRR, and monitor resident frequently when there is a change of shift. A review of Resident 110's care plans dated 8/24/18 through 1/10/19, did not address the resident's sedation, lethargy or drowsiness, as recorded in the progress notes of 9/20/18, 9/21/18, 9/25/18, 9/27/18, 9/28/18, or the use of [MEDICATION(S)] and [MEDICATION(S)] (benzodiazepines) and opioids ([MEDICATION(S)]- a narcotic), that may result in profound sedation to decrease the chance for additional falls. On February 6, 2019 at 4 p.m., during and observation and concurrent interview with Resident 110, the resident could not recall falling in the facility, but only at home. A review of Resident 110's Physician Progress Note dated October 1, 2018 at 10:52 a.m. by primary care physician indicated: Nursing called re: pharmacy's recommendation to stop [MEDICATION(S)] and go back to [MEDICATION(S)]. Asked nursing to contact hospice regarding this recommendation. Resident 110 has been on [MEDICATION(S)] 1 mg twice daily since September 11, 2018, and continues to take this medication. A request for Resident 110's Medication Regimen Review by the facility's pharmacist for this period was requested, facility did not provide a copy as requested for review. A review of Resident 110's Medication Administration Record indicated the resident received the following medications: - From 8/24/18 through 9/30/18, the resident received [MEDICATION(S)] 1 mg 43 times and [MEDICATION(S)] 0.5 mg 15 times. - From 8/24/18 through 12/5/18, the resident received [MEDICATION(S)] PRN 12 times and [MEDICATION(S)] 10/325 mg three time a day for severe generalized pain. - From 9/6/18 through 9/11/18, the resident received [MEDICATION(S)] 0.5 mg twice a day, and from 9/11/18 to 2/15/19, at the time of survey, the resident received [MEDICATION(S)] 1 mg twice a day. - From 9/1/18 through 9/17/18, the resident received [MEDICATION(S)] 25 mg at bedtime and [MEDICATION(S)] 12.5 mg at bedtime from 9/17/18 to 2/15/19, at the time of survey. During an interview on February 11, 2019, at 9:14 a.m. with Registered Nurse 5 (RN 5) who worked during the 11 p.m. to 7 a.m. night shift on September 18, 2018, she stated Resident 110 went to the bathroom at night, without using the call light. RN 5 stated Resident 110 is very forgetful, but is alert, and oriented to name, and place. On February 7, 2019, at 9:30 a.m., during an interview with the Director of Nurses (DON) the DON stated he was unable to locate the investigative report for Resident 110's fall with fracture that occurred on September 18, 2018. On February 11, 2019 at 9:42 a.m., during a phone interview with Certified Nursing Assistant 4 (CNA 4) she stated she had provided care to Resident 110 during the 11 p.m. to 7 a.m. shift on September 18, 2018 (second fall). CNA 4 stated she was on break that night approximately 3 a.m., and told her co-worker she was going to lunch. CNA 4 stated that Resident 110 was alert and oriented and does not use the call light when she needs help. On February 11, 2019, at 4:01 p.m., during an interview with the DON when asked if Resident 110 had surgery after the arm fracture, on September 18, 2018, he stated, the resident did not but wore an arm sling. When asked why Resident 110 takes two medications for anxiety ([MEDICATION(S)] and [MEDICATION(S)]), he stated, the resident is on hospice care (care for people facing a life-limiting illness or injury, hospice care involves a team-oriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient's needs and wishes). The DON stated the physician was called on September 26, 2018, because Resident 110 was hallucinating (perception of something not present). A review of the Boxed Warning (a boxed warning is the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects) for [MEDICATION(S)] and [MEDICATION(S)] indicate that concomitant use of benzodiazepines and opioids (also known as narcotic) may result in profound sedation (the reduction of irritability or agitation), respiratory depression (a decline in the ability of a person to breathe), coma (a state of unconsciousness in which a person cannot be awakened), and death. A review of the facility's policy and procedure titled, Fall Reduction/Prevention Program, revised December 2015, indicated pharmacy services will be notified of the admission to review the resident/patient's medications and will notify the nurse of medications that may increase fall risk. The policy indicated pharmacy services will be notified of a fall to screen the resident/patient's medications that may increase fall risk. A pharmacist will communicate the recommendations for any medication adjustment to the Director of Nursing. b. A review of the clinical record indicated Resident 4 was readmitted to the facility on [DATE], with diagnoses including left distal femur (thigh bone) fracture (break in the bone) and cerebellar ataxia (a progressive disorder that affects balance and coordination). A review of the Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate a resident's risk of fall) dated 7/19/18, indicated Resident 4 was considered a high risk potential for falls with a score of 13, and took three to four medications currently and or within the last 7 days, and has 4 to 3 or more predisposing diseases. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/18/18, indicated Resident 4 made self-understood, understood others, and has intact cognitive skills (the core skills the brain uses to think, read, learn, remember, reason, and pay attention). The MDS indicated Resident 4 required extensive assistance from staff for dressing, transferring, toileting, and personal hygiene and required 2 or more persons for physical assistance. A review of the falls management care plan problem start date of 7/13/17, indicated the goal was to reduce severity of fall-related injury. The care plan interventions indicated to use a stand assist lift (a mobile aid intended to be used on a horizontal surface for raising to a standing position and short transfer of residents such as raising from bed and transit to wheelchair, or from wheelchair to toilet) for transferring from 8 p.m., until 7 a.m., for safety. The care plan did not specify the resident required 2 person assistance with transfers, until the plan was updated on 2/8/19. A review of the Resident Care Plan Review Form dated 10/18/18, at 6:28 a.m., indicated Resident 4 was a high risk for falls with history of recent falls, requires assistance with activities daily living (ADLs refers to resident's daily self care activities) needs rehabilitation therapy for a decline in ADLs due to status-post (referring to a state that follows an intervention), fracture of left distal femur fracture (a break of the thigh bone just above the knee). A review of the Post Accident Assessment and Intervention Form (PAAI) dated 10/10/18, at 7:51 a.m., indicated Resident 4 was transferred using the stand assist lift, was observed sitting on the edge of the bed, lost her balance and slid to the floor. The PAAI Form indicated Resident 4 let go of the side rail, when she lost balance and started to lean forward. The PAAI Form indicated the Interdisciplinary Team (IDT, a group of healthcare providers from different fields who work together to provide the best outcome for a resident) determined the root cause of this fall was a balance deficit. The PAAI Form indicated the IDT added interventions to discontinue use of the lift. A review of the Licensed Personnel Progress Notes dated 10/10/18, at 12:30 p.m., indicated Resident 4 was transferred to the general acute care hospital (GACH) for further evaluation and received an x-ray (captures images of the human body for the purposes of diagnosis) which indicated Resident 4 sustained a possible displaced (distal femur fracture. A review of the GACH history and physical (H&P) dated 10/11/18, at 11:30 a.m., indicated Resident 4 received a computed tomography report (CT scan, uses X-rays to make detailed pictures of structures inside the body) confirmed the resident had a fracture. The GACH H&P indicated Resident 4 has a gait and balance disorder and was wheelchair bound. During an interview on 2/5/19, at 8:48 a.m., Resident 4 stated she used to go to the toilet using the stand assist lift. Resident 4 stated after her fall she had no choice but to urinate in her briefs. Resident 4 stated when she came back from the hospital she had a urinary indwelling catheter (A flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage), but was removed and now she is unable to get up to use the toilet. Resident 4 stated she was told she cannot bear weight on her left leg after she fell , and broke her left leg. Resident 4 stated she does not know how many persons were needed to transfer her, but as long as she can remember, there was always one staff transferring her before the fall incident. On 2/5/19, at 1:20 p.m., in an interview, Resident 4 stated she was sitting on the edge of the bed, after going from the toilet to the bed, using the stand assist lift. Resident 4 stated she let go of the bar and the Certified Nursing Assistant (CNA) pulled away the stand assist lift, and then she fell . Resident 4 stated the CNA tried to come around to catch her, but she still fell . During an interview on 2/8/19, at 7:17 a.m., CNA 1 stated she was the CNA assigned to Resident 4 on 10/10/18, when Resident 4 fell . CNA 1 stated she assisted Resident 4 to the bathroom using the stand assist lift and then transferred the resident back to bed. CNA 1 stated Resident 4 usually sits holding the handrail of the bed, but when the resident let go of the handrail, the resident fell forward. CNA 1 stated she tried to hold Resident 4 and assisted the resident to the floor. CNA 1 stated Resident 4's feet were on the floor and the resident fell on her knees. CNA 1 stated she called the supervisor. CNA 1 stated the resident complained of pain of her left leg, then CNA 1 assisted the resident back to bed. CNA 1 stated 2 people were needed to transfer Resident 4 when using the stand assist lift. CNA 1 stated Resident 4 was not able to wait, so she transferred the resident by herself. CNA 1 stated Resident 4 preferred female CNAs and there were no female CNAs available, at that time to assist. During an interview on 2/11/19, at 7:29 a.m., CNA 2 stated she is the regular CNA assigned to care for Resident 4. CNA 2 stated prior to the fall, Resident 4 used the stand assist lift when transferring and toileting, with 2 person support. CNA 2 stated depending on how much the resident drinks, she may have to take the resident 4-5 times to the toilet during her shift. CNA 2 stated after the resident's fall incident, the resident had a urinary catheter. CNA 2 stated the urinary catheter was discontinued, but now the resident uses briefs while in bed. CNA 2 stated after the incident she has not used the stand assist lift for the resident for transferring or toileting. CNA 2 stated Resident 4 always had balance problems, leans forward and should have 2 people (assisting) at all times. During a concurrent interview and record review of Resident 4's clinical record on 2/11/19, at 9:28 a.m., the Minimum Data Set Nurse 1 (MDS 1) confirmed on 7/18/18, and 10/18/18, Resident 4 needed extensive assistance with 2 person (physical) support with toileting and transferring. During a concurrent interview, and record review of Resident 4's Self-Care Deficit Care Plan on 2/11/19 at 9:32 a.m., the MDS 1 confirmed the interventions for stand assist lift use was discontinued on 10/22/18, and was changed to use of a resident transport lift (a mechanical device designed to lift and transport residents safely) on 10/22/18. MDS 1 confirmed the care plan intervention changed to use of a stand assist lift with 2 persons, on 2/8/19. MDS 1 stated the interventions were updated because there was a new physician's order placed on 2/5/19, and the resident's care plan was updated on 2/8/19. During an interview on 2/11/19, at 1:48 p.m., Physical Therapist 1 (PT 1) stated prior to Resident 4's fall incident, the treatment plan included sitting to standing with the Restorative Nursing Aide (RNA) at the rail, and working on balance and trunk control. PT 1 stated there were no prior concerns for the resident's toileting needs. PT 1 stated the resident was using the stand assist lift for transfers to the toilet or the shower chair. PT 1 stated after the fall incident, Resident 4's treatment plan included left leg brace with non-weight bearing (the amount of weight a resident puts on the leg on which surgery has been performed) as tolerated, electrical stimulation on the muscles, isometrics (a type of exercise), recliner chair so the resident can get on the transport lift and remove the immobilizer, for range of motion (the full movement potential of a joint) exercises. PT 1 stated about 6 weeks ago the resident's left knee brace was discontinued and the resident is now is weight bearing as tolerated. PT 1 stated the resident started back with using the stand assist lift. PT 1 stated he had started training the staff with the use of the stand assist lift on all shifts. PT 1 stated Resident 4 was continent of urine and bowel before, and is incorporating urine and bowel training. During an interview on 2/12/19, at 7:47 a.m., the Director of Nursing (DON) stated for Resident 4 the best practice is to have two persons when using the stand assist lift. The DON stated the CNAs have a buddy system in place. A review of the in-service training program titled Ergonomic-Use of Gait Belt/Sara/Hoyer for Safe Ambulation and Transferring dated 7/24/18, indicated the course content included checking resident physical and mental status if any changes reported before transferring or ambulation, getting help if using sara/hoyer lifts before starting, and do not rush. A review of the CNA skills competency log completed date 4/26/18, indicated CNA 1 was oriented when transferring for residents with use of a stand assist lift. A review of the Operator's Instruction Manual for SARA 3000 (a type of stand assist lift) dated 11/2014, indicated that SARA 3000 shall always be handled by a trained caregiver and continuously attending to the resident. A review of the facility's policy and procedure titled Moving or Positioning a Resident effective date 10/2006, indicated that the purpose of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment. The policy indicated with sara lift one person assist should be sufficient. The facility policy did not indicate special considerations for residents who were unsafe to be transferred with one person support, using the stand assist lift, including residents who require two person physical assistance with transfers or who have balance problems.

