Every finding on record at Kensington Gardens Rehab and Nursing Center

Based on observations, interviews, and record review, the facility failed to provide wound care in accordance with professional standards for two residents (#1 and #3) of three residents sampled. Findings included: On 8/27/26 at 9:21 a.m. Resident #1 was observed sitting in a wheelchair, eyes closed, shaking, breathing rapidly, and non-responsive to verbalizations. Staff B, Licensed Practical Nurse (LPN) responded to the resident room and was unable to elicit a response from the resident. As the staff member left the room, the resident opened eyes saying (pronoun) was fine. Staff C, Licensed Practical Nurse/Unit Manager came into room and resident informed the staff member they were okay. Staff C placed pulse oximeter on resident and Staff B returned and administered a nebulizing medication to the resident. Bilateral rolled gauze covering of the lower extremities had large areas stained with a tan-coloring unknown substance. Staff C observed the dressing and stated the dressings were not dated. One black flying insect was observed flying near the residents lower extremities. Staff C stated staff have to change dressings because they (bilateral lower extremities) weep. On 8/27/26 at 11:46 a.m. Resident #1 reported refusing wound care, the resident's lower extremities were covered with a blanket with a flying insects flying nearby. Review of Resident #1s admission Record showed the resident was admitted on [DATE] and 3/19/26. The record included diagnoses not limited to chronic obstructive pulmonary disease with (acute) exacerbation, cellulitis of left and right lower limb, carrier or suspected carrier of methicillin resistant staphylococcus aureus (MRSA), and not elsewhere classified lymphedema. Review of Resident #1s August 2026 Treatment Administration Record (TAR) included orders as follows: Wound care: cleanse right lower with Dakin's 1/4 strength, pat dry, apply calcium alginate ag, blue super absorbent pad and wrap with (rolled gauze) and secure with tape daily and as needed (prn). Wrap with ace bandage for compression every evening shift for wound care . The TAR showed this signed off as completed on 8/26/26. Wound care: cleanse left lower with Dakin's 1/4 strength, pat dry, apply calcium alginate ag, blue super absorbent pad and wrap with (rolled gauze) and secure with tape daily and as needed (prn). Wrap with ace bandage for compression every evening shift for wound care . The TAR showed this signed off as completed on 8/26/26. Wound care: Cleanse right lower with Dakin's 1/4 strength, pat dry, apply Calcium Alginate Ag, blue super absorbent pad and wrap with (rolled gauze) and secure with tape daily and as needed (prn). Wrap with ace bandage for compression as needed for dislodgement/saturation. The TAR showed the dressing had been changed (PRN) as needed on 8/22/26. Wound Care: Cleanse Left Lower Leg With Dakin's 1/4 Strength, pat dry, apply Calcium Alginate Ag, Blue super absorbent pad And wrap with (rolled gauze) and secure with tape daily And PRN. Wrap with Ace Bandage For Compression as needed for Dislodgment/Saturation. The TAR showed the dressing was last changed (PRN) as needed on 8/22/26. Review of a Skin/Wound progress note, created on 8/24/26 effective 8/20/26, reported Resident #1s Wounds Deteriorating as per Providers assessment. Review of the Wound Care providers progress note, dated 8/20/26, showed the daily wound care will be maintained as recommended by the primary team and leg elevation and compression wraps are advised to reduce swelling. The wounds involving both lower extremities continue to deteriorate, with increased wound size and worsening wound bed appearance. The patient remains poorly compliant with recommended edema- control measures and continues to sleep in the wheelchair, resulting in prolonged dependent positioning of the lower extremities. Per nursing staff, the patient has also intermittently refused scheduled wound care. Review of Resident #1s care plan showed the resident required enhanced/contact barrier precautions during high contact resident care activities related to carrier C. Auris (and) MRSA history (hx). The interventions instructed staff to maintain enhanced barrier precautions during high contact care activities of dressing, bathing, showering, transferring, providing hygiene, changing linens, (and) changing briefs or assisting with toileting. An interview was conducted with Staff B on 8/27/26 at 12:05 p.m. Staff B stated Resident #1 had refused wound care one time when the staff member worked the 3 p.m. – 11 p.m. shift but hadn't received any report of the resident refusing wound care. The staff member stated the resident's wounds had lots of drainage and if there was a lot of drainage we have to redo the dressings. An interview was conducted with Staff E, Registered Nurse (RN) on 8/27/26 at 12:16 p.m. Staff E reported being the facility's dedicated wound care nurse Monday – Fridays. The Director of Nursing (DON) stated the floor nurses were responsible for wound care on Saturday and Sunday's. Staff E stated Resident #1's wounds have deteriorated as of today and last week, has copious drainage, a lot of serosanguinous fluid bilateral lower extremities caused by edema. The staff member described the wound as having a granulation wound bed with maceration and the peri-wound was dry and scaly. During an interview on 8/27/26 at 12:50 p.m. the DON stated if Resident #1's dressings are saturated, other shift nurses were supposed to change the dressings and they should be dated. Review of the policy – Clean Dressing Change, revised 01/2024, showed the purpose was to provide guidelines for the application of dry clean dressings. The procedure showed if the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. Review of the policy did not address as needed (prn) dressing changes when a resident refused and if dressings are dated, per professional standards, when completed. Review of Resident #3's admission record revealed an admission date of 03/06/2023. Resident #3 was admitted to the facility with diagnosis to include paraplegia, pressure ulcer of sacral region stage 4, neuromuscular dysfunction of bladder, and acquired absence of right leg above the knee. Review of Resident #3's Active orders revealed: Wound care: Cleanse Left Ischial, Wound Cleaner, Pat Dry, Peri wound with skin prep, collagen powder to wound. day shift for pressure ulcers. Wound care: Cleanse Right Ischial, Wound Cleaner, Pat Dry, Peri wound with skin prep, collagen powder to wound. day shift for pressure ulcers. Review of Resident #3's Treatment Administration Record (TAR) revealed: Wound care: Cleanse Left Ischial was not completed on August 5th, 18th, and 24th. Wound care: Cleanse Right Ischial was not completed on August 5th, 18th, and 24th. During an interview on 08/27/2026 at 12:19 p.m. Staff A, LPN stated residents who have wounds have orders they follow. We want to make sure we assess the wounds and speak with the wound care nurse. The nurses can sign off on the TAR the wounds dressing were changed, but a lot of times the wound care nurse will also sign off them for us. She could not review Resident #3's TAR because she stated she did not know how to look back on the TAR. During an interview on 08/27/2026 at 1:43 p.m., the wound care nurse and Director of Nursing (DON), stated we document on the TAR you just click it off. There should be something. The Wound Care Nurse stated she does not have time to monitor the nurses to ensure the wound care is being completed for residents. I do all the dressing changes for Resident #3. I work Monday through Friday 8-4:30p.m. Wound Care Nurse and The DON reviewed Resident #3 TAR and stated it is missing documentation for August 5th, 18th, and 24th. We are not sure why there is a whole on those days.

Based on observations, interviews, and record review, the facility failed to ensure two residents (#1 and #4) of twelve residents receiving wound care had Enhanced Barrier Precautions implemented for high contact care activities as recommended by the Centers of Disease Control and Prevention (CDC). Findings included: 1. An observation on 8/27/26 at 9:21 a.m. showed Resident #1 sitting in wheelchair with bilateral lower extremities covered with tan-colored stained rolled gauze from below the knee to ankles. Staff C, Licensed Practical Nurse/Unit Manager, stated the bilateral dressings were not dated as to when the dressing had been applied and staff have to change them because they weep. The observation showed the area outside the room was not posted with an Enhanced Barrier Precaution (EBP) sign or available Personal Protective Equipment (PPE) caddy was outside the room. An interview was conducted on 8/27/26 at 12:35 p.m. with Staff D, Certified Nursing Assistant (CNA). Staff D shook head and stated Resident #1 was not on any type of precautions, if on precautions there would be a sign on the door and a caddy outside. The staff member pointed to nearby EBP signs on other resident's door frames. Staff D observed Resident #1s doorway and confirmed there was no EBP sign posted. An interview was conducted with Staff E, Wound Care Registered Nurse on 8/27/26 at 12:38 p.m. The staff member stated Resident #1 should be on EBP and there was not a sign for EBP on the door. Review of Resident #1s admission Record showed the resident was admitted on [DATE] and 3/19/26. The record included diagnoses not limited to cellulitis of left and right lower limbs, carrier of suspected carrier of methicillin resistant staphylococcus aureus (MRSA) and carrier of other infectious diseases. Review of the August 2026 Treatment Administration Record (TAR) for Resident #1 showed staff were administering wound care to bilateral lower extremities which included the cleaning with 1/4 strength Dakin's solution, applying calcium alginate Ag, a blue super absorbent pad and rolled gauze. Review of Resident #1s care plan showed the resident required Enhanced/Contact Barrier Precautions during high contact resident care activities related to (r/t) carrier (of) c. Auris (and) MRSA history. The interventions showed high contact care activities included dressing, bathing, showering, transferring, providing hygiene, changing linens, (and/or) changing briefs or assisting with toileting. Review of the wound care providers note on 8/20/26 showed Resident #1s bilateral lower leg wounds were deteriorating and both had a large amount of serous drainage, the right leg drainage had a strong odor and the left had a mild odor. 2. An observation was conducted on 8/27/26 at 1:14 p.m. of the area outside Resident #4's room. The area surrounding the door and/or the door did not reveal EBP had been implemented for the resident. An interview was conducted with Staff F, Certified Nursing Assistant (CNA) on 8/27/26 at 1:12 p.m. The staff member stated Resident #4 did not have a wound. An interview was conducted with Staff G, CNA on 8/27/26 at 1:14 p.m. outside of Resident #4's room. The staff member reported Resident #4 did have a wound to the right lower extremity. Staff G reported dressing in gown and gloves when going in (to the room) and doing any care. Review of Resident #4s record showed the resident was admitted on [DATE] and 8/14/26. The primary admitting diagnosis was subsequent encounter (for) infection and inflammatory reaction due to internal left knee prosthesis and unspecified local infection of the skin and subcutaneous tissue. Review of Resident #4s physician orders included but not limited to the following:Wound Care: Cleanse left medial lower leg with normal saline (NS), gently pat dry, protect peri-wound with skin prep, apply Santyl, calcium alginate, Abdominal (ABD) pad and secure with conforming rolled gauze with tape daily and as needed (prn).Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precaution for left upper arm mid-line. Review of the CDC guidelines for health care providers, reviewed on April 2, 2024 - Implementation of Personal Protective Equipment (PPE) Use in Nursing homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) showed: Residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs. The guidance showed the use of EBP was to expand the use of PPE and for the use of gown and gloves during high-contact resident care activities that provide oprovide opportunities for transfer of MDRSs to staff hands and clothing. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The listed examples of high-contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, (and) wound care: any skin opening requiring a dressing.