Based on record review and interviews, the facility failed to implement Resident 1's care plan intervention after the resident had actual fall for one of one resident (Resident 1). On July 19, 2015, Resident, 1 who was identified as having history of multiple falls (two falls), was in a wheelchair, in the dining room, the certified nursing assistant (CNA 5) left Resident 1 to attend to another resident. Resident 1 opened the door in the dining room (D/R), got up from his wheelchair, lost his balance, landed on the floor on his left side, and hit his head on the floor. Resident 1 sustained a laceration (cut) to his left cheek, measuring 3 centimeters (cm) x 0.5 cm, a skin tear on his left hand, and a bump on his left eyebrow. Resident 1 required surgical treatment (five sutures/stitches to his left cheek) at a general acute care hospital. Resident 1's care plan dated May 2, 2015, indicated the resident had actual fall, the falls management included to monitor Resident 1 constantly while on activity. One of the approaches was to increase assistance, and surveillance (monitoring of the behavior and activities), locate the resident near nursing station/staff when out of bed. This deficient practice resulted in Resident 1 falling off the wheelchair, sustaining laceration to his left cheek, skin tear to his left hand, and requiring surgical treatment at the acute care hospital. This deficient practice placed Resident 1 at risk for excessive bleeding of the skin tear, wound infection, and head injury. Findings: The Department received an entity reported incident dated July 21, 2015 indicating on July 19, 2015, at 3:40 p.m., Resident 1 was trying to open the double door in the dining room (D/R) when he got up and landed on the floor. CNA 5 witnessed this incident as she was assisting another resident going out of the D/R. The report indicated Resident 1 sustained left a cheek laceration size 3 x 3 centimeter (cm) and depth 0.5 cm. The physician was notified and Resident 1 was transferred to a general acute care hospital emergency room . Resident 1 returned back to the facility at 7:45 p.m., with 5 sutures on his left cheek. A review of Resident 1 medical records indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nursing Admission Assessment/Licensed Nurse Admitting Notes indicated Resident 1 was alert and oriented x 3 (person, place, and time) with forgetfulness. He was able to transfer with one person assistance and was wheelchair bound. A review of Resident 1's care plan dated April 3, 2015, titled, At high Risk for Falls/Injuries related to depression, transferring self from w/c to chair, and use of psychotropic medications (mood stabilizing drug). The staff's interventions included: observation of the resident during activities, meals, medication pass, mobility/hydration; maintain safe environment free from clutter, adequate lighting, remove or identify safe hazards. A review of Resident 1's Fall Risk Predictive Factors Admission Assessment dated April 3, 2015 indicated a score of 11 (10 or greater, High Risk). The admission Minimum Data Set (MDS- an assessment and care plan tool) dated April 13, 2015, indicated Resident 1 required extensive assistance from the staff for activities of daily living such as transferring, dressing, toileting, and personal hygiene. Resident 1 used a walker and wheelchair (w/c) for mobility. The Care Area Assessment (CAA) dated April 16, 2015, indicated Resident 1 had short term memory loss, forgetful of detailed information, poor insight and judgment. The CAA indicated Resident 1 was at risk for fall/injuries due to advance age, depression (feeling of sadness and loss of interest), new environment, and use of psychotropic medications (medication that alter the chemical level in the brain which impact mood and behavior). The CAA Licensed Nurse Admitting Notes indicated Resident 1 had a behavior of constantly trying to get out of bed. A review of Progress Notes dated April 20, 2015, at 3:54 p.m., indicated Resident 1 was trying to get out of bed and into w/c. The plan was for staff to monitor closely. A Post Accident Assessment and Intervention Risk dated April 21, 2015, at 3:45 p.m., indicated status [REDACTED]. Resident 1's physical limitations included balance deficit, weakness, and functional status. The interventions added to the care plan included resident would be closely monitored and supervised while he was by himself in bed. Resident 1's care plan dated April 21, 2015, indicated the resident had actual fall. The goal was to reduce incidence of falls and severity of fall related injury. The approaches included to: increase assistance and surveillance, locate near station/staff when out of bed; constantly remind resident to use call light when need assistance. A review of the nurses notes dated May 2, 2015, at 8:02 a.m., indicated Resident 1 slipped out of this w/c (wheelchair) onto the D/R floor. Resident 1 was trying to maneuver around the corner of the dining room table to place himself for breakfast when he slipped off the pad (of the wheelchair) and onto the floor. A review of Resident Progress Notes, dated June 8, 2015, at 2:13 p.m., indicated Resident 1 was observed in the D/R sitting on the floor. Resident 1 was trying to transfer himself from w/c to a chair and slipped onto the floor in a sitting position. A review of Resident 1's care plan titled, Falls Management - Actual Fall, dated May 2, 2015, indicated the resident's goals included reducing incidence of fall and severity of fall related injury and constantly remind resident to ask for help during transfer. There was a notation which indicated edit reason- new fall on June 8, 2015. The staff's interventions included: monitoring resident constantly while on activity; to increase assistance, surveillance, and locate near station/staff when out of bed. The quarterly MDS dated [DATE], Section J. 1900 Health Conditions Fall Since Admission indicated Resident 1 had 2 falls and one with injury since admission to the facility. A review of Progress Notes dated July 13, 2015, at 10:51 a.m., indicated this quarter, Resident 1 had an increase in his psychotropic medication for dementia and mood swings due to getting up from bed and w/c. (wheelchair) Getting up from w/c was almost daily. A review of Progress Notes, dated July 19, 2015, at 3:40 p.m., indicated Resident 1 was in the D/R (dining room) watching a movie together with other patients and CNA 5 in attendance. CNA 5 walked over to open the D/R door for another resident who wanted to use the bathroom. (While Staff 5 was with another resident), Resident 1 opened the other D/R door. Resident 1 lost his balance and landed on the floor, on his left side, and his head hit the floor. Resident 1 was assessed with [REDACTED]. He was alert and orientated. A review of a physician's orders [REDACTED]. A review of the Acute Care Hospital Discharge instructions dated July 19, 2015, indicated Resident 1 had been evaluated for the following condition(s): Initial encounters Fall and Facial laceration. A review of Progress Notes, dated July 19, 2015, at 7:45 p.m., indicated Resident 1 returned to the facility. Resident 1 had 5 sutures on his left cheek and 3 steri- strips (adhesive surgical tape) on his left hand. A computed tomography scan (CAT- scan is a series of X-ray images) of the head was performed, and the result showed no hemorrhage (bleeding). A review of the Post Accident Assessment and Intervention dated July 19, 2015 indicated unwitnessed fall, limitation prior to fall (unstable gait and balance deficit), transfer to acute care facility due to laceration, fell in the past 30 days. The contributing factors indicated Resident 1 lost his balance when he stood up from wheelchair. The new interventions added to care plan include:CNA (certified nursing assistant) to closely watch Resident 1 where he was due to tendency to get up unattended; encourage Resident 1 to ask for help; and educate CNA to observe 4 P's (positioning, pain, personal needs, and personal belongings). During an interview on August 20, 2015, at 10:10 a.m., RN 1 stated on April 20, 2015, Resident 1 got up from bed to hide his biography, upon returning to bed lost his balance, held on to the bed, and dropped to the floor. When asked what was the change in care plan intervention after the fall, Staff 1 stated, Teaching was added to monitoring constantly. When asked what does monitoring constantly mean, Staff 1 stated, a certified nursing assistant (CNA) with light duty is assigned to provide 1:1 to Resident 1. When asked if Resident 1 was at high risk for falls, Staff 1 stated, Yes, high risk due to periods of forgetfulness. During an interview on August 20, 2015, at 10:30 a.m., LVN 4 stated she had completed the initial fall risk for Resident 1. Resident 1 was confused and had short term memory problems. LVN 4 reviewed the care plans and stated the staff's interventions included to educate the resident which was not possible for this resident. LVN 4 further stated Resident 1 was confused, had short term memory problems, and always tried to get out of his wheelchair to go to the elevator. During an interview on August 20, 2105, at 10:55 a.m., CNA 5 stated she was assigned to Resident 1 on July 19, 2015. CNA 5 stated Resident 1 was trying to transfer from wheelchair to chair as soon as she turned her back (to assist another resident). Resident 1 has periods of forgetfulness, high risk for fall and the resident is not cooperative. When asked how was she informed of high risk for falls, CNA 5 stated she obtained information on computer, and the report given by the charge nurse during the change of shift. When asked what frequent monitoring means, CNA 5 stated to keep an eye on the resident. CNA 5 further stated she monitors and stays with Resident 1 in the resident's room. During interviews on August 21, 2015, between 9:20 a.m. and 9:40 a.m., LVN 2 stated Resident 1 was wheelchair bound (dependent) and he would switch (transfer) from wheelchair to a chair while in the dining room. LVN 2 stated she was informed that Resident 1 was in the dining room and had slipped from his wheelchair on May 2, 2015. When asked what close visual monitoring means, Staff 2 stated certified nursing assistant (CNA) to stay close (to the resident). LVN 2 stated there was a CNA assigned to Resident 1. RN 3 stated LVN 2 informed her Resident 1 was lying down in the D/R. Resident 1 stated he wanted to get around the table and the resident propelled himself and slipped off pad (wheelchair pad for pressure reducing). RN 3 further stated Resident 1's wheelchair was assessed and increased assistance and surveillance was added to the care plan. When asked how was Resident 1's cognitive status, RN 3 stated Resident 1 was alert with some confusion. During a telephone interview on September 3, 2015, at 10:10, a.m., CNA 6 stated she was assigned to monitor 15-20 residents in the dining room between 3:30 p.m. to 4 p.m. (during the shift change). CNA 6 stated her responsibilities included to provide water to those residents that requested, ensure no resident gets up from wheel chair unattended. CNA 6 stated she was in the dining room when Resident 1 fell on [DATE]. CNA 6 stated while she walked over to open the dinning room door for another resident who wanted to use the bathroom, Resident 1 used her wheel chair to push against the other dining room door, got up and fell . CNA 6 stated she saw Resident 1 fell . CNA 6 stated she could not help Resident 1, as there was no other staff in the dining room at that time. During a telephone interview on September 3, 2015, at 2 p.m., LVN 6 stated Resident 1 was a 1:1 at times (of incident). When asked to clarify her statement, LVN 6 stated Resident 1 had 1:1 but not continuous. LVN 6 further stated Resident 1 would attempt to get out of bed and wheelchair constantly. When asked to clarify 1:1 intervention, she stated Resident 1 would have one staff sit with him. LVN 6 stated We did it (1:1 intervention) whenever we needed it. We would switch assignments around to provide the 1:1 intervention for Resident 1. LVN 6 further stated all nursing staff was aware Resident 1 was at high risk for falls. Reviews of the facility's policies titled, Care Plan Comprehensive, dated September 2009, reviewed July 2009, and approved August 2015 indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's needs was developed. Each resident's comprehensive care plan builds on the resident's strengths. The care plans were revised as changes in the resident's condition dictate. Each resident's comprehensive care plan was designed to incorporate identified problem areas. The nursing supervisor uses the care plan to assist with the CNA's daily/weekly work assignments sheets. The facility's policy titled, Fall Reduction/Prevention Program, dated February 2011, reviewed on July 2015, and approved on August 2015, indicted the purpose was to provide an environment that was free from accident hazards, to provide supervision and assistive devices to each resident through a program of assessment, risk identification and application of interventions.

Based on observation, interview and record review, the facility failed to protect Resident 1 from being slapped on the hand by Resident 2's private companion. On July 22, 2015, the facility activity director witnessed Resident 2's private companion slap Resident 1's hand (the side not indicated). The nurse note dated July 22, 2015, indicated Resident 1 had skin reddish at the back of the left hand measuring 2.5 centimeters (cm) by 0.8 cm. On July 31, 2015, Resident 1's left hand was observed with red mark. Findings: On July 31, 2015, at 7:30 a.m., an unannounced visit was made to the facility to investigate an entity report incident (ERI) regarding Resident 1 being slapped by Resident 2's private companion. A review of Resident 1's medical record indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan developed for behavioral symptoms and dated July 8, 2015, indicated one of the approaches was to place Resident 1 at a safe distance from others as to prevent injury, when the resident is in public areas with other residents (e.g. activities, meals, in front of nursing station, etc.). Another care plan developed for cognitive loss/dementia dated July 8, 2015, indicated Resident 1 had severe cognitive impairment, memory loss, and recall deficit. A review of Resident 1's nurses' notes dated July 22, 2015 at 3:46 p.m., indicated Resident 1 had a reddish discoloration at the back of the left hand measuring 2.5 cm x 0.8 cm, no swelling, and skin intact. The resident denies any pain and discomfort. The resident's range of motion was within normal limits. A review of the facility's investigative report dated July 23, 2015, indicated on July 22, 2015, the activity director witnessed a private companion of Resident 2 slap the hand of Resident 1. The private companion of Resident 2 stated Resident 1 hit her three times in the left arm and she tapped her (Resident 1) for her to stop. A review of the nurses' notes dated July 31, 2015, at 10:13 a.m., indicated Resident 1's left hand skin discoloration had decreased to a light red ecchymosis (black and blue) area measuring 0.7 cm by 0 .5 cm. No expression of pain noted when the discoloration area was touched. During a tour of the 5th floor on July 31, 2015 at 10:10 a.m., Resident 1 was sitting in the dining room by herself, and a table was in front of her. The red mark was observed on Resident 1's left hand. An attempt to interview Resident 1 was unsuccessfully as Resident 1 did not respond to greetings and did not react to the evaluator who was standing next to her. During an interview on July 31, 2015, at 10:37 a.m., the human resources (HR) manager stated all companions should have been screened by HR upon hiring, however the social services did not notify HR of Resident 2's companion being present in the facility. Resident 2's companion had not been screened by the facility's HR. During a telephone interview on August 6, 2015, at 12:20 p.m., the first floor activity director stated on July 22, 2015, she had to cover the activities on the 5th floor. She stated she brought Resident 1 to the dining/activity room to attend the activity. She placed Resident 1 in the second row, at a square table, located in the middle of the room. There was also another resident on the other side of the table. She noticed the private companion bring Resident 2 into the activity, and she (the private companion) sat next to Resident 1. While she (activity director) was passing books to other residents for the sing along, she saw Resident 2's companion using her cell phone, then she heard the voice saying ouch. The activity director turned around, and saw Resident 1's right hand on the companion's left arm. She saw Resident 2's companion hitting Resident 1's right hand once (at the same time a sound with an 8/10 intensity). The companion removed the resident hand from her arm, stood up and left the room. Resident 1 remained calm. The activity director then reported the incident to her supervisor. A review of the facility's policy and procedure titled, Private Duty Companion with a review date of September 2010 stipulated the director of Staff Development and Human Resources, and/or designee shall review qualifications and approve all private companions hired outside the facility. A review of the facility's policy and procedure titled, Abuse Prevention with an annual review date of July 2015 stipulated each resident/patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. A review of the facility's policy and procedure titled, Abuse Training with an annual review date of July 2015 stipulated all employees/caregivers will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this facility. Annual and as necessary in-service will be provided for review of facility's Policy on Abuse Prevention and Mandated Reporting.

Based on observation, interview and record review, the facility staff failed to prevent falls with serious injuries for 2 of 33 (6 and 19) sampled residents and to prevent falls with minor injuries and potential to injury for 4 residents (1, 24, 25, and 26) . For Resident 6, on September 23, 2012, CNA 6 assisted Resident 6 (who was assessed as requiring two persons physical assist during transfer) from a wheelchair to the bed. Resident 6 lost her balance and slid from the wheelchair on to the floor. The fall was not reported to the director of nursing (DON) until September 27, 2012, when the resident complained of hip pain. The x-ray was taken and showed acute pelvic fracture (broken hip) with a right femoral neck displacement (the head the femur, long bone running through the thigh, was shifted from the hip bone). On September 27, 2012, the resident was transferred to an acute care hospital where she underwent surgical procedure of a right hip hemiarthroplasty (hip replacement). For Resident 19, on February 28, 2012, CNA 1 wheeled Resident 19 out of the bathroom backward, and the resident slipped out of the wheelchair and landed on the floor. The resident was transferred to an acute care hospital and was admitted with [DIAGNOSES REDACTED]. Findings: 1. During a recertification survey on April 4, 2013, at 10 a.m., the initial tour of the unit was conducted with the Nurse Manager (NM 2), Resident 6 was observed asleep, lying in a low air loss mattress (medical mattress for patients at risk of, or treatment of [REDACTED]. On April 10, 2013, a review of the Admission Record dated October 7, 2010, indicated Resident 6 had [DIAGNOSES REDACTED]. On October 3, 2012, the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident was assessed as requiring two persons physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair), and requiring extensive assistance with two or more persons physical assist for standing position. The resident's balance was not steady during transitions from surface to surface and only able to stabilize with staff assistance. The Care Plan dated February 16, 2012, and updated on August 7, 2012, identified the problem of "potential for falls/injuries" related to impaired vision, unsteady gait, neuropathic pain, the use of wheelchair, impaired hearing, the use of hypertensive medications and diuretic, incontinence, diabetes mellitus, anemia and required 1-2 person assist with transfer. During an interview on April 12, 2013, at 8:30 a.m., when the MDS Coordinator (RN 6) was asked regarding the care problem, she stated the resident was assessed as requiring two persons physical assist, the care plan should indicate that the resident required two person assist with transfer and "not 1-2 person assist". A review of the ADL Flow Record dated July 1 through 31, 2012 revealed during transfer on the day shift (7-3), the resident required extensive assistance with one person. On the evening shift (3-11) from July 16 through 27, 2012, during transfer, the resident was total dependence on staff with one person assist. The ADL Flow Record dated August 1 through 23, 27 through 31, 2012, indicated in the day shift during transfer, the resident required extensive assistance with one person assist. On August 24 through 26, 2012, it was documented the resident was totally dependent on staff with one person assist. On the evening shift from August 1 through 26, 2012, it was documented the resident required extensive assistance with one person assist during transfer. However on August 27 through 31, 2012, it was documented the resident was totally dependent on staff with one person assist during transfer. The ADL Flow Record dated September 1 through 27, 2012, indicated on the day and evening shifts, the resident required extensive assistance with one person physical assist during transfer. However on the night shift dated September 1 through 9, 2012, it was documented the resident was totally dependent on staff with two person assist. On September 16 and 17, 2012, it was documented the resident was totally dependent on staff with one person assist during transfer. A review of Resident 6's Nursing Record dated September 27, 2012, during the 7 a.m. to 3 p.m. shift indicated the following: At 10:45 a.m., Nurse Practitioner was called and notified of the left hip pain and the incident of fall on September 23, 2012. The note indicated that while the resident was being transferred from the wheelchair to her bed, the resident slipped and CNA grabbed and assisted her to the floor. There was no injury noted at that time. At 11 a.m., there was a new order for stat x-ray of the right hip and pelvis and the ordered was noted and carried out. The resident's daughter was called and notified. At 12 p.m., the resident was up in a wheelchair for lunch with good appetite in no acute distress. At 2 p.m., the result of the pelvis and right hip x-ray was received and showed pelvic fracture (broken hip) with right femoral neck and lateral displacement. The Nurse Practitioner was called and ordered to transfer the resident to an acute care hospital. The resident's daughter was aware. At 3:45 p.m., the resident left the facility via ambulance to an acute care hospital. A review of the clinical record from the acute care hospital revealed Resident 6 was admitted to the hospital on September 27, 2012 and on September 30, 2012, the resident underwent [REDACTED]. On April 10, 2013, at 1:05 p.m., during an interview, CNA 6 stated that on September 23, 2012, after lunch she went to pick up Resident 6 from the nursing station. CNA 6 stated she wheeled the resident to her room and placed the wheelchair closed to the bed. She then assisted the resident to stand. CNA 6 stated she placed her right leg in between resident's legs while assisting the resident to stand, however the resident lost her balance and slid down to the floor. CNA 6 stated the resident was lying on the floor with the CNA's legs under the resident. CNA 6 stated she called for help, LVN 5 and two other CNAs came and they placed the resident back to bed. When CNA 6 was asked if she was aware that Resident 6 required two persons physical assist during transfer, she stated she was aware. CNA 6 further added that according to her assignment on September 23, 2012, for the 7-3 shift, Resident 6 needed assistance and it meant only one person to assist the resident. She stated according to the CNA assignment on the 3-11 shift, the resident required extensive assist and may use Sara lift. On 11-3 shift, CNA assignment worksheet indicated the resident required extensive assist with Sara lift. CNA 6 clarified that if Sara lift is being used during transfer, it requires two persons physical assist. On April 10, 2013 at 2 p.m., during an interview, CNA 7 stated that on September 23, 2012, after lunch, the resident told her she was having pain. CNA 7 stated she inquired further and the resident told her that she had a fall 2-3 days ago. CNA 7 stated she told LVN 5 what the resident told her and LVN 5 gave the resident medication for pain. She stated the resident was transferred to the hospital later that day. On April 11, 2013, at 7:15 a.m., during an interview with the Unit Manager (UM 2), she stated the CNA worksheet assignment was completed by the licensed nurses based on the resident assessment. The assignment indicated what the staff should do during a provision of care such as providing extensive assistance or use Sara lift for transfer. 