Based on record reviews and interviews the facility failed to implement an effective Antibiotic Stewardship program as evidence by the lack of tracking of infections and not ensuring antibiotic use met infection criteria. Findings included: Review of the facility December 2025 Infection and Antibiotic Tracking Tool showed symptoms related to antibiotic use as urinary tract symptoms. The tool revealed Resident #42 was diagnosed with an urinary tract infection (UTI) with symptoms of urinary tract symptoms and leukocytosis, an urine test was obtained with no documentation of white blood cell count (WBC), colony count, or culture results. The documentation showed the resident was treated with Ceftriaxone for 7 days (12/20-12/27/25) and the urinalysis (UA) was negative (neg). Review of the facility January 2026 Infection and Antibiotic Tracking Tool revealed the tool was incomplete, symptoms were not listed and did not show if a culture or test had been obtained for five of nineteen facility acquired conditions treated with antibiotics. Review of Resident #30s tracking tool documentation showed the resident was treated with Nitrofurantoin from 1/8 to 1/18/26 for a facility-acquired urinary tract infection (UTI). The tool did not reveal the resident had symptoms, if a test had been obtained, or the results of the testing. Review of Resident #30s progress note dated 1/5/26 at 9:32 p.m. showed the resident complained of not feeling like herself. The staff received orders for testing including an urinalysis. Review of the note showed on 1/8/26 the physician was notified of the urinalysis culture and sensitivity results. The urine culture showed a colony count of >100,000 of Escherichia coli with many bacteria. Review of Resident #30s record did not show an infection surveillance criteria had not been completed to determine the necessity of the residents antibiotic use. Review of Resident #31s tracking tool documentation showed the resident was treated for a facility-acquired skin and soft tissue infection. The tool did not reveal the resident had any symptoms, did not show results of a test or culture or if any had been obtained. The tool revealed the resident was treated with doxycycline from 1/3 to 1/17/26 for a lower extremity ([NAME]) wound. A Situation, Background, Appearance, and Review showed the resident had a skin wound or ulcer which started on 12/29/25 and had not occurred before. The SBAR showed no changes in skin had been observed and pain was not applicable to the change in condition. Review of Resident #31s infection surveillance criteria showed cellulitis was suspected, the resident had a left [NAME] with open wound/cellulitis. The surveillance tool showed to meet infection criteria either pus or four other signs/symptoms (s/s) were required. The documentation showed no pus, and three of the four required s/s were met. The conclusion was the condition did not meet criteria for infection. During an interview on 2/18/26 at 2:00 p.m. the Infection Preventionist (IP) reported normally does the line listing every week, runs an antibiotic report sometimes during the week and does the line listing from that, I try to do it every week. The IP reported checking antibiotics by using the order listing and the electronic dashboard, checks the dashboard every day, and does the surveillance criteria probably every week when order listing report is ran. The IP stated urinary tract symptoms are burning with urination, frequency, new incontinency, feeling urgency, and needing to pee'. The IP stated when someone has an UTI not all of the reported symptoms are exhibited. The IP reviewed the line listing and confirmed the listing should identify what type of urinary tract symptoms were exhibited and would have to look at the resident record to see what had been exhibited. The IP stated they don't check antibiotic when coming from the hospital assumes the hospital has done it. The IP stated the January line listing was not complete and corporate expectation was for it to be done by the sixth of the month. An interview was conducted with the Director of Nursing (DON) on 2/18/26 at 3:14 p.m. The DON stated the expectation for (infection) line listings was they should be completed. The [NAME] revealed the line listing, usually updates (it) continuously, it's an ongoing document, continuously is needed. The DON confirmed the listing should be updated when a new antibiotic was ordered, with culture/(test) results, and completion dates, the infection surveillance criteria should be done weekly. The DON reviewed Resident #31s line listing and stated it should be completed entirely. The DON reviewed Resident #30s line listing documentation, stating the listing should show symptoms, test results, and be completed entirely. The DON confirmed Resident #30 did not have a surveillance criteria completed. The DON stated C. auris was in the building, there should be tracking, where they (resident) had been, and should have EBP if colonized. She stated the IP should have a list of current C. auris residents not just a list of persons on EBP and there should be signage on (resident) door. Review of the policy - Nursing - Infection Control - Antibiotic Stewardship, revised 2/2023, revealed Antibiotic Stewardship is the effort to measure and improve how antibiotics use with residents. It is a commitment of education, action, and response to effectively treat infections, protect residents from harm caused by unnecessary antibiotic use, and combat antibiotic resistance. Antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program.1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.The policy did not address the completion of tracking and surveillance tools. Review of the policy - Infection Control - Infection Prevention and Control Program, revised 1/2024, revealed An infection prevention and control program (IPCP) our established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.2. The elements of the infection prevention and control program consist of coordination/ oversight, policies/ procedures, surveillance, data analysts, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.4. The infection prevention the control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends.The Antibiotic Stewardship portion revealed:1. Culture reports, sensitivity data, and antibiotic usage reviews are included in the surveillance activities.2. Medical criteria and standardized definitions of infections are used to help recognize and manage infections.

Based on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to staff performing hand hygiene between providing care for two (#27 and #28) resident's and failed to ensure an enhanced barrier precaution sign was posted for one (#29) of thirteen residents diagnosed with a infectious disease.Findings included: On 2/17/26 at 9:40 a.m. Staff J, Restorative Aide (RA) was observed standing next to Resident #27s bed. The staff member was observed removing a pair of gloves, leaving the room, crossing the hallway, and entering Resident #28s room. The staff member came out of room holding a pair of disposable gloves going to the laundry cart parked further down the hallway. Staff J returned to Resident #28s room and was heard informing the resident that a splint would be put on Resident #28. The staff member exited the room and stated hand hygiene should have been performed after removing gloves and had not completed the task in between the two resident's. Review of the facility's December and January infection line listings was completed on 2/18/26 at 10:51 a.m. The line listings did not reveal any resident had been diagnosed with the fungal infection of Candida auris (C. auris). The listing did reveal skin and soft tissue infections. The review of January listing showed multiple incomplete areas regarding symptoms exhibited, if culture or testing had been done, and/or results of the culture or testing. The December listing included generalized symptoms such as pain, acute functional decline, and urinary tract symptoms. An interview was conducted with the Infection Preventionist (IP) on 2/18/26 at 10:59 a.m. The IP reported not tracking or having a list of residents diagnosed with C. auris. The IP stated resident's with C. Auris should be on Enhanced Barrier Precautions (EBP) forever and did track EBPs. On 2/18/26 at 12:44 p.m. the IP provided a list of resident's who had been diagnosed with C. Auris and stated they do not add them to the line listing as those residents are not receiving antibiotics. The IP reported tracking C. Auris based on the EBPs. The IP reported having failed job as life had been hectic and recently quit smoking and had been working from home. Review of the list showing names of residents currently diagnosed with C. Auris included Resident #29. An observation was made on 2/18/26 as staff were removing lunch trays from resident rooms. The door and surrounding area outside of Resident #29s room did not show a precaution sign was posted. The [NAME] was hung on the door. During the observation multiple Certified Nursing Assistants (CNAs) were seen at the meal cart. Staff L, CNA was observed leaving Resident #29s room and reported being assigned to Resident #29. The staff member reported there was no precautions for the resident and two other unknown staff members also reported Resident #29 did not have precautions as the resident only had a wound. Review of Resident #29s admission Record showed the resident was admitted on [DATE], 1/17/26, and 2/12/26. The record included diagnoses not limited to acute and chronic respiratory failure with hypoxia and unspecified severe protein-calorie malnutrition. The diagnoses did not include C. Auris. Review of Resident #29s active physician orders included an order dated 2/12/26 at 6:36 p.m. for Enhanced Barrier: Encourage and assist resident to maintain enhanced barrier precautions for C. Auris, intravenous (IV), and wound every shift. Review of the Center of Disease Control and Prevention (CDC) website revealed Candida auris (C. auris) was an emerging fungus, spread in hospitals, and could cause severe multidrug-resistant illness, (https://www.cdc.gov/candida-auris/index.html). The CDC Infection Control Guidance for C. auris, dated April 24, 2024, revealed the fungus spreads easily in healthcare settings and can cause outbreaks, environmental disinfection, staff training, and hand hygiene can prevent outbreaks. C. auris can colonize patients and persist on surfaces for many months and is not killed by some common disinfectants. The guidance showed However, facilities may assign rooms based on single (or a limited number of) high-concern multi-drug resistant organisms (MDROs) (e.g. C. auris or carbapenemase-producing Enterobacterales) without regard to co-colonizing organisms. Ensuring that all healthcare personnel adhere to infection control recommendations is critical to preventing transmission of C. auris, other MDROs, and communicable diseases. Ensure that an appropriate sign is present on the patient's door to alert healthcare personnel and visitors of recommended precautions. An interview was conducted with the Infection Preventionist (IP) on 2/18/26 at 2:00 p.m. The IP stated all the residents on the C. auris list should have a sign posted, usually checks on Mondays but this week hadn't been usual, and Resident #29 was just readmitted . The IP reviewed the resident's record and stated the resident had been readmitted on the twelfth (2/12/26) and should have been on precautions at that time. The IP confirmed making the list of residents with C. auris today, usually pulled an order listing report for EBPs on Mondays, and walks the halls to ensure signs are posted. The IP stated staff should be aware of precautions and hand hygiene should be done before during and after care, absolutely should be done in between patients and before putting gloves on. Review of the policy - Hand Hygiene Infection Control, revised 6/2023, revealed Hand hygiene is the single most important measure for preventing the spread of infection. This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. The procedure included but not limited to situations that require hand hygiene: before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), and after removing gloves or aprons. Review of the policy - Infection Control - Infection Prevention and Control Program, revised 1/2024, An infection prevention and control program (IPCP) are established and maintained provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program is based on accepted national infection prevention and control standards in accordance with local, state, and federal regulations and guidelines. The elements of the infection prevention and control program consist of coordination/ oversight, policies/ procedures, surveillance, data analyst, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The important facets of infection prevention included but not limited to: a. Identifying possible infections or potential complications of existing infections; b. Instituting measures to avoid complications or dissemination;c. Educating staff and ensuring that they adhere to proper techniques and procedures;g. Implementing appropriate isolation precautions when necessary; andh. Following established general and disease-specific guidelines such as those of the CDC. Review of the policy - Transmission Based Precautions, revised 2/2024, revealed All staff receive training on transmission-based precautions upon hire and at least annually.The procedure revealed Initiation of Transmission-based Precautions:a. In order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively.b. The order of for isolation will specify the type of isolation and reason for isolation. The duration will depend upon the infection in physician recommendations.5. Enhanced Barrier Precautions: a. Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: i. Wounds or indwelling medical devices when colonization is present ii. Infection or colonization with an MDRO and/or C. auris (CAURIS).The policy showed the recommended transmission-based precautions for C. auris was enhanced barrier if colonized with no duration time.

Based on observation, record review, and interview, the facility failed to develop a comprehensive grievance policy and procedure, failed to implement the grievance procedure to investigate customer care concerns for two residents (#8 and #2), and failed to have evidence of informing the results of grievance investigation for four residents (#9, #8, #10, and #2) of four residents sampled for grievances.Findings included: A review of the facility's Grievances - Resident Rights policy and procedure, last revised 07/2024, documented the guideline: The Administrator and staff will make prompt efforts to resolve grievance so the satisfaction of the resident and / or representative.The Procedure:Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and/or in writing upon request including a rationale for the response. 8. Upon receipt of a grievance and/ or complaint, the Grievance Officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5) working days of receiving the grievance and/ or complaint. In the event the facilities investigation exceeds five (5) working days, the resident/ responsible party will be notified. 9. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the allegations. All alleged violations of neglect, abuse and / or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law. 10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any, need to be taken. 12. The resident, or person filing the grievance and/ or complaint on behalf of the resident will be informed (verbally and/ or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems.a. The Administrator, or his or her designee, will make such reports orally within ten (10) working days of the filing of the grievance or complaint with the facility.b. A written summary of the investigation will also be provided to the resident upon request, and a copy will be filed in the business office.Review of the facility Grievance policy and procedure revealed there was no listing of the notification to State Survey Agency and State Long-Term Care Ombudsman program.A review of Resident #2's clinical chart, the admission record, documented an admission of 12/04/2025. The diagnosis information included but not limited to chronic pain syndrome; heart failure; bipolar disorder, muscle weakness (generalized) and neuromuscular dysfunction of bladder. A review of a Brief Interview for Mental Status (BIMS), dated 12/08/2025, documented a score of 15, which indicated the resident was cognitively intact.Review of grievances showed Resident #2 filed a grievance dated as received 01/14/2026, filed by the resident, date of incident, 01/14/2026, documented as investigated by the Director of Nursing (DON), and resolved on 01/14/2026.For Resident #2's grievance, dated 01/14/2026, Call light response time., the SSA said, the concern was about call light response time. The SSA was unable to answer the length of time reported by the resident for the grievance.A review of Resident #8's clinical chart, the admission record, documented an admission of 12/05/2025. The diagnosis information included but not limited to Necrotizing Fasciitis, Type 2 Diabetes Mellitus without complications; chronic combined systolic (congestive) and diastolic (congestive) heart failure; difficulty in walking; muscle weakness; and colostomy status. A review of a Brief Interview for Mental Status (BIMS), dated 12/08/2025, and 01/15/2026, documented a score of 15, which indicated the resident was cognitively intact.Review of grievances showed Resident #8 filed a grievance dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated by the Assistant Director of Nursing (ADON) and resolved on 12/12/2025. Review of grievances showed Resident #8 filed a second grievance dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated and resolved on 12/12/2025.On 01/15/2026 at 1:14 p.m., an interview was conducted with the Social Services Assistant (SSA) and Staff H, a social Worker at a sister facility. During the interview, review of Resident #8's 12/11/2025 grievance was conducted. The grievance showed Resident voiced concern about customer service and waited too long for call light to be answered, which was documented to have occurred on 12/10/25. During the interview, the SSA said she gave this one to the ADON and staff were trained on call lights. The SSA said she did not know the length of time the call bell light had not been responded to. When asked if a statement had been obtained from the resident, the SSA did not answer.For Resident #8's second grievance, dated 12/11/2025, Resident voiced concern about customer service. The SSA stated this one, the resident had a complaint about staff not answering phones when called. The SA stated staff were trained on phones are to be answered.A review of Resident #9's clinical chart, the admission record, documented an admission of 11/03/2025. The diagnosis information included: displaced comminuted fracture of shaft of left femur, lack of coordination and need for assistance with personal care. A review of a Brief Interview for Mental Status (BIMS), dated 11/14/2025, documented a score of 14, which indicated the resident was cognitively intact.Review of grievances showed Resident #9 filed a grievance received on 12/01/2025, filed by the resident's family member, date of incident, 12/01/2025, the Social Service Assistant (SSA) was listed as the person investigating the incident; dated as resolved on 12/02/2025.A review of Resident #10's clinical chart, the admission record, documented an admission of 12/19/2025. The diagnosis information included: Chronic pain syndrome; cervical disc degeneration; and muscle weakness (generalized). A review of a Brief Interview for Mental Status (BIMS), dated 01/07/2026, documented a score of 13, which indicated the resident was cognitively intact.Review of grievances showed Resident #10 filed a grievance, dated as received on 12/26/2025, filed by the resident, date of incident 12/26/2025, documented as investigated by the ADON, and resolved on 12/16/2025.On 01/15/2026 at 12:05 p.m., an interview was conducted with the SSA and Staff H. The grievances for #9, #8, #10, and #2 were reviewed. The grievance forms, the area for the resident/ responsible party notification of resolution name and signature area were blank on the grievances for #9, #8, #10, and #2. Staff H stated a follow-up should have taken place with the residents.On 1/15/2025 at 1:58 p.m., an interview was conducted with Resident #8. Regarding the grievance about call bell light response time dated 12/11/25, he stated, oh yea, that was when my colostomy bag had broken open and I had feces on my stomach. It took three hours for them to answer the call bell light. I thought that was a little excessive. He said, the colostomy is supposed to be changed as needed. It was coming away from the skin with feces on it. He said he was worried about the integrity of the wound. Resident #8 said, I had to wait for the nurse. The nurse had three admissions that night. That is why I filed the grievance. I filed it, and that is as far as it went. No one came and talked to me about it. An interview was conducted on 01/15/2026 at 3:41 p.m. with the Director of Nursing (DON). regarding Resident #8's grievance form, dated 12/11/2025, waited too long for call light to be answered. She stated the ADON took care of the grievance. The DON reviewed the grievance and stated it looks like it was a customer service issue. She stated, I do not know how long he waited. When asked if she should know, she stated, not necessarily. The DON confirmed she was the Abuse Coordinator. She stated the grievance was talked about in the morning meeting the day following the submission of the grievance. She stated she recalled the grievance was about the staff came in and were rude. When asked if a resident had waited three hours for the call bell light to be responded to, she stated, three hours, that would be a problem. No patient should have to wait for an extended period of time. The DON confirmed no resident interview was attached to the grievance as part of the investigation. When asked how an investigation could be conducted without an interview with the resident voicing the concern, the DON stated, call light response times are something we are educating staff on. For Resident #8's 2nd grievance, the 12/11/2025, Resident voiced concern about customer service, the DON confirmed no statement from the resident was available to review for the grievance. For Resident #2's grievance, dated 01/14/2026, call light response time. The DON confirmed she had filled out the grievance; she had received the grievance from staff. The DON confirmed no statement from Resident #2 was available to reflect the resident had been interviewed regarding her concern.