2. The closed record for resident 19 was reviewed on April 5, 2013. The face sheet indicated Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual MDS (Minimum Data Set) dated November 27, 2011 indicated that the resident was usually able to make her self understood and usually able to understand others. Per the MDS the resident was able to transfer to wheelchair and transfer on and off toilet with one person extensive assistance. The MDS indicated resident was not able to ambulate in room. The Resident Care Plan initiated December 14, 2010 with last update September 1, 2011 identified the problem for "At risk for Falls/Injuries" related to: [DIAGNOSES REDACTED]. The MDS also indicated the resident used wheelchair for her mobility and required extensive assistance with one person physical assist for transfer, locomotion on and off the unit, and toilet use. The "ADL Flow Record" for February 28, 2012 indicated that the resident was totally dependent on staff for transferring from wheelchair to toilet. A review of Resident 19's closed record under "Nurses's Record"dated 2/28/12 at 9:45 a.m. indicated after the licensed nurse was called by CNA 1 to the resident's room, LVN 1 found the resident lying flat on bathroom floor with the head towards the door. The resident complained of sever pain in the left leg. When LVN 1 asked CNA 1 what happened she stated"resident slipped out of wheelchair while being pushed out of the bathroom" Resident 19 was assessed by RN 1 and Nurse Practitioner. The resident was medicated with one tablet of Vicodin. There was an order to transfer the resident to an acute care hospital via 9-1-1. At 10 a.m. the resident was transferred to the hospital via paramedics. At 3 p.m., the note indicated the nurse called the hospital and noted the resident was admitted with [DIAGNOSES REDACTED]. A review of Resident 19's "Post fall assessment" dated February 28, 2012, disclosed the resident was found on the bathroom floor lying flat on her back. The resident was with CNA 1. CNA 1 stated she pulled the wheelchair out of the bathroom with resident sitting on it, suddenly the resident slid off the wheelchair and landed on the floor. According to the post fall assessment item #32, the facility required the investigation by RN to ascertain the root cause of the fall to include any environmental hazards, the staff practice, resident factors, supervision and assisted devices. There was no root cause of the fall and the action plan to prevent further falls. On April 12, 2013 at 1 p.m., a telephone interview was conducted with CNA1 who was assisting Resident 19 from bathroom back to bed. She stated that while she was pulling Resident 19 who was sitting in a wheelchair backwards out of the bathroom, the resident slid out of the wheelchair and landed on the floor. She stated that neither the wheelchair nor the floor was wet. When asked if there was any thing she could have done to prevent the resident from falling, she stated maybe she could have held the resident with one hand while pulling the wheelchair backward. During an interview with Director of Education (DOE) on April 12, 2013 at 1 p.m., she stated even though there is no specific policy that states a resident should not be pulled backwards while in a wheelchair, this instruction is covered during orientation and continued in-services. She further stated that the resident can become confused and disoriented if being pulled backwards. 3. The clinical record for Resident 25 was reviewed on April 10, 2013, at 3:20 p.m. The Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The full Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 25 required extensive assistance with two-person assist for transfer and walk in room. Resident 25 was assessed as not being steady gait, only able to stabilize with staff assistance when moving to seated to standing position. The resident walked with assistive device, when moving on and off the toilet, and surface-to-surface transfer. The care plan initiated on January 7, 2013 identified the resident as "At Risk for Falls" related to needed extensive assist and the resident is in the facility's "Blue Ribbon Program". Another care plan titled "At Risk for Falls/Injuries" dated January 9, 2013 indicated Resident 25 "requires two persons assist for transfers." The "ADL Flow Record" (the certified nurse assistant's, CNA, documentation) for February 23-28, 2013, the CNAs had documented Resident 25 needed total dependence (full staff performance every time during the entire shift) with one- person physical assist for locomotion in his room during the day and evening shifts. The CNAs documented on February 23 to 28, 2013 that Resident 25 needed a one-person assist for transfers. The CNAs documented Resident 25 needed extensive to total dependence for locomotion in his room for the day and evening shifts for the period of March 1 to March 15, 2013. The CNAs documented on March 1 to March 15, 2013 that Resident 25 needed a one-person transfer. The Fall Risk Assessment score for Resident 25 dated February 14, 2013 was 12. The form indicated a total score above 10 represents high risk for falls. The "CNA Assignment Worksheet" dated March 11, 2013 and March 12, 2013 indicated Resident 25 needed a two-person assist for all shifts. The "SBAR Communication and Progress Note" dated March 12, 2013 at 7 p.m. indicated Resident 25 had a fall. The form indicated Resident 25 was "in urgent need to do a bowel movement and could not wait for another person to help." The form indicated CNA 2 called for another person to assist, but proceeded to help the resident herself (she did wait of help from another person). In the process of CNA 2 assisting Resident 25 to sit on the toilet alone, Resident 25 slid on to the floor and hit his elbows on his wheelchair resulting in small abrasions to his elbows. In addition, the form indicated Resident 25 did not have time to put on his shoes. The documentation of the facility's investigation of the incident indicated Resident 25 was only wearing socks which are not non-skid. The Registered Nurse (RN) assessment and documentation by RN 3 indicated Resident 25 had bilateral elbow abrasions. The "Risk Management Inter-disciplinary Team (IDT) Meeting Notes" dated March 15, 2013 indicated that after a review of the nursing documentation, post-fall assessment, and care plan, the IDT recommended to "make sure resident has non-skid shoes on during transfers, monitor for late appearance of skin discoloration, swelling, pain; q (every) 15 min (minute) monitoring." During the interview on April 10, 2013, at 2:50 p.m., RN 3 stated she found Resident 25 with CNA 2 in Resident 25's bathroom, sitting with his legs extended on the floor. RN 3 stated Resident 25 required 2-person maximum assist. RN 3 stated CNA 2 wheeled Resident 25 to the bathroom, and "since he was only wearing socks, he slid." RN 3 stated the fall could have not been prevented because Resident 3 was insistent informed CNA 2 he would help her. The personnel file for CNA 2 was reviewed. The "Employee Separation Form" dated March 25, 2013 indicated CNA 2 was terminated from the facility due to not following policies and procedures related to patient care. Three attempts to contact CNA 2 via the three telephone numbers in her employee file were unsuccessful. 4. The clinical record for Resident 24 was reviewed on April 10, 2013, at 12:30 p.m. The Face Sheet indicated Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The "Fall Risk Assessment" dated September 25, 2012 indicated a score of 15 which is high risk for falls. The fall risk assessment score on November 7, 2012 indicated a score of 17. The form indicated a total score above 10 represents high risk for falls. The Full Assessment MDS dated [DATE] indicated Resident 24 required extensive assistance with 1-person assist for bed mobility, transfers, walk in the room and corridor, and locomotion on and off the unit. The MDS also indicated Resident 24 was not steady in gait and was only able to stabilize her balance with staff assistance during moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. The "ADL Flow Record" dated November 1 to 7, 2013 indicated Resident 24 needed extensive assistance with 1-person assist during the day shift, total dependence on staff with 1-person assist during evening shift, and the activity did not occur on night shift for locomotion in the room. The "Resident Care Plan Review" dated September 27, 2012 indicated Resident 24 is high risk for falls due to "ambulates using walker with extensive assist, muscle weakness". The "At Risk for Falls/Injuries" dated September 26, 2012 indicated to assess and document degree of orientation to determine safety needs of residents, bed alarm/bed at lowest position, provide constant reminders to ask assistance from staff when needed and use of call light when in bed for staff. The licensed nurse "Weekly Summary" dated November 2, 2012 indicated Resident 24 required extensive assist with transfer and bed mobility. The "SBAR Communication and Progress Note" dated November 8, 2012 indicated Licensed Vocational Nurse (LVN 2) heard Resident 24 yelling "Help me! Help me!" on November 7, 2012, at 11:50 p.m. The document indicated when LVN 2 entered Resident 24's room, Resident 24 was found kneeling on the floor next to her bed, with both hands holding to the bed. LVN 2 documented Resident 24 was disoriented to time, with confusion. The Nurses' Record dated November 7, 2012, at 11:50 p.m. indicated RN 4 found LVN 2 assisting Resident 24. The resident was in a kneeling position facing the bed. RN 4 documented the bed was in the lowest position and a bed alarm was attached to it. However, there was no documentation of the bed alarm sounding off when the resident was attempting to get out of bed. During the interview with Unit Manager (UM 1) on April 12, 2013, at 11:18 a.m., UM1 stated Resident 24 is alert, oriented, but does need a 1-person assist. 5. The clinical record for Resident 26 was reviewed on April 10, 2013, at 1:30 p.m. The Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] indicated Resident 26 had a score of 12 which is high risk for falls. On January 12, 2013, Resident 26 had a score of 12; on February 8, 2013, Resident 26 had a higher score of 14. On March 2, 2013, Resident 26 had a fall risk score of 12. The Full Assessment MDS dated [DATE] indicated Resident 26 needed extensive assistance with 1-person assist for transfers, walk in her room/corridor, and locomotion in/off the unit. The MDS also indicated Resident 26 ' s gait was not steady and the resident is only able to stabilize her balance with staff assistance during moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. Resident 26 had functional limitation in range of motion on both upper extremities. The "At Risk for Falls/Injuries" care plan dated December 26, 2012 indicated Resident 26 is a high risk for falls. Interventions included observation of resident during cares; observation and report changes to gait/balance/posture, assist with transfers, toileting, and mobility; and, apply bed and chair alarm for safety. The "SBAR Communication and Progress Note" dated January 19, 2013, at 8 a.m. indicated Resident 26 had a fall. The document indicated UM 2 received a report from the CNA 3 that Resident 26 got up from bed without assistance while CNA 3 was trying to raise the resident's bed. Resident 26 fell from the bed, landing on her left knee. The document indicated upon assessment, an open skin on the left knee which was 1 centimeter (cm) by 1 cm by 0.1 cm in size was noted. UM 2 documented that Resident 26 "requires frequent reminder to wait for help and do not perform activities without assistance due to poor gait/balance and high risk for falls and injury." There was no revision of the Falls/Injury care plan noted post-fall. During an interview with CNA 3 on April 12, 2013, at 8:20 a.m., CNA 3 stated she was going to get Resident 26 up from bed to go to the bathroom. CNA 3 stated she had to walk to the foot of the bed to raise the bed to the level safe for her to assist Resident 26 out of bed. CNA 3 stated while she was raising the bed (away from the resident), Resident 26 tried to get up and slid down the side of the bed on her knees. CNA 3 stated the fall could have been prevented if the bed was equipped with a remote control to raise the bed, as in other beds used in the facility, and she (CNA 3) would have not left Resident 26's side. The "SBAR Communication and Progress Note" dated February 8, 2013, at 3:30 p.m. indicated Resident 26 had a fall incident. RN 3 documented Resident 26 was sitting in front of the nurse's station when she suddenly got