Based on interview and record review the facility failed to provide quality of care related to resident assessments for a change in condition of vascular wounds for two residents (#4 and #11) of six sampled residents. Findings included: 1. Resident #4 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the admissions record showed diagnoses included but not limited to diabetes, acquired below knee amputation, Chronic Obstructive Pulmonary Disease (COPD), Peripheral vascular disease, muscle weakness, permanent atrial fibrillation, Chronic systolic congestive heart failure, and pulmonary hypertension. Review of the Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 or cognitively intact. Section GG showed he required maximum assistance for toileting and bathing. Section O, showed he was on oxygen. Review of the physician orders showedResident was a full codeContinuous oxygen at 2 liters per minute via nasal cannula for shortness of breathAlbuterol sulfate inhalation nebulization solution 0.63 milligram/3 milliliter orally via nebulizer every 6 hours as needed for shortness of breath and / or wheezingProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB Review of the [DATE] Medication Administration Record (MAR) showed ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB was given on [DATE] at 11:03 p.m. and was ineffectiveAlbuterol sulfate inhalation nebulization solution 0.63 milligram/3 milliliter orally via nebulizer every 6 hours as needed for shortness of breath and / or wheezing was given on [DATE] at 11:18 p.m. and was ineffective.Oxycontin ER 12 hour 40 mg give by mouth at bedtime as of [DATE] was given at 8:00 p.m. Review of the progress notes showed: On [DATE] per Medical Doctor (MD), change oxycontin to once daily at 8 p.m.On [DATE] at 11:02 a.m. ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB by Staff C, Licensed Practical Nurse (LPN)On [DATE] at 11:18 p.m. Albuterol Sulfate Inhalation Nebulization Solution 0.63 MG/3ML 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath and/or wheezing by Staff C, LPNReview of a progress note for Resident #1 showed on [DATE] 12:20 a.m. received report at beginning of shift from outgoing nurse stating resident was not easily waking up. This writer went to check on resident, he appeared restless and sounded congested, gave albuterol inhaler, nebulizer treatment and called 911. Emergency personnel arrived immediately and attended to the resident. Resident expired at 11:59 p.m. Notified Provider through answering service, notified DON (Director of Nursing), and attempting to notify emergency contact. Staff C, LPN (Licensed Practical Nurse).Review of the Weights and Vitals Summary showed[DATE] at 8:39 a.m. blood pressure was [DATE]/25 at 8:39 a.m. pulse was 90 During an interview on [DATE] at 2:17 p.m. Staff C, LPN stated that she remembered the resident. He passed away at the beginning of her shift. She stated he was not doing well the outgoing nurse had said. Staff C stated she was doing her rounds and the outgoing nurse was sitting at nurses' station. Staff C stated he sounded like he was congested and wheezing. She stated she called his name. and he looked at her and was wheezing. Staff C stated she went out and got his breathing stuff, Albuterol and his nebulizer. She stated his pulse oximetry was in the 80s and she called 911. Staff C stated his pulse was elevated, but did not remember the number. She stated his respirations were elevated. Staff C, LPN stated she did not check his blood pressure. She stated the resident seemed to do better after the Albuterol and nebulizer. Staff C stated she called her co-worker, Staff D, LPN to check on him. Staff C stated the resident did have a pulse and was breathing when 911 got here. She stated 911 came right away. She stated the emergency people come in groups of three. The first group assessed him. She stated she thought they will put the resident on the gurney and take him out, but they started CPR (cardiopulmonary resuscitation). She stated then a second group and then a third group came in. Staff C stated she did not start CPR because he was alive when the paramedics came in. Staff C stated the outgoing aide stated the resident was not doing well all day. The aide told Staff C that he was more sleepy and not eating. Staff C stated his roommate stated he was not doing well all day. Staff C stated she does not know why they did not send him out earlier. Staff C stated he was on antibiotics and stuff. Staff C stated she had not seen him in a couple weeks. Staff C stated the outgoing nurse, Staff E, LPN, UM (Unit Manager), did not make it sound critical, we did our narcotic count. Review of the record did not show documentation that the resident's emergency contact was notified of the change.During an interview on [DATE] at 1:37 p.m. the Director of Nursing (DON) and regional nurse stated Staff E, LPN, UM worked day shift and evening shift that day, [DATE]. The DON stated Staff E reported to Staff C, LPN that the resident was fatigue most of the day but responsive. Staff C reported that when she came onto duty she went to check on him and confirmed he appeared to be fatigue and she stated in her note, that he appeared to restless and a little congested. The DON stated Staff C gave the resident the Albuterol inhaler with no improvement. Staff C called 911 and EMS arrived to the facility. The DON stated Staff C stated they (EMS) were in the room and hooking him up and he was alert at that time. And then he coded. The DON stated Staff C stated EMS initiated CPR. EMS pronounced at 11:59 p.m. The DON stated the staff called her after he had passed. The staff attempted to call his friend. The staff made the DON aware they were unable to reach his friend. The DON was not sure if the staff put oxygen on the resident or not. The DON stated EMS was only a block away. The DON stated she did not notice the time frames between the medication was administered at 11:02 p.m. and 11:18 p.m. and the time of death of 11:59 p.m. The DON stated she did not ask about the 40-minute difference. The DON stated she does not what was going on for the 40 minutes. The DON verified there was not an SBAR written, no assessment or vital signs documented as performed, no progress note. The DON stated she does not know if the resident had oxygen on or not. The DON read the progress note which showed she gave him his Proair at 11:02 p.m. for shortness of breath prn and his nebulizer treatment at 11:18 p.m. due to the wheezing. The DON stated the nurse showed they were ineffective. The DON stated he was being treated with Guaifenesin and on antibiotics for respiratory infection from a positive chest x-ray. The DON stated he was also getting Lasix for CHF. The DON stated she did not get a call that the resident was not feeling well. The DON stated she only got a call after the fact to report he did not look good and the breathing treatment did not work and 911 was called. The DON stated he coded when EMS got there and he died. The DON verified there were no vital signs in the chart since 8:39 a.m. The DON stated Staff E, LPN called the doctor at 1:32 p.m. it appears from the progress note that the oxycodone was decreased from every 12 hours to daily.2. Resident #11 was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. Review of the admissions record showed diagnoses included but not limited to congestive heart failure, heart transplant status, end stage renal disease and dependent on dialysis, diabetes, lymphedema, immunodeficiency due to drugs, non-pressure chronic ulcer of right lower leg, morbid obesity, atrial fibrillation, anemia, chronic embolism and thrombosis of right popliteal vein ([DATE]), chronic venous hypertension, heart transplant rejection, history of pulmonary embolism, Peripheral Vascular Disease, hypertensive heart disease with heart failure. Review of the admission Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. Section GG showed resident required moderate assistance for toileting and showering. Section M, skin conditions showed resident had 2 venous ulcers present. Review of the physician orders showedWound care to evaluate and treat as of [DATE].Wound Consult, leg wound and buttock wound on [DATE]Upon discharge may have home health for SN/PT/OT to eval and treat as indicated as of [DATE]. Wound care: cleanse left buttock with normal saline, pat dry, apply Santyl and foam dressing daily as of [DATE] for pressure ulcerWound Care: Cleanse Left Buttock with Wound Cleanser, pat dry, apply Manuka Honey and cover With a silicone bordered dressing daily and prn for pressure ulcer as of [DATE] and again as of [DATE] after hospitalization. Wound Care: Cleanse right lower extremity with normal saline, pat dry, apply xeroform, calcium alginate, abdominal pads, and wrap with kerlix dressing daily as of [DATE].Wound Care: Cleanse right lower extremity with normal saline, pat dry, apply Santyl and Calcium Alginate, apply blue Superabsorbent pad and wrap with kerlix and secure with tape daily and prn for stasis ulcer as of [DATE] and [DATE] after hospitalization. Wound Care: cleanse right lateral and anterior lower leg with normal saline, pat dry and apply Santyl and Calcium Alginate AG. Apply blue superabsorbent pad and wrap with kerlix and secure with tape daily and prn as of [DATE] for stasis ulcer. Review of the [DATE] Treatment Administration Record (TAR) showed--Wound Care: Cleanse Left Buttock with Wound Cleanser, pat dry, apply Manuka Honey and cover With a silicone bordered dressing daily and prn for pressure ulcer as of [DATE] was performed on [DATE], [DATE] only. Not performed on [DATE] due to out of facility, [DATE] due to out of facility and refused; then on [DATE] he was sent to the hospital.--Wound Care: Cleanse Left Buttock with Wound Cleanser, pat dry, apply Manuka Honey and cover With a silicone bordered dressing daily and prn for pressure ulcer as of [DATE] after hospitalization showed performed on [DATE] through [DATE], [DATE] not in facility, 12/25 and [DATE] performed, [DATE] was blank; performed [DATE] to [DATE] and [DATE] was out of facility.--Wound Care: Cleanse right lower extremity with normal saline, pat dry, apply Santyl and Calcium Alginate, apply blue Superabsorbent pad and wrap with kerlix and secure with tape daily and prn for stasis ulcer as of [DATE] showed was performed on [DATE], [DATE] only. Not performed on [DATE] due to out of facility, [DATE] due to out of facility and refused; then on [DATE] he was sent to the hospital.--Wound Care: Cleanse right lower extremity with normal saline, pat dry, apply Santyl and Calcium Alginate, apply blue Superabsorbent pad and wrap with kerlix and secure with tape daily and prn for stasis ulcer as of [DATE] after hospitalization showed [DATE] through [DATE], [DATE] not in facility, 12/25 and [DATE] performed, [DATE] was blank;[DATE] was performed; [DATE] was not due to out of facility; [DATE] was blank as well as [DATE].--Wound Care: cleanse right lateral and anterior lower leg with normal saline, pat dry and apply Santyl and Calcium Alginate AG. Apply blue superabsorbent pad and wrap with kerlix and secure with tape daily and prn as of [DATE] for stasis ulcer showed not performed on [DATE] due to out of facility. Review of the [DATE] TAR showed --Wound Care: Cleanse Left Buttock with Wound Cleanser, pat dry, apply Manuka Honey and cover With a silicone bordered dressing daily and prn for pressure ulcer as of [DATE] after hospitalization showed performed on [DATE], [DATE] was blank, [DATE] showed out of facility, [DATE] through [DATE] was performed, [DATE] was blank, [DATE] through [DATE] showed performed. [DATE] (discharge) showed refused. --Wound Care: cleanse right lateral and anterior lower leg with normal saline, pat dry and apply Santyl and Calcium Alginate AG. Apply blue super absorbent pad and wrap with kerlix and secure with tape daily and prn as of [DATE] for stasis ulcer showed performed on [DATE], 1/2 /26 was blank; [DATE] was not done; [DATE] through [DATE] was performed; [DATE] was blank; 1/926 was not performed; [DATE] to [DATE] was performed; [DATE] (discharge) showed refused. Review of admission readmission Nursing Evaluation dated [DATE] showed right buttock with open area and left buttock with open area.Review of admission readmission Nursing Evaluation dated [DATE] showed left buttock open area wound team to evaluate. Right lower leg (rear) wound, wound [NAME] to evaluate. Progress notes showedOn [DATE], SBAR, due to resident had critical lab results. Obtained order from NP (nurse practitioner) to send out to hospital for blood transfusion.On [DATE], Resident re-admitted from hospital [DATE] approx. 8:45 p.m. via wheelchair and escorted to room. Refused skin assessment at this time. Will try again later. Ambulates with slow gait. Denies pain at this time. Call light within reach. Will continue to monitor.On [DATE], On this date, writer and wound care provider attempted to render services with resident. Resident returned from dialysis and was asked to remain in his room to be seen. Resident agreed. When provider and writer went back to resident room for assessment resident was not in room. writer will re-attempt. Staff F, Registered Nurse (RN)On [DATE], resident discharged home today with all medications and personal belongings via family transport. No c/o pain or respiratory distress voiced. Resident educated on medications, wound care and to follow up with primary in 1-2 days following discharge. Resident refused wound care prior to discharge. VS stable 132/78,20,72,98%,97.2On [DATE], Resident discharged home with the refusal of home health services. discharged with all personal belongings and medications. Review of the Wound Evaluation - Weekly dated [DATE] showed right lower leg stasis ulcer identified on [DATE] that was 15 centimeters (cm) x 20 cm x 0.2 cm; serosanguineous moderate mild odor drainage; 30% granulation, 70% slough. cluster wounds. Treatment included Santyl and calcium alginate. Signed by Staff F, RNReview of the Wound Evaluation - Weekly dated [DATE] showed left buttock stage III pressure ulcer, identified on [DATE]. Preadmission area. Size: 1.5 cm x 1.3 cm x 0.2 cm.Review of the Wound Evaluation - Weekly dated [DATE] showed right lower leg venous ulcer. Size: 17 cm x18 cm x 0.8 cm, identified [DATE], Serous large copious amount of thin, watery drainage with no odor. 30% epithelial, 10% granulation, 10% slough, and 50% necrotic. cluster wounds. Santyl and silver alginate as treatment.Review of the Wound Evaluation - Weekly dated [DATE] showed right medial anterior lower leg venous wound identified on [DATE]. Size showed 19 cm x 25 cm x 0.8 cm. Serous, large copious amount thin watery drainage, no odor. 30% epithelial, 10% slough, 30% necrotic adipose exposed. Santyl and silver alginate as of [DATE] for treatment. Wound Evaluations provided on [DATE] (at the end of the survey) for the following dates were all blank: [DATE], [DATE], [DATE]. Wound Evaluations provided on [DATE] (at the end of the survey) for the following dates: [DATE], [DATE] and [DATE] for the right lateral lower leg and right medial anterior lower leg documented as written on [DATE]. Review of the Skin Check, Weekly dated [DATE] showed right buttock stage I DTI (Deep tissue injury), left buttock Stage III DTI; right lower leg front unstageable venous status ulcer; right lower leg (rear) unstageable venous status ulcer. Review of the Skin Check, Weekly dated [DATE] showed right later leg vascular and right medial anterior leg vascular. Review of the wound care Nurse Practitioner note dated [DATE] showed resident being evaluated for right lower leg ulcers. Reviewed progress note on [DATE]. Resident seen for initial evaluation of wound. Left buttock pressure ulcer assessed with facility wound care nurse. Patient with lymphedema in both legs, presenting with extensive ulcers on the right leg covering approximately 60% of the limb, with a large area of necrotic tissue. Considering that the patient is immunosuppressed, has chronic kidney disease with chronic anemia on hemodialysis, and diabetes, the risk of infection is significantly elevated. Due to the extent of the necrotic tissue and the large amount of drainage from the wounds, it is recommended to initiate Ivy antibiotic therapy then transfer the patient to a hospital for surgical debridement. In the meantime, we will continue treatment with Sanyl for enzymatic debridement and calcium alginate for secretion control period a discussion of the patients management was completed during the encounter with patient, wound care nurse and a ADON. Lower Extremity Assessment: Edema Assessment: left and right extremity edema. Wound Assessments: Wound #1, right lateral lower leg is a full thickness venous ulcer and has received a status of not healed. Initial wound encounter measurements are 17cm x 18 cm. 0.8cm, with area of 306 sq cm. Necrotic adipose is exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. The patient reports a wound pain of 2/10. The wound margin is thickened. Wound bed has 10% granulation, 10% sloth, 50% escar, and 30% epithelialization. The peri-wound skin texture is normal. The peri-wound skin moisture is normal. The Peri-wound skin color is normal. Cluster wounds with skin in between area. Wound #2, right medial anterior lower leg is a full thickness venous ulcer and has received a status of not healed. Initial wounding counter measurements are 19 cm length x 25 cm width x 0.8 cm depth, with an area of 475 square centimeter. Necrotic adipose is exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a copious amount of serious drainage noted with which has no odor. The patient reports a wound pain of level 2/10. The wound margin is thickened. Wound bed has 10% granulation, 10% sloth, 50% escrow, and 30% epithelialization. The peri- wound skin texture is normal. The peri-wound skin moisture is normal. The Peri-wound skin color is normal. General notes: cluster wounds with skin between. Additional orders: Coordination of care / Education and Counseling Plan of Care discussed the facility nursing staff as below detailing need, progress, and goal wound care nurse and ADON plan of care discussed the patient as below detailing need, progress, and goal current wound status treatment to plan to transfer to hospital. Review of the care plans showed resident had a pressure ulcer related to history of area left buttock as of [DATE], Interventions included but not limited to administer medications and treatments as ordered by the MD as of [DATE]. Complete weekly skin checks. Measure length, width, and depth, if possible. Document status of wound and healing progress monitor for s/s of infection. Report changes to MD as indicated as of [DATE]. Wound Care MD/ APRN consult as ordered / indicated as of [DATE].Resident had a venous/stasis / lymphedema ulcer of the right and left lower leg, right medial anterior lower leg as of [DATE]. Interventions included but not limited to evaluate wound for size, depth, margins: per-wound skin, sinuses, undermining, exudates, edema granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician and resident / representative as indicated as of [DATE]. Monitor for worsening of wound, change in skin status ie: s/s of infection, non-healing, new areas to MD and update resident/ representative as indicated as of [DATE]. Treatments as ordered and monitor effects, update MD/Resident/representative as indicated as of 1q[DATE]. Wound physician consult as indicated as of [DATE].Review of the Discharge Summary provided at the end of the survey on [DATE] showed resident refused to let nurse look at left buttock; chronic vascular wound right lower leg (front); lymphedema left lower leg (front); chronic vascular wound and lymphedema right lower leg (rear); lymphedema left lower leg (rear). Staff G, LPNDuring an interview on [DATE] at 1:59 p.m. with the DON and the regional nurse, the DON stated the resident had chronic vascular wounds of the lower extremity. The DON stated the wound nurse saw him on [DATE] showing the lower right leg wound. The DON could not verify if the wound was on the front or the back of the right leg. The DON verified that on [DATE] the resident had a Stage III buttocks pressure ulcer per the [DATE] Wound Evaluation. The DON verified the only Wound Evaluations in the e-chart were dated [DATE] for a right lower leg stasis ulcer and left buttocks and for [DATE] for right lower leg venous ulcer and right medial anterior lower leg venous wound. The DON stated the wounds were to be evaluated including size and description at least weekly. The DON stated maybe the wound care doctor did not send their notes in. The DON could not verify when the wound doctor starting seeing the resident or when the wound doctor saw the resident. The DON stated the wound care nurse should still be documenting at least weekly, following up. The DON verified the Discharge Summary (which was not completed) showed right lower leg front open wound, left lower leg front open wound, right lower leg rear open wound, left lower leg rear open wound. The DON stated when the resident first came in, he had a right and left buttock wound, then it changed to just the left buttock. The DON stated they were treating both of his lower extremities. The DON was reviewing the orders in the e-chart and stated they had treatment in place for his right lower leg. They had an order to place skin prep on both of his heels. The DON stated for the lower right leg they were using Santyl, Calcium Alginate and wrapping it with a pad. When asked about the wound care not consistently being provided, the DON stated on [DATE] at 2:45 p.m. he refused wound care upon discharge. The DON did not address the other lack of care. When asked about description of wound weekly, no answer. Review of the facility's policy, Prevention of Skin Impairment / Pressure Injury. Revised 01/2024 showed The purpose of this policy is to provide information regarding identification of skin wound risk factors and interventions