up from her chair, pivoted, lost her balance, and fell on her left side. RN 3 documented Resident 26 was assessed and a bump on her forehead (between her eyeballs) was noted. The report of facility investigation of the fall incident indicated the reason for the urgency for Resident 26 was that she wanted to go to her husband in a nearby room. The report indicated the resident appeared to be overly anxious about her husband's health and wants to check on him every now and then. The report indicated the staff was unable to prevent the fall because the incident happened so fast. The CNA's documentation on the ADL Flow Sheet for February 1 to 9, 2013 indicated Resident 26 needed limited assistance with locomotion in the hallway with one person physical assist. The IDT Meeting Notes dated February 11, 2013 indicated a recommendation of applying a chair alarm when Resident 26 is sitting in a regular chair or wheelchair. The SBAR Communication and Progress Note dated March 2, 2013, at 3:30 p.m. indicated Resident 26 had a fall incident at 2:30 p.m. LVN 3 documented she heard an alarm ringing and went in the dining room, she found Resident 26 sitting on the floor next to her wheelchair. LVN 3 documented Resident 26 informed her that Resident 26 wanted to leave the room and not participate in the activity. LVN 3 documented Resident 3 did not call for help. There was no documentation of an RN assessment post-fall found in Resident 26's clinical record. The report of the facility's investigation of the incident indicated Resident 26's fall was due to the resident's poor awareness of safety and forgetfulness. In addition, the fall was due to poor staff practice because the patient was sitting in the main dining room unattended. During the interview with LVN 3 on April 12, 2013, at 9:50 a.m., LVN 3 stated the residents were watching a movie. She went into the main dining room when she heard an alarm ring. She was standing in the hallway, by the nursing station. LVN 3 stated she found Resident 26 already sitting on the foot rest of her wheelchair. LVN 3 stated the Activity personnel was in the room, but was not supposed to be left with the residents by herself. The CNA was supposed to be with the residents, but sometimes, they step out and leave the residents with the Activities staff. 6. The clinical record for Resident 1 was reviewed on April 5, 2013, at 8:40 a.m. The Face Sheet indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1's admitting [DIAGNOSES REDACTED]. The Full Assessment MDS dated [DATE] indicated Resident 1 was total dependence on staff with 2-person assist with bed mobility, transfers, walk in the room/corridor, and locomotion in/off the unit. Resident 1 was assessed as not steady with balance during transitions (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer) and walking, only able to stabilize with staff assistance. Resident 1 was assessed with [REDACTED]. The MDS indicated Resident 1 uses a wheelchair as a mobility device. The Fall Risk assessment dated [DATE] indicated Resident 1 had a score of 10. A score of above 10 represents a high risk for falls. Resident 1's score on January 3, 2013 was 11, which made her a high risk for falls. Her score is 13 on January 22, 2013 was 13, and 15 on February 7, 2013. The CNA Assignment Worksheet dated January 2, 2013 11-7 shift indicated Resident 1 required assist with ambulation, ambulates with a front wheel walker to all meals with assist, and had a bed and chair alarm. The CNA Assignment Worksheet dated January 3, 2013 for 3-11 shift indicated Resident 1 needed "2-person assist with AD (activities with daily living), and was a high risk for falls." The boxes for chair and bed alarm were left blank. The SBAR Communication and Progress Note dated January 3, 2013, at 6:50 a.m. indicated Resident 1 had a fall on January 3, 2013, at 1:20 a.m. LVN 4 documented Resident 1 was found lying on the floor next to her bed on her right side. The facility investigation report indicated Resident 1 was trying to sit up on the side of her bed and slipped off the bed. The report indicated Resident 1 was non-compliant at times by not using call light for help, and Resident 1's bed was not safe for leg dangling due to the bed was inflated with air rendering it slippery. (What is the action plan to prevent further falls?) The Nurse's Record dated January 3, 2013, at 1:20 p.m. indicated Resident 1 was trying to get up on her own, without calling for help. Resident 1 complained of minimal pain on her right shoulder with movement. Resident 1 also had a bluish discoloration noted on her right shin area. The record indicated body alarm and landing pad were in place. A radiology report of the right shoulder dated January 3, 2013, at 11:12 a.m. indicated Resident 1 has an anterior medial shoulder dislocation. The humeral head was partially deformed and eroded. The Nurse's Record dated January 3, 2013, at 6:15 p.m. indicated Resident 1's right upper extremity was immobilized. The pre-fall care plan was requested from Medical Records Staff 1 (MR 1) and on April 5, 2013, at 1:40 p.m., MR 1 stated she was unable to find documentation of a care plan regarding falls prior to the January 3, 2013. The "At Risk for Falls/Injuries" post-fall care plan dated January 3, 2013 indicated an intervention for a 15-minute observation for 2 weeks was initiated. In addition, the same intervention was added on January 12, 2013, along with a use of a landing pad on both sides of the bed and the use of a bed and wheelchair alarms. There was no documentation of a 15-minute observation between the dates of January 4 to January 22, 2013 found in the clinical record. MR 1 was interviewed on April 10, 2013, at 9:25 a.m. She stated after she reviewed both the current and thinned clinical records and was unable to find documentation of the "Close Observation 15 minute" form dated January 4 to January 22, 2013 in Resident 1's clinical records. During the interview with the Executive Director of Nursing (EDON) at 10:14 a.m., the EDON stated the facility does not have a policy regarding the every 15-minute observation check. The EDON stated, "there is no paper doesn't mean it was not done. We will look for it." It is at the nurse's discretion to initiate that intervention. The surveyor showed the EDON the post-fall care plan with the intervention of a 15-minute observation initiated on January 4 and January 12, 2013. The EDON stated "then, it needs to be done." There was no documentation of the Close Observation 15 Minutes form from January 4 to the 22, 2013 provided to the survey at the time of facility exit. The "ADL Flow Record" dated January 16 to January 23, 2013 indicated Resident 1 was totally dependent with a two-person assist with bed mobility for all shifts and total dependence with a two-person assist with transfers for day and evening shifts. The CNAs were documenting transfers did not occur on night shift. The SBAR Communication and Progress Note dated January 22, 2013, at 4:30 p.m. indicated Resident 1 had a fall from the bed to the floor at 4:30 p.m. The form indicated a social worker heard a loud voice coming from Resident 1's room, calling for help. The form indicated that RN 5 found Resident 1 on the floor, face down with her head under the over-bed table. RN 5 documented Resident 1 wanted to sit up in bed, but did not use the call light. Resident 1 was on a low air loss mattress and slid from the bed to the floor. The form indicated that as a result of the fall, Resident 1 had a bump on her left forehead measuring 1.5 cm by 1.5 cm. In addition, Resident 1 had an open skin on her left forehead measuring 0.5 cm by 0.3 cm and another skin tear on her right elbow measuring 0.5 cm by 0.5 cm. Resident 1 also had a skin discoloration on her right hand measuring 3 cm by 3 cm. The CNA Assignment Worksheet dated February 6, 2013 and February 7, 2013 indicated Resident 1 needed 2-person assist with transfers, is a high-risk for falls, and is on a landing pad, bed alarm, and chair alarm. The "Risk Management Inter-Disciplinary (IDT) Meeting Notes" dated January 23, 2013 indicated the IDT recommended to discontinue the low air loss mattress and replace it with a pressure reducing mattress, change the resident's chair to a reclining wheelchair with leg lifts, place on the Blue Ribbon program, and continue with the bed/wheelchair alarms and low bed with landing pads. RN 5 was interviewed on April 9, 2013, at 2:50 p.m. RN 5 stated she saw Resident 1 at 4 p.m. watching television in Resident 1' s room. Later, the social worker said she heard a loud voice calling. RN 5 stated when she arrived in the room, Resident 1 was face down, body flat with the head next to the bedside over-bed table. Resident 1 was trying to get to her chair and in the process, slid off the bed. RN 5 stated the "flat" bed alarm was on, but did not sound off. The bed alarm was a pressure alarm under the resident's trunk and was supposed to alarm when pressure was off from the device. The alarm stayed in place and Resident 1 slipped off from the side of it. RN 5 stated Resident 1 was on a low air loss mattress, and the mattress was slippery because the mattress did not have a bolster to prevent the resident from slipping off the bed. RN 5 stated Resident 1 had a cut on the forehead, a cut on the right elbow and a skin discoloration on the right hand. RN 5 stated that after Resident 1's fall, they removed the air loss mattress and the chair. The ADL Flow Sheet dated February 1 to February 7, 2013 indicated Resident 1 needed extensive assist to total dependence with 1- or 2-person assist with bed mobility and transfers. The SBAR Communication and Progress Note dated February 7, 2013 indicated Resident 1 had a fall at 5:20 a.m. The document indicated CNA 5 found Resident 1 on the floor, close to the bed, in a supine position. The document indicated Resident 1 stated she tried to turn, sit up on the edge of the bed, but did not have enough strength in her lower extremities to maintain balance and bear weight. RN Supervisor was called to assess the resident. The Nurse's Record da

Based on record review and interview, the facility failed to provide a two person assist during transfers for Resident 1, who had a right leg amputation (removal of a right leg) and required a two person assist with transfers. On September 11, 2011 at 4:30 p.m., a certified nursing assistant (CNA 1) transferred Resident 1 from the bathroom (toilet seat) back to the wheelchair without another person assist. Resident 1 fell during transfer and sustained a left leg fracture (broken left leg). The resident required a transfer to the general acute care hospital for surgical intervention. Findings: On November 4, 2011, an unannounced visit was made to the facility to conduct a complaint investigation of Resident 1's fall incident resulting in a fracture. Resident 1's medical record was reviewed on November 4, 2011. The admission record indicated the resident was a [AGE] year old, readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident 1 required extensive assistance in transfers with a two person assist, where the resident was involved in the activity and the staff provided the weight-bearing support. The MDS also indicated Resident 1 required extensive assistance in locomotion on the unit and was totally dependent on facility staff in toilet use. A review of the Fall Risk assessment dated [DATE], indicated Resident 1 scored a zero under the ambulatory status parameter. This indicated the resident was fully dependent or non ambulatory, where the person assisting does 100% of the activity. However, the MDS quarterly assessment indicated the resident was involved in ambulating activity and the staff provided weight bearing support. This indicated there was a discrepancy between the MDS quarterly assessment and the fall risk assessment, both completed in July 2011 by the same registered nurse (RN 1). The "Fall Risk Assessment" indicated the resident was assessed as being non-high risk for fall. A review of the care plan dated January 26, 2011 indicated Resident 1 was at risk for falls/injuries related to impaired mobility and non ambulatory status [REDACTED]. The goal updated July 27, 2011, indicated the resident was to participate and make decisions regarding activities of daily living as tolerated for 90 days. The staff approaches or interventions included gentle handling with bed mobility and transfers, and observe and report changes to gait, balance and posture. The interventions also indicated Resident 1 completed physical therapy on January 21, 2011 and was able to transfer to the toilet for periodic toilet use. There was no description of how the staff would assist the resident for toilet use (1-person or 2-person assist). However, per the MDS quarterly assessment, a 2-person assist in transfer was required for this resident. A review of the CNA Assignment Worksheet for the 3-11 shift dated September 5 - 11, 2011 indicated Resident 1's Protocol was total care, 2 person assist, with transfers. A review of the Progress Note dated September 11, 2011 at 4:30 p.m., indicated Resident 1 slid down on the floor when CNA 1 was assisting her from the toilet seat. The progress note indicated the CNA could not control the fall, so she slid the resident down on the floor. Resident 1 stated she was having pain in the left upper leg, the on-call physician was notified and ordered to transfer Resident 1 to the emergency room of an acute care hospital for evaluation and rule out fracture. A review of the "Post Fall Assessment" dated September 11, 2011 indicated Resident 1 was found on the bathroom floor in a sitting position next to the shower chair, CNA 1 was with the resident as she was attempting to transfer the resident, however the resident "was not wearing safe shoes" (the facility failed to describe what the "safe shoes" were). The resident stated "I was sliding down from the shower chair." The CNA stated "I lowered her down to the floor on a sitting position." The investigation by RN in the Post Fall Assessment indicated the CNA called the charge nurse to help her. The charge nurse stated he saw the resident sitting on the floor, and the resident's left leg twisted in an angle. The charge nurse and the CNA assisted or carried the resident back to the wheelchair. The charge nurse called the supervisor, and the "head to toe assessment done". The resident was noted with skin tear on the right hand, and the left upper leg was swollen and painful to touch. The investigation section indicated the "CNA did not follow a 2 person assist protocol." During an interview on January 13, 2012 at 3 p.m., the RN Unit Manager stated the CNA "Assignment Worksheet" informed the CNA if the resident was a one person or a two person assist. The RN nurse Supervisor (RN 2) stated "it was missed". A review of the Radiology Exam from the acute care hospital dated September 11, 2011 indicated an angulated displaced fracture (two ends of the broken bone are separated from each other) involving the left femoral shaft (body of the leg), a spiral fracture (broken bone caused by twisting force to the bone) extending from the transverse fracture (broken across the bone) down to the distal left femur (thigh bone), and the impression indicated a left femoral shaft fracture (broken left leg). A review of the Operative Note from the acute care facility dated September 12, 2011, indicated Resident 1 was diagnosed with [REDACTED]. A review of the Employee Warning form dated September 12, 2011, indicated CNA 1 was suspended for three days pending an investigation of the incident. The employee warning form indicated CNA 1 was re-educated regarding safe and proper transfers and seeking assistance when necessary. A review of the Certified Nursing Assistant job description dated October 2007, indicated the purpose was to provide each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as the CNA may be directed by the supervisor. A review of the facility's policy and procedure titled Fall Reduction Program revised November 2011, indicated the fall reduction interventions would be communicated to all relevant staff and responsibility would be assigned. The policy indicated, for example, the CNA assignments would be updated to reflect interventions (i.e. 2 person assist with transfer), and information would be shared during the shift to shift report by charge nurses. The policy indicated the Interdisciplinary Team (IDT) would determine the type and frequency of supervision and this would be included in the care plan and communicated to the rest of the relevant staff.

Based on observations, record reviews, and interviews, the facility failed to identify environmental hazards to ensure the residents' environment remained free of accident hazards for 1 of 30 sample residents (25). The facility also failed to provide adequate supervision that was consistent with the residents' goals and plan of care in order to reduce the risk of accidents and to modify interventions as necessary for 5 of 30 sample residents (25, 28, 14, 15 and 20). a. Resident 25, who was identified to be at risk for wandering out of the facility, propelling fast in her wheelchair, and lacking safety awareness, was not adequately supervised in the 1st floor nursing station which resulted in the resident wheeling herself out of the building. Resident 25 was found on the staircase, leading down to the basement parking lot, out of her wheelchair with her face down. The staircase did not have a security gate to prevent access by a wheelchair bound resident. Resident 25 sustained multiple lacerations, ruptured globe (eye socket), and facial fractures requiring transfer to an acute hospital where she received surgery for [REDACTED]. Subsequently, Resident 25 expired ten days later at the acute hospital. b. For Resident 28, the facility staff failed to provide 1:1 supervision as indicated in the care plan while the resident was ambulating, using a front wheel walker (FWW). Resident 28 sustained a pelvic fracture after a fall requiring transfer to an acute hospital for an evaluation. During the hospital stay, Resident 28 developed [DIAGNOSES REDACTED] (impairment or loss of brain function) seven days after the fall and required tube feeding due to poor cognition. Resident 28 was readmitted to the facility under hospice care and expired nine days later after the fall incident. c. Resident 14 was left in the dining room unsupervised which resulted in a fall from her wheelchair, hitting her head to the floor, and sustaining a hematoma on the right forehead. d. For Resident 15, who required supervision while ambulating and was at risk for recurrent falls, the facility staff failed to modify the resident's care plans for falls to include interventions based on the recommendations by the Inter-Disciplinary Team. e. Resident 20, who was assessed to require 2 persons assist in transferring, was transferred from bed to wheelchair by one staff member. This resulted in Resident 20 having an avoidable and assisted fall and sustaining a blood blister and pain in the right knee. Findings: a. On [DATE] at 10:45 a.m., a review of Resident 25's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. with advanced dementia, Glaucoma (a disease that increases the inner eye pressure with progressive loss of vision), Multiple Sclerosis (MS, a chronic disease of the central nervous system involving destruction of nerve sheaths around the nerves; slows or blocks transmission of nerve impulses), Osteoarthritis (degenerative joint disease accompanied by pain and stiffness), and muscle weakness. The Minimum Data Set (MDS), an assessment and care screening tool, dated [DATE], indicated the resident had short-term memory problem and her cognitive skills for daily decision-making was moderately impaired (decisions poor, cues/supervision required). The MDS also indicated the resident required extensive assistance (2 person physical assist) from staff for bed mobility, transfer and locomotion. Her primary mode of locomotion was a wheelchair due to resident's chronic multiple sclerosis (over [AGE] years). A review of the Social Services Quarterly notes, dated [DATE], indicated to "continue to reinforce regarding wandering outside of JEK (Joyce Eisenberg Keffer) building using direct and gentle approach. Encourage verbalization when she wants to do something like going to Synagogue (Jewish Temple, place of worship)." A review of the "At Risk for Falls/Injuries" care plan, dated [DATE], and updated on [DATE] and [DATE], indicated Resident 25 was identified as high risk for falls related to lack of safety awareness, on lexapro (an anti-depressant), glaucoma, neuropathy and use of wheel chair, and able to propel self out of the building. The care plan approaches included: assessing and documenting the degree of orientation to determine safety needs of resident; monitoring the medications for fall related side effects (blurred vision, dizziness, lightheadedness, muscle cramps or pain); ensuring the resident had eyeglasses on; and maintaining a safe environment free from clutter, and removing or identifying safety hazards. The "At Risk for Falls/Injuries" care plan was updated on [DATE], to include the following approaches after a fall incident: Fall IDT to assess for cause of fall and implement interventions related to fall; wheelchair alarm; bed at lowest position; and 2 persons assist with gait belt during transfers. There was no documentation found in the care plan addressing "safety alteration related to the wandering behavior" of the resident wheeling self out of the building or interventions which would include adequate supervision in order to reduce the risk of an accident. A review of the Nurses' Record, dated from [DATE] through [DATE], indicated "continuous monitoring of resident being made for safety due to lack of safety awareness and episodes of wandering behavior." On [DATE], during the 7 a.m. to 3 p.m. shift, the Nurses' Record indicated "On every 15 minute monitoring for going out of the building; frequent visual monitoring for safety." On [DATE], a care plan was developed regarding "Safety Alteration Related to Wandering Behavior" of the resident wheeling self out of the building. The approaches included: monitoring the resident's location and/or whereabouts through visual checks every 15 minutes, indefinitely, to ensure resident does not go out of the building by self; scheduling an IDT meeting with the son to review plan of care when available; and placing a blue ribbon sticker identification with fall assessment score of 12 (total score above 10 represents High Risk). Further review of the care plan revealed the care plan was updated on the following dates: On [DATE], the IDT met with the caregiver and requested her to notify staff when she leaves (hours vary daily) and resident in identified location; On [DATE], the IDT met with the resident's son to discuss moving the resident to the 4th floor, son will discuss with family and caregiver; and on [DATE], the IDT met with son and a decision was made to move the resident to the 4th floor when a room is available. There was no documentation that the care plan interventions were modified to address a close watch of every 10 minutes or a one-to-one monitoring if the resident was at risk for wandering and was attempting to leave the facility despite close watch every 10 minutes, as stipulated in the facility's policy and procedure. A review of an update note, dated [DATE], to the "At Risk for Falls/Injuries" care plan indicated the resident left out of the building in wheelchair and did not follow staff instructions when told to wait for assistance after meals. There was no documentation that the care plan interventions were modified to address a close watch of every 10 minutes or a one-to-one monitoring if the resident was at risk for wandering and was attempting to leave the facility despite close watch every 10 minutes, as stipulated in the facility's policy and procedure. A review of the IDT meeting notes, dated [DATE], indicated the IDT met with caregiver and resident to discuss staff concerns regarding resident's safety and wandering episodes. "When in her wheelchair, the resident is very fast and propells herself to get out of the building. The automatic opening, double doors provide easy access for the resident to get out of the building and wander about, with the possibility of getting hurt." The caregiver and resident agreed to move to the 4th floor to eliminate easy access in getting out of the building. Resident 25 was shown the 4th floor room but disagreed with the room move. There was no documentation of discussing a close watch of the resident every 10 minutes or providing one-to-one monitoring as indicated in the facility's policy and procedure. A review of the Social Service Notes, dated [DATE], indicated the resident was leaving the building without staff going with her to the Synagogue