for specific risk factors. Guideline: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. ProcedureRisk Assessment:1. Assess the resident on admission for existing wound risk factors.2. Conduct a comprehensive skin assessment upon admission, including:a. skin integrity - any evidence of existing or developing pressure ulcers or injuries;B. Areas of impaired circulation due to pressure our positioning or medical devices.3. Inspect the skin when performing or assisting with personal care or ADL's.Risk Factors:2. Examples of these risk factors include but are not limited to:a. Impaired / decreased mobility and decreased functional ability;B. Comorbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus;C. Drugs such as steroids that may affect healing;d. Impaired diffuse or localized blood flow, for example, generalized arteriosclerosis or lower extremity arterial insufficiency;E. Resident refusal of some aspects of care and treatment;F. Cognitive impairment;G. Exposure of skin to urinary and fecal incontinence;H. Under nutrition, malnutrition, and hydration deficits;I. The presence of previously healed pressure ulcer / PiPrevention1. Select appropriate support services based on the residence mobility, continents, skin moisture and perfusion, body size, weight, and overall risk factors.Monitoring / Documenting:1. Evaluate, report, and document potential changes in the skin2. Notify the physician and the resident / resident representative of changes in the skin.3. Review the interventions and strategies for effectiveness on an ongoing basis.4. Evaluate open areas per physician orders. Review of the facility's policy, Change in Resident Condition or Status-Resident Rights, revised on 6.2023 showed Facility shall notify the resident, his or her Attending Physician, and representative of changes in their resident's medical / mental condition and / or status.Guideline: To ensure the facility provides timely notification in accordance with State and Federal regulations as it pertains to residents' rights.Procedure:1. The nurse will notify the resident's Attending Physician or physician on call when there has been a:D. Significant change in the resident's physical / emotional / mental condition;E. Need to alter the resident's medical treatment significantly;G. Need to transfer the resident to a hospital / treatment center;I. Specific instruction to notify the physician of physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions;C. Requires interdisciplinary review and / or revision to the care plan;D. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument.3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status;E. It is necessary to transfer the resident to a hospital / treatment center.5. The nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status.

Based on interview and record review the facility failed to provide assessments post falls including vital signs and neurological checks for one resident (#3) of three sampled residents.Findings included: Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged on 01/03/2026 to the hospital. Review of the admission record showed diagnoses included but not limited to diabetes, anemia, dementia, pancreatic cancer, depression, protein-calorie malnutrition, myocardial infarction, atrioventricular block first degree, nonrheumatic aortic valve stenosis, dysphagia, colostomy, history of breast cancer, arial fibrillation, anxiety, history of falls, and hypotension.Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13, meaning cognitively intact. Section GG showed the resident required supervision or touching assistance for toileting and bathing. Review of progress notes and SBARs (Situation, Background, Assessment, Recommendation) showedOn 12/31/25 at 12:00 p.m. SBAR showed resident had a fall. Vital signs are documented but the date and time are not shown on the SBAR. 10. Neurological Evaluation showed not clinically applicable to the change in condition being reported. Reminded to use call light for assist. Primary Care Clinician notified on 12/31/25 at 12:00 p.m., no new orders. Family / Health Care Agent Notified: self on 12/31/25 at 12:00 p.m. signed by Staff A.LPN (Licensed Practical Nurse)On 12/31/25, documented at 3:06 p.m. SBAR (from progress notes) for fall, Vital signs were as follows: BP (blood pressure) 130/72 on 12/31/25 at 9:14 a.m.; pulse 72 on 12/31/25 at 10:07 a.m.; respirations 18 on 12/31/25 at 10:07 a.m.; pulse oximetry of 97% on 12/31/25 at 12:08 p.m. (Per the Director of Nursing (DON) interview the fall occurred on 12/31/25 at 10:45 a.m.). The Primary Care Provider responded with recommendations of no new orders. Signed by Staff A LPN.On 12/31/25 at 10:59 p.m., This writer returned from lunch break and was made aware by staff of resident being on the floor, went to room and found resident laying on the floor with her head facing her bed and her feet facing the TV, observed small amount of blood on her back of her head, also noted a small raised open area was cleansed with normal saline (NS), patted dry and band aid applied, resident was able to move all her upper and lower extremities well on command with no grimacing in pain, however complained of slight pain on her ankle but stated it was just okay,. Left a message for NP (nurse practitioner) on call, also left a message for [family member], neuro-checks initiated per facility's protocol of unwitnessed falls. documented by Staff B, Licensed Practical Nurse (LPN).On 12/31/25 at 11:00 p.m. SBAR showed for fall. Vital signs showed BP 112/82, Pulse 87, respirations 20/ pulse oximetry 98%. Skin evaluation showed no changes observed. Pain Evaluation showed resident did not have any pain. Reminded to use call light for assistance. Primary Care Clinician notified on 12/31/25 at 10:30 p.m., no orders / awaiting for call back. [Family member] notified on 12/31/25 at 11:00 p.m. Signed by Staff B, LPNOn 12/31/25 at 11:07 p.m., Pain Evaluation showed a pain level of 4. Pain located in front of left shoulder (chronic).01/02/26, 8:44 a.m., IDT (Interdisciplinary Team) note: Review of fall from 12/31/25. Resident observed on the floor beside her bed. Resident reported that she took medication from outside facility that increased drowsiness. New intervention: Education provided to resident and family about not bringing medications from outside the facility. Resident and family verbalized understanding.On 01/02/26, at 8:50 a.m.: IDT note: Review of fall from 12/31/25. Resident observed on the floor beside her bed after attempting to get out of bed (OOB) unassisted. New intervention: Labs, UA (urinalysis) ordered, education provided to resident to call and wait for assistance before transfer.Review of neurological checks documentation provided showed on 12/31/25 the neurological checks were started at 10:10 p.m. until 01/03/26 on 7-3 shift. No neurological checks documentation was provided starting for the 12/31/25 fall at approximately 10:45 a.m.Review of the care plans showed Resident #3 was at risk for falls related to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medication usage as of 04/10/2024. Interventions included but not limited to: educate family to not provide resident with outside medications, educate the resident to not take medication that is not provided by facility nursing staff as of 01/01/2026. Educate the resident to wait for assistance with transfers as of 01/01/2026. Labs to be obtained for acute change as of 01/02/2026.During an interview on 01/15/26 at 1:26 p.m. Staff A, LPN was reviewing the e-chart and stated Resident #3s first fall happened on 12/31/25 at around 10:59 p.m. per the SBAR. Staff A stated the fall happened on the 3-11 shift. She stated Staff B, LPN was working that shift. She stated Staff B found her and her head was bleeding. Staff A stated if a resident was found on the floor unwitnessed, they would do the vital signs, call the medical provider with a report and call the family. They would perform neuro checks on paper. Staff A stated the resident did not fall on her shift. Staff A stated the resident told her she found a pink pill (Benadryl) on the floor and took it.During an interview on 01/15/26 at 4:28 p.m. Staff B, LPN stated the resident had a previous fall that day and had a history of falling. Staff B stated the resident hit her head during the fall. He stated he was returning from his lunch break and an aide assigned to her got me. Staff B found her lying on with the side of her face toward the bed and her back to the doorway. He stated he asked the resident questions and noticed a raised area with blood on the back of her head. There was no active bleeding. Staff B stated the nurse working with him that night was doing the vital signs and neuro checks and pain assessment. The resident was having pain in her ankle and shoulder. The resident stated it was arthritis. Staff B stated the fall occurred on the 3-11 shift, around 9 p.m. or 10 p.m. Staff B stated they were doing the neuro checks on her, for an unwitnessed fall. Staff B stated the other nurse called the medical provider and sent an alert. Staff B stated we do vital signs, neuro checks and monitor closely while waiting for the medical provider to call back. The family was called. We do neuro checks on paper for 72 hours. Staff B stated he washed the cut with normal saline and put a Band-Aid on it. Staff B stated the resident was alert and had no confusion. We put her to bed, laid her down. Staff B stated we had one of the aides sit in the hallway to monitor her. Staff B stated the resident had a fall earlier in the day.On 1/16/26 at 10:44 a.m. the DON stated everything should be in the scanned into the e-chart unless waiting in medical records to be scanned (neurological checks). On documentation review on 01/16/26 at 10:46 a.m., no neuro checks in the e-chart. On 01/16/26 at 11:00 a.m. the DON and regional nurse consultant stated Resident #3 had a fall on 12/31/25 at 10:45 a.m. The DON verified the SBAR only stipulated in the morning. The DON stated the SBAR does not specifically the time of the fall. The DON stated the provider was notified at 12:00 p.m. and had no new orders. The DON stated the process for an unwitnessed fall was to assess the resident, initiate neuro checks, notified the doctor, and notify the family. The DON verified per their internal form the fall occurred at 10:45 a.m. and that the SBAR did not specify a fall time. The DON verified the vital signs on the SBAR (for the morning fall) showed the following blood pressure is from 9:14 a.m., pulse is from 10:07 a.m., respirations are from 10:07 a.m. O2 sats from 12:08 p.m. no neuro checks done for this patient. The DON verified the vital signs were documented as occurring before the fall occurred. The DON stated they did not have any vital signs or neuro checks at the time of fall. The DON verified the resident herself was notified of the fall and the family should have been notified. The DON stated the resident stated she found a pink pill on the floor, The