or anywhere. The Social Worker (SW) explained the dangers of leaving the building without staff and reminded resident that she needed to ask someone to be with her when leaving the building. A review of the IDT meeting notes, dated [DATE], indicated IDT met with the resident's son to inform him that the resident was at further risk for falls and injury. The resident's son stated, "He would discuss with the family and the caregiver about moving the resident to the 4th floor and let the facility know." There was no documentation of discussing a close watch of the resident every 10 minutes or providing one-to-one monitoring as indicated in the facility's policy and procedure. The facility's policy and procedure titled, "Elopement/Code Brown" dated [DATE] and revised on October on 21, 2010, indicated "All residents shall be assessed by the IDT regarding the risk of wandering on admission, daily and when behavior changes. If the resident is at risk for wandering and the resident is attempting to leave despite close watch every 10 minutes, a one-to-one will be instituted and physician notified." A review of the Nurses' Record, dated [DATE] for the 7 a.m. to 3 p.m. shift, indicated the resident was awake, verbally responsive with periods of confusion; monitoring for wheeling herself out of the building every 15 minutes. In addition, the charge nurse and staff nurse were taking turns to keep an eye on the resident for safety. A review of the Nurses' Record, dated [DATE] at 9:10 a.m., indicated CNA 2 and Staff O (maintenance supervisor), who happened to be outside, heard the resident yelling out for help outside of the JEK 1 (Joyce Eisenberg Keefer building, first floor). When they responded to the location of the noise, they found resident face down on left side of face, leaning on the staircase and platform (eleven stairs down, platform, and then 11 more stairs) that leads to the basement parking lot. Immediately, Employee F, the Charge Nurse, was paged from the walkie talkie. Employee F immediately called Employee E, the RN Supervisor, and all responded to location of incident immediately for assessment. At the same time, paramedics were called. Resident 25 was noted with laceration on the left side of temporal lobe, laceration to the left side of the eye, and laceration to the right leg. Resident 25 continued to yell out for help, screaming of pain. Paramedics arrived on location at 9:17 a.m. and took over assessment of the injuries sustained. Resident 25 was taken to an acute hospital. The resident's son and caretaker were both notified of the resident's fall and injuries. At 1 p.m., the resident was admitted to the acute hospital due to fractures and treatment needed. On [DATE] at 11:30 a.m., a review of the facility's internal investigative report, dated [DATE], indicated CNA 2 thought she remembered Resident 25 being wheeled out of the dining room by CNA 3 after breakfast at 9 a.m. and placed by the nurses' station with other residents. All CNAs continued taking all other residents out of the dining room to the nurses' station and to the lobby. A review of the "Observation 15 minutes Record," dated [DATE], indicated Resident 25 was last seen at 9 a.m. in her bathroom. On [DATE] at 2 p.m., during an interview, Employee I, Administrator, stated that she and Employee C walked the facility grounds on [DATE], shortly after Resident 25's accident, to identify any potential environmental hazards and individual resident risks of an accident. Employee I stated there were three identified potential environmental hazard areas: the staircase by JEK1 leading to the basement parking lot (where the accident occurred); the staircase to the basement along the East side of the building by the administration offices; and, the stairs by the South exit automatic opening, double doors, near the Jake & Janet Farley Library, leading to the parking lot. Within the week after the accident, the security gates with tight springs, were installed at the three identified environmental hazard areas. On [DATE] at 2:15 p.m., the surveyor toured the facility grounds with Employee I and observation was made of all three security gates. On [DATE] at 9:20 a.m., in an interview, CNA 2, who was assigned to Resident 25, stated "She last saw Resident 25 around 8:45 a.m. at the breakfast table eating. She was assisting another resident to the beauty salon which was located outside, off the patio near the Deli Shop; CNA 2 heard Resident 25 yelling for help. Employee O and CNA 2 responded and found resident on the staircase by JEK 1 out of her wheelchair with her head face down and left side of face leaning on the staircase. CNA 2 called Employee F on the walkie talkie. CNA 2 stated Employee O stayed with the resident, as she went to get help from inside the building. Paramedics were called. Employees E and F responded immediately and assessed the resident. Paramedics arrived and the resident was transferred to an acute hospital's emergency room (ER) for treatment (TX)." CNA 2 further stated, "Resident 25 was already on every 15 minute checks due to (d/t) prior episodes of wheeling herself out of the building; this information was given in change-of-shift report that morning." On [DATE] at 3:45 p.m., during an interview, Employee O stated, "He was doing campus checks, when he heard someone yelling for help. He found Resident 25 on the staircase of JEK1, lying between the ninth step and the platform, the resident's wheelchair was lying next to and on top of her. He was hesitant to remove the wheelchair, as the resident was bleeding a lot from her face and nose; resident was crying and complaining of pain. Employee O stayed with the resident until Employee E came." According to the acute hospital's emergency department trauma notes Resident 25 was brought to the emergency roiagnom on [DATE] at 9:35 a.m., after a fall from 10 flights of stairs with facial trauma, shortness of breath, vomiting and weakness. A review of the Physician Documentation exam, by Physician A, the Attending Physician, revealed: large left parietal scalp hematoma (left side of the head scalp bone with a mass of blood that has gone into the tissue); lacerations of the left cheek and left eye; blood clotted in both nares (openings of the nose); swelling of the nose, left cheek and left eye; left pupil with hyphema (hemorrhage within the chamber of the eye), 100% opacification (development of a spot in the area of the cornea or lens of the eye) with blood, cannot rule out (r/o) ruptured globe (eye socket); left eyelid with extensive, complex laceration; skin tear and bruising to right hand; and, laceration to left shin. The laboratory report, dated [DATE] at 11:33 a.m., indicated the resident had an elevated troponin (protein that has a key role in muscle contraction) of 3.86 ng/mL (normal range 0XXX,[DATE].10 ng/mL) on admission, suggestive of a non-ST-elevation myocardial infarction (sudden insufficiency of arterial or venous blood supply due to occlusion of a coronary artery). After initial stabilization, the resident was taken to cardiac catheterization lab for testing; triple-vessel disease and coronary artery disease (CAD, obstruction or closing of the coronary arteries) were identified. The resident was evaluated by Physician F, Cardiothoracic surgeon, and due to comorbidities and resident's poor overall clinical condition, it was recommended that the resident be treated medically. A review of a computed tomography (CT) scan without contrast of the facial bones, dated [DATE] at 10:53 a.m., revealed a complex left tripod fracture, which included a depressed orbital floor fracture, anterior and posterior maxillary sinus wall fracture, zygomatic arch fracture, lateral orbital wall fracture, comminuted nasal bone fracture, and blood seen in the left maxillary sinus, posterior nasopharynx, and posterior optic globe with possible retinal or choroidal detachment (fractures to: the eye socket, sinus wall, cheek bone, the back of the eye socket wall, and nose; blood in the sinus wall, the back of the nose and pharynx, and the back of the eye socket, and possible eye detachment). According to the history and physical examination [REDACTED]. Resident 25 was admitted to the intensive care unit (ICU) for pulmonary (pertaining to the lungs) and neurologic monitoring. The following consultations were obtained: Medical to assist in management of medical issues; Pulmonary to manage COPD; and, ears, nose and throat (ENT) and facial surgery for [REDACTED]. A review of the Consultation report by Physician C, Medical Consult, dated [DATE], revealed the medical plan included pain and nausea control and to be kept nothing by mouth (NPO) until a decision was made about surgery. The resident was placed on antibiotics for facial injuries and stress ulcer prophylaxis (prevention measure) due to the resident's high doses of steroids every day. Jobst pumps (a mechanical devise used to prevent blot clots in the legs) applied to her lower extremities for deep vein thrombosis (DVT) prophylaxis for now, as pharmacologic DVT prophylaxis is contraindicated d/t facial fracture. A review of the Consultation report by Physician D, Pulmonary consult, dated [DATE], revealed the pulmonary plan included aggressive pulmonary toilet (respiratory therapist percusses the chest to loosen mucus from the lungs, then removes the excess fluids and mucus from the lungs making the airways more open) with handheld nebulizer (HHN, a breathing treatment apparatus for throwing a jet of spray with medication) therapy and incentive spirometry (a breathing apparatus used to encourage deep, sustained inhaling efforts). The resident's overall prognosis looked guarded to poor. The resident would require intubation for surgery; however, the resident did not wish to be intubated if she should suffer progressive deterioration. A review of the Consultation report by Physician E, ENT and facial surgery consult, dated [DATE], revealed the plan included ice pack with elevation to the left face to allow the swelling to come down for two to three days before surgery to perform definitive repair of the left lower lid lacerations and open reduction/internal fixation of orbital floor and zygomatic fracture (opening of the cheek bone, securing the fractures inside of the eye socket with a plate and screws to stablize the eye socket, and the cheek). A review of the Swallowing Evaluation, dated [DATE], revealed the resident presented with advanced dementia and decreased cognition. Impressions of the testing indicated the resident demonstrated clinical signs and symptoms (s/s) of aspirations on both thin and nectar thick liquids by cup and straw. The resident expectorated (spitting of mucus or other fluids from the lungs and trachea) numerous times and required oral suctioning; resident's left lower face was not functioning. The recommendation was to keep the resident nothing by mouth (NPO). A review of the Operative Record completed by Physician E, dated [DATE], revealed the left upper lid was retracted; it was noted she had a laceration in the globe (eye socket) which measured approximately 1 millimeter (mm); the decision was made not to proceed with any fracture repair. However, a decision was made to loosely repair the left lower lid avulsion laceration of the medial canthal (the angel of the eye) and the left lateral canthal regions; repair to the nose was also made. The left eye was then taped with an eye patch after irrigation. The resident was then taken to the recovery room, so the surgeon could discuss with the family the possibility of having the resident undergo a globe exploration. A review of the Operative Record completed by Physician G, Ophthalmology consult, dated [DATE], revealed the pre-operative [DIAGNOSES REDACTED]. A decision was made to take the resident immediately back to the operating room (OR) for repair of the left eye with extensive corneoscleral laceration (a deep cut of the tough, white outer coat of the eyeball and the transparent structure forming the backside of the eyeball) with prolapsing uveal tissue (the circular pigmented membrane behind the cornea), and exploration of left side orbit. At the end of the procedure, an injection of gentamician, Ancef (antibiotics to prevent infection) and Decadron (to decrease swelling) was given in the inferior conjunctival fornix. Maxitrol (a combination of a steroid and antibiotics used to help reduce swelling, redness and itching of the eye) ointment was applied to the resident's eye with a light patch placed over the resident's eye. The resident was taken to the recovery room and awakened from anesthesia without complication. The physician's orders [REDACTED]. Total parenteral nutrition (TPN, a highly concentrated caloric and nutritional solution given to residents due to illness or injury) was ordered and started. The Physician's Progress Record, dated [DATE] at 7 a.m., revealed the resident's laboratory results indicated the resident was anemic due to blood loss and one unit of Red Blood Cells (RBC's) was ordered and transfused. The Physician's Progress Record, dated [DATE] at 9:50 a.m., revealed the resident had low urine output yet responding to blood transfusion. A review of the Consultation report by Physician H, Coronary Revascularization surgeon, dated [DATE], indicated that due to the resident's COPD, severe left ventricular (LV) dysfunction with 3-vessel coronary artery disease (CAD) and significant medical problems, the resident would not be a candidate for surgical intervention and the recommendation was for conservative therapy. A review of the Gastroenterology Consultation report by Physician I, dated [DATE], revealed that based on a myocardial infarction (death to some of the tissue of the middle and thicker layer of the heart wall as a result of interruption of the blood supply to the area) in the last 7 days, the Cardiothoracic surgeon note stating the resident was not an operative candidate and speaking with the son, the direction of care was more palliative and hospice-type rather than feeding tube placement, which would only prolong suffering with the risk being more greater than the benefit. The Physician's Progress Record, dated [DATE], indicated the primary physician and all consultants had a lengthy discussion with the son and agreed the medical management of palliative (affording relief, but not cure) and hospice-type (end-of-life care provided by health professionals and volunteers; the goal of care is to help people who are dying have peace, comfort and dignity) care would be given. The Nursing, Patient Progress Record notes, dated [DATE] at 2:15 a.m., revealed the resident's throat sounds were gurgled and respiratory therapy (RT) was called to suction. The RT suctioned the resident and removed little, pinkish mucous. The resident's respirations did not improve and started to have abnormal breathing. Resident 25 stopped breathing and turned pale. Resident 25 was a "do not resuscitate/do not intubate" (DNR/DNI), and no code was called. At 2:50 a.m. and 3:10 a.m., the primary physician was notified of the resident's expiration. At 3:38 a.m., Family Medicine, Physician J pronounced the resident expired. b. On [DATE], during the recertification survey, Resident 28's clinical record was reviewed. The admission record indicated Resident 28 was originally admitted on [DATE], and was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated Resident 28 had a short-term memory problem and was moderately impaired in cognitive skills for daily decision - making and required supervision while ambulating on and off the unit, during transfer and walking in room. According to the Fall Risk assessment dated [DATE], Resident 28 had a fall in the last three months and required supervision or assistance in ambulation. The fall risk assessment also indicated Resident 28's fall assessment score was sixteen, and a score of ten or greater was considered a high risk for falls. A review of the care plan dated [DATE], indicated Resident 28 was at risk for falls/injuries related to impaired cognition, lack of coordination and gait abnormality. The goal for Resident 28 was to be free of injury daily for three months. The care plan approaches included observing the resident during activities and mobility. The falls/injuries care plan was updated on [DATE], and a new staff approach was to provide a 1:1 "assist" when the resident was pacing in the hallway. A review of the fall investigation form dated [DATE], indicated the investigating nurse supervisor (Staff B) recommended the staff to provide assistance at all times while Resident 28 was ambulating. A review of the Inter-disciplinary Team (IDT) meeting notes dated [DATE], indicated Resident 28 sustained a fall on [DATE]. The IDT meeting notes indicated the interventions for Resident 28 included providing a 1:1 "intervention" when pacing in the hallway. On [DATE], a review of the Nurse's Record dated [DATE] at 2:35 p.m., indicated Resident 28 fell again. The nurse's record indicated the resident was walking in front of the nurse's station with a FWW (front wheel walker) "independently", lost her balance, fell and landed on her buttocks. There was no documentation the staff was supervising or assisting the resident at this time. The Nurse's Record also indicated Resident 28 was holding her groin and grimacing. The Nurse's Record further indicated that at 3:05 p.m., Resident 28 started screaming so loud with pain, was grimacing, and holding her left pelvic area. A 911 (medical emergency telephone number) was called, and the resident was then transferred to an acute care hospital. A review of the risk for falls care plans dated [DATE] and [DATE], indicated the plan of care was not updated after Resident 28's fall on [DATE], to address new interventions designed to prevent future falls and injuries. The care plans did not indicate frequent visual checks as a staff approach, social service evaluation or IDT re-evaluation as a staff approach as indicated in the facility's policy and procedure. A review of the policy and procedure titled, Fall Prevention revised [DATE], indicated the resident would be assessed for appropriate approaches in establishing or updating the resident care plan as necessary, which may include frequent visual checks, social services evaluation and the IDT would assess and re-evaluate all residents post fall and as needed. During an interview with the nurse manager (Staff A) on [DATE] at 10:15 a.m., she stated that "1:1 assist" as indicated in the care plan meant that a staff member should have been with Resident 28 to provide "1:1 supervision." Staff A also stated the care plan had not been updated with new or different approaches for the fall incident on [DATE]. A review of the emergency room Report from the acute care facility, dated [DATE] at 6:44 p.m., indicated Resident 28 had a non-displaced left pelvic fracture (bone cracked with broken pieces still in alignment), an orthopedic consult was called, and the resident was admitted to the acute hospital. A review of the acute hospital's Transfer Summary dated [DATE], (seven days after fall) indicated that during the hospital course, Resident 28 was confused and delirious, with [DIAGNOSES REDACTED] (impairment or loss of brain function). The resident had dysphagia (difficulty swallowing) and a nasogastric tube was inserted, with tube feeding started due to resident's poor cognition. The physician's assessment and plan included pelvic fracture, stable and delirium with [DIAGNOSES REDACTED], with increased agitation and delusions. A review of the physician's orders [REDACTED].The physician's orders [REDACTED]. On [DATE] at 10:25 a.m., in an interview, the medical record staff member stated Resident 28 was discharged from the facility on [DATE], (nine days later) because she died . A review of the facility's policy and procedure titled, Fall Prevention revised [DATE], indicated all residents would receive adequate supervision and assistive devices to prevent accidents and any resident identified as "at risk" for falls would have an individual treatment plan that included interventions to prevent fall from occurring. c. A review of the admission record indicated Resident 14, who was originally admitted on [DATE] and was readmitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE], indicated Resident 14 was moderately impaired in cognitive skills for daily decision- making and required extensive assistance while ambulating on and off the unit, during transfer and while walking in the room. The MDS also indicated Resident 14 also had a short-term memory problem, able to recall what was just learned after five minutes, her cognitive skills for decision-making was moderately impaired, and fell in the last 30 days and the last 31 - 180 days. A review of the fall risk assessment dated [DATE], indicated Resident 14 had five (5) incidents of falls since admission (Oct. 21, 2010, [DATE], [DATE], [DATE], and [DATE]). Resident 14's fall risk assessment score was twenty, and a score of ten or greater was considered a high risk for falls. The fall risk assessment also indicated the resident required supervision or assistance in ambulation, but frequently the resident did not obtain the required assistance from the staff. A review of the care plan dated [DATE], indicated Resident 14 was a high risk for recurrent falls/injuries related to dementia with agitation and history of falls. The goal for Resident 14 was to be free of injury daily for three months. The staff approaches included observing the resident during activities and mobility, applying a lap tray for positioning and providing 1:1 companion when available. A review of the Nurse's Record dated [DATE], indicated Resident 14 fell again (four days after the most recent fall, making this her sixth fall). The Nurse's Record indicated the resident fell from her wheelchair, hit her head to the floor in the big dining room and a big raised area/bump was noted on Resident 14's

Based on record review and interview, the facility failed to maintain clinical records on each resident that were accurately documented by failing to ensure that Resident 4's Treatment Flowsheet pertaining to checking the oxygen saturations (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) accurately reflected the service provided by the licensed nurse on October 10, 2010. The entry in the resident's medical record was made in the knowledge that the record falsely reflected the resident's oxygen saturation level. Findings: The medical record for Resident 4 was reviewed on October 27, 2010, at 10:20 a.m. The Admission Face Sheet indicated Resident 4 was admitted to the facility on [DATE], and was readmitted on [DATE]. His admitting [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment dated [DATE], identified the resident had memory problems, his cognitive skills for decision-making were impaired, and required extensive to total assistance in activities of daily living. The recapitulation of physician's orders [REDACTED]. A review of the document titled, "Treatments Flowsheet" dated September 12, 2010 to October 12, 2010, indicated the space for the oxygen saturation reading for October 10, 2010, Shift 1, was left blank. On October 27, 2010 at 10:20 a.m., a copy of the Treatment Flowsheet was requested from Employee F. When another staff member returned the copy of the Treatment Flowsheet to the surveyor at 10:42 a.m., the blank space for the oxygen saturation reading for October 10, 2010, Shift 1, was filled in with a value of 95. Employee F, nurse manager, was interviewed on October 27, 2010, at 10:42 a.m. She stated, "It was me. She (the staff who photocopied the document) told me that this (the space for the oxygen saturation reading for October 10, 2010, Shift 1) is blank." "I said, "here" and I wrote on it. I'm sorry." Employee F was interviewed again at 11:15 a.m. She stated that she was not the nurse who took care of Resident 4 on October 10, 2010. Employee F stated, "I don't even remember if I worked that day." When the surveyor asked Employee F where the value of 95 that she wrote on the blank space of oxygen saturation reading for October 10, 2010, Shift 1, came from, she stated, "I took the O2 sat (oxygen saturation) reading today just before I wrote it down. I know I am the nurse manager and should have been the good example." During a meeting with the administrator and the chief operations officer on October 28, 2010, at 9:23 a.m., the administrator stated that Employee F was suspended effective the afternoon of October 27, 2010, pending the facility investigation of the incident. The facility policy and procedure titled, "Medication and Treatment Administration Record" dated June 2004, indicated the nurse who administered the treatment is to record his/her initials in the appropriate box on the treatment administration record. Initials are to be identified with the nurse's signature and title on the form.