DON stated they did look at her floor but did not find anything her floor. The DON stated she could not recall if they looked at any other rooms for pills on the floor. The DON stated Resident #3 had another fall that evening. The DON stated the resident fell at 10:00 p.m. The DON stated Staff B, LPN put in a note that when he returned from his break the staff made him aware the resident was found on the floor. The DON verified the exact time of the fall was not in the progress note. The DON stated the vitals signs were done after the fall, per the documentation. The DON verified the SBAR (for the second fall) showed they were awaiting a call back from the medical provider. The DON verified there was no documentation the medical provider called back after the notification and no follow up was documented even though the resident hit her head in the fall. The DON stated the expectation was to find documentation they talked to a doctor about the fall and her hitting her head. The DON verified the IDT note stated the resident had a family member bring medication from the outside. The DON stated they believe the family brought in Benadryl. The DON stated the internal report showed the resident was leaning over in her chair for the pill on the floor and fell out of the chair. The DON verified this information was not in the e-chart. The DON stated we told the resident to not bring any medication in from the outside and ask us and we will get it for you. The DON stated she did not know who spoke with the family regarding not bringing medication in from the outside. The DON verified the documentation showed they spoke with the family but she was not sure who did, maybe the Unit Manager. The DON stated she expected to see neurological checks after the first fall. Review of the facility's policy, Change in Resident Condition or Status-Resident Rights, revised on 6.2023 showed Facility shall notify the resident, his or her Attending Physician, and representative of changes in their resident's medical / mental condition and / or status.Guideline: To ensure the facility provides timely notification in accordance with State and Federal regulations as it pertains to residents' rights.Procedure:1. The nurse will notify the resident's Attending Physician or physician on call when there has been a:A. Accident or incident involving the resident;D. Significant change in the resident's physical / emotional / mental condition;E. Need to alter the resident's medical treatment significantly;G. Need to transfer the resident to a hospital / treatment center;I. Specific instruction to notify the physician of physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:C. Requires interdisciplinary review and / or revision to the care plan;D. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument.3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. The resident is involved in an accident or incident that results in an injury including injuries of an unknown origin;E. It is necessary to transfer the resident to a hospital / treatment center.5. The nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status. Review of the facility's policy, Falls - Managing, Preventing, and Documentation, revised 09/2025 showed each resident will have an individualized plan of care that will be reviewed and modified as needed to include fall interventions most appropriate to their individual needs and diagnosis.Definition A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.Resident - Centered Approaches to Managing Falls and Fall Risk1. The staff will implement a resident - centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with the history of falls.Monitoring Subsequent Falls and Fall Risk2. if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed the attending physician will help the staff reconsider possible causes that may not previously have been identified.Documentation1. residents who experience a file will have appropriate documentation completed in the facility risk management portal or on paper.

Based on observation, interview, and record review the facility failed to provide an Quality Assessment and Assurance (QAA) practice that demonstrated identification, monitoring, and implementation of an effective action plan to correct previously cited deficient practice at F689 in regards to: 1) preventing a vulnerable resident with severe cognitive impairment from exiting the facility for one resident (#26) out of two residents reviewed for elopement risk; and 2) ensuring elopement risk binders were updated/accurate to ensure staff knew who was at risk for four out of four binders reviewed. Findings included: On 2/17/26 at 9:52 a.m., Staff A, Certified Nursing Assistant (CNA) was observed sitting outside Resident #26's room. An interview with Staff A, CNA revealed Resident #26, Left through the front door last week or over the weekend. She said during this shift she was on one-to-one (1:1) supervision with the resident because Resident #26 exited the facility. A review of Resident #26's admission record revealed an admission date of 3/27/25. Further review of the admission record revealed diagnoses to include encephalopathy, depression, anxiety disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, insomnia, and cognitive communication deficit. A review of Resident #26's physician orders revealed the following:- LOA [leave of absence]: Resident may have therapeutic LOA privileges. With escort., with an order date of 3/27/25.- Melatonin Oral Tablet (Melatonin) Give 3 mg [milligrams] by mouth at bedtime for insomnia., with an order date of 3/31/25.- Zoloft Oral Tablet (Sertraline HCl [hydrochloride]) Give 50 mg by mouth one time a day for depression, with an order date of 6/4/25.- Lorazepam (Ativan) Gel 0.5mg/ml [milliliter] (Lorazepam Gel) *Controlled Drug*. Apply to inner wrists topically every 12 hours as needed for anxiety for 14 Days 1ml per application. Always apply with gloves., with an order date of 2/10/26. A review of Resident #26's discontinued orders revealed the following:- Wander guard/Alert Device Left ankle: Check device function QD [once a day] and replace as needed. every night shift., with an order date of 2/13/26 and end date on 2/17/26.- Wander guard/Alert Device Left ankle: Verify placement Q [every] Shift. May replace and move location as needed. Inspect skin surfaces under and around device. Notify physician of abnormal findings., with an order date of 2/13/26 and end date on 2/17/26. A review of Resident #26's evaluations for brief interview for mental status (BIMS) score revealed on 6/26/25 her BIMS evaluation showed a score of four indicating severe impairment and on the quarterly minimum data set (MDS), dated [DATE], showed a BIMS score of 6 indicating severe impairment.A review of Resident #26's care plan revealed the following:- The resident is at risk for falls R/T [related to] weakness, cognitive impairment. Date Initiated: 03/29/2025- The resident is resistive to care/refusing care r/t adjustment to nursing home, cognitive impairment. Medication Refusal. resident also refuses lunch and meals, refusing melatonin, refusing showers/bathing Date Initiated: 04/04/2025 Revision on: 12/22/2025, with interventions to include, If resident resistive with care/ADLS [activities of daily living], reassure resident, leave and return at a later time or a later negotiated time. Date Initiated: 04/04/2025.- The resident at risk and or have actual impaired cognitive function/impaired thought processes r/t cognitive impairment Date Initiated: 03/29/2025, with interventions to include, Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Date Initiated: 03/29/2025.- The resident has a mood problem Anxiety, Dementia, Depression Date Initiated 10/27/2025.- The resident has a history of exhibiting the following behaviors: attention seeking behaviors while staff cares for other residents, confabulatory self- harm statements, cuts off wander guardDate Initiated: 10/27/2025 Revision on: 02/17/2026., with interventions to include, Redirection w/[with] activities but not limited physical activity, sensory items, structured activities Date Initiated: 10/27/2025 . 1:1 supervision Date Initiated: 02/16/2025 Revision on: 2/17/2026.- The resident is at risk r/t exit Seeking Behavior Disoriented to place, Exit Seeking Behaviors, Impaired safety awareness, Medical Diagnoses (Dementia, Alzheimer's Disease, Lewy-body Dementia, TBI [traumatic brain injury], Etc. [etcetera]) Date Initiated: 02/13/2026, with interventions to include, Check alert bracelet placement as ordered/indicated Date Initiated: 02/13/2026 1:1 supervision Date Initiated: 02/16/2026 . Increased Supervision Date Initiated: 02/13/2026 . A review of Resident #26's assessments included the following:- admission readmission nursing evaluation, dated 7/30/25, .SECTION c. Elopement Risk Evaluation 3. Resident has cognitive status impairment (i.e. short term memory loss, BIMS score, diagnosis, etc.) b. No 4. Has the resident expressed a desire to leave the facility? b. No 5. Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles, etc.) b. No- Elopement risk, dated 2/13/26, .Locomotion/Mobility 2. Does the resident have the ability to ambulate/propel independently (with or without use of assistive device/wheelchair) a. Yes Cognitive Status 3. Resident has cognitive status impairment (i.e. short term memory loss, BIMS score, diagnosis, etc.) a. Yes Desire to leave 4. Has the resident expressed a desire to leave the facility? a. Yes Exit Seeking 5. Does the resident exhibit exit-seeking behavior (e.g. walk towards exits, manipulate doors, handles, etc.) a. Yes . 8. Interventions/Approaches 1. Diversionary Activities 3. Resident Re-direction 9. Increased staff observation 10. Placement of wanderguard/alert bracelet . A review of Resident #26's progress notes revealed the following:- Medication administration, dated 2/9/26, BEHAVIOR: . refused all due meds [medications]-MD [medical doctor] made aware.- Room change notification, dated 2/11/26, On 02/11/2026 [Resident #26] will be moving from [room number] to [room number] due to resident request. Resident was notified of the room change on 02/11/2026. The resident representative was notified on [family member] by phone.Resident is agreeable to a room change.Resident's representative is agreeable to a room change at this time.- Progress note, dated 2/13/26, Visited with [Resident #26] this evening. Laying in her bed watching tv [television] as she usual does during the evening time. Denies any pain, states she is good. Has no complaints, glad she is back in her old room.- Medication administration, dated 2/15/26, Wander guard/Alert Device Left ankle: Verify placement Q Shift. May replace and move location as needed. Inspect skin surfaces under and around device. Notify physician of abnormal findings. every shift Wander guard not in place. Resident has 15 min [minute] check in place.- Progress note, dated 2/16/26, Late Entry:.: Resident was placed on 1:1 monitoring as resident was noncompliant with maintaining wanderguard. Resident remains at her baseline psychosocial. No concerns noted. A review of Resident #26's psychiatry progress notes revealed the following:- 1/29/26, .History Of Present Illness: Patient is a [personal health information] seen today for follow up psychiatric and medication management visit with a history of depression, anxiety, insomnia and dementia. Upon assessment, pt [patient] is alert and oriented to self, sitting in bedroom watching television. Due to cognitive decline patient thought process is disorganized and tangential, poor insight to mental health. Patient states she is waiting for her mother to bring her to school. Denies concerns. Previous visit, ativan gel was not renewed as patient has decreased anxiousness and medication had not been needed for extended period of time. Per nursing, patient anxiety continues to decrease. When experiencing increased confusion, patient has been responding well to verbal redirection. Chief Complaint: Anxiety dementia . Review of Systems: . Personality Does the patient report impulsivity, emotional instability, fear of abandonment, manipulative or attention-seeking behavior, or unusual traits?: Impulsivity . Cognition Does the patient report memory loss, confusion, difficulty concentrating, problem-solving, understanding, reasoning, or disorganized thinking?: Reasoning, Disorganized thinking, Confusion, Memory loss, Understanding . Mental Status: Orientation: Oriented x1 [aware of person only] Short-Term Memory: Unable to assess due to cognitive decline Long-Term Memory: Unable to assess due to cognitive decline Fund Of Knowledge: Not able to assess due to cognitive decline . Thought Process: Disorganized, Slow and impoverished thinking Associations: Tangential . Mood: Anxious . Insight: Poor . Judgment: Does not appear capable of making decisions utilizing executive functions . A review of Resident #26's primary medical provider notes revealed the following:- 2/9/26, .Subjective Patient seen and examined at bedside this am [morning]. No new changes or complaints. VSS [vital signs stable] and afebrile. Physical Exam .Psychiatry: On examination Alert & oriented x3 [aware of person, place, and time], intact recent and remote memory, good judgment and insight, normal mood and affect . Plan Nursing-continue with medication and skin integrity management. Nursing assessment of Braden score. A review of the primary medical provider's note showed no documentation that addressed Resident #26 refusing all medications on 2/9/26. On 2/17/26 at 12:32 p.m., an interview was conducted with Staff A, CNA. She said another staff member provided 1:1 supervision, which started last night, for Resident #26. She stated sometime last week Resident #26 exited the front door of the facility, Almost to the road. She said around 3:00 p.m. she was leaving for the day and as she was walking through the parking lot, she observed two therapy staff outside with the resident. She recalled Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM) and Staff F, business office assistant (BOA) were also there. Staff A, CNA said she had never seen Resident #26 attempt to exit the facility. She said the resident typically walked to the nurse's station or would grab her purse, then stand at the door of her room and look around. She said the resident also fidgeted and throws items. Staff A, CNA said Resident #26 had been refusing medications, including most recently her morning medications. When asked if the resident had a wander guard when she exited or currently had one she stated, She's supposed to have one, I think so. When asked if the facility had elopement books, Staff A, CNA stated, There would be one at nurse's station She was not sure if she had any residents currently who an elopement risk. She said she would look out for residents who constantly needed to be re-directed or trying to exit the facility. She said she did not have any residents assigned to her with those behaviors. On 2/17/26 at 12:43 p.m., an interview was conducted with Staff B, activities assistant/receptionist. She provided the elopement binder located in the receptionist area. She said there are binders at nurse's stations as well. A review of the elopement binder showed information for Resident #32, Resident #26, and Resident #39. She said if a resident had a wander guard and entered the lobby area, the door would lock automatically. Staff B, activities assistant said the receptionist had to let a resident out the door even if they do not have a wander guard. She said she had not seen or heard of a resident exiting the facility. On 2/17/26 at 12:50 p.m., an interview was conducted with Staff C, LPN/UM. He described Resident #26 as pleasant but, Prone to confusion. Confused most of the time and increases with change. He said the resident would start talking about family and children, and say she was trying to get to an elevator. He stated on 2/13/26 was the, Last real episode of confusion. Staff C, LPN/UM said she had a room change to the long-term care side. He said around the change of shift in the afternoon, the resident had confusion, walked back to her previous room, went to the front area, followed someone, then exited the front doors. He said the resident was in the receptionist's eyesight who called for help. He recalled a code orange, the facility's code for a missing person, called overhead. He said the receptionist at the time was Staff F, BOA. Staff C, LPN/UM said by the time he got to the front the Nursing Home Administrator (NHA), Director of Nursing (DON), and one or two CNAs were present. He said a maintenance staff member was at the front door with Resident #26, walking into the facility. He said Staff D, Physical Therapist was also walking back into the facility with Resident #26. Staff C, LPN/UM stated Resident #26 is back in her previous room as they wanted to let her be and, Doesn't make sense to upset her. Staff C, LPN/UM said Resident #26 was not an elopement risk previously and did not have a wander guard. He said she typically had her purse and would stand at the door but had never tried to exit. He said when she was first admitted to the facility, he recalled she may have attempted to exit due to the change in environment, but she was easily re-directed. Staff C, LPN/UM said Resident #26 is on 1:1 supervision, which started last night. He stated there was no change to the elopement protocol and confirmed, Whenever something happens, the facility completed education. He stated staff should, Be attentive to who's coming in and out, as residents sometimes looked like visitors. When asked about the cameras located in the lobby and outside the front doors, he said the cameras do not work. On 2/17/26 at 1:11 p.m., an interview was conducted with Staff D, PT. He said on 2/13/26, later in the afternoon/after lunch, he was in the therapy gym when Staff E, PTA asked him, Is it that one of our residents? Staff D, PT said he went over to the window and saw Resident #26 walking straight towards the street outside of the facility. He said she was on the right side of the parking lot. He said they both ran out. Staff D, PT said when they got to the resident she was by a large oak tree at the end of the facility, which he described as an, Empty space by the north wing. He stated Resident #26 was upset, slapping his hand, and saying, Why are you stopping me from going to my wedding. Staff D, PT and Staff E, PTA guided the resident back to the facility. He stated, Quite a few people came by to assist. He recalled the staff present were Staff F, BOA, Staff C, UM/LPN and the business office manager (BOM). He said he did not alert anyone as they were focused on Resident #26. Staff D, PT said since they were running outside, he figured that is what alerted facility staff to assist. He said Resident #26 is no longer on therapy caseload as she is independent but needed to be guided on where to go. He stated she, Clutches her bag and walks around. Staff D, PT said the resident previously had a wander guard, but she took it off. He said Staff K, BOA told him she took off the wander guard. He said if she had a wander guard the alarm would have been triggered, and he did not recall the alarm sounding. On 2/17/26 at 1:33 p.m., an interview was conducted with Staff F, BOA. She said she did not witness Resident #26 leaving the facility as she was in the BOM's office. She said she assisted with bringing the resident back when she was right outside of the front door. Staff F, BOA said therapy staff was outside with the resident already. She said Staff G, receptionist told her and the BOM that Resident #26 had walked out the door. She said she was familiar with the resident because she was typically in the receptionist area. She said the resident has hearing difficulties and can be confused depending on the day. She confirmed Resident #26 did not have a wander guard on when she exited the facility. Staff F, BOA stated, I was told she [Resident #26] was going to get one but not sure if she had one [wander guard]. She stated she was not sure how the resident exited as, The receptionist has to physically unlock the door. On 2/17/26 at 2:26 p.m., a telephone interview was conducted with Staff G, receptionist. When asked about what happened on 2/13/26, she stated, It was a little hectic, multiple people in the lobby. She said there was a food delivery, and she was on the phone trying to call the resident to come get their food. Staff G, receptionist said she also had a resident wanting to get money out, and a gift bag was placed in front of her. She recalled Resident #26 had been walking back and forth. She said she pushed the button to let the person delivering food out the door and the resident followed behind them. Staff G, receptionist stated, I kind of said to myself, did she go out the door? She said by the time she went to the lobby, someone from therapy said, She shouldn't be out there. She said she started to run out the front door but saw therapy staff members were there. Staff G, receptionist said since therapy was there, money was on the counter, and multiple people in the lobby, she did not go outside and instead went back to the receptionist area. She said she did not know the exact spot Resident #26 was found but confirmed she saw her walking to the parking lot. She said the resident did not have a wander guard on that day. She stated, The door opens if she's [Resident #26] is in the lobby so apparently she didn't have one prior. She said the door would not open if a resident with a wander guard came to the lobby. Staff G, receptionist said Resident #26 is in the elopement binder and believed she had been there prior to 2/13/26. She said the resident typically comes to the lobby, stands at the desk, and talks with her. On 2/17/26 at 3:42 p.m., a review of the facility's elopement binders showed the following:- 200 hall included the following residents: Resident #32, Resident #26, Resident #38, Resident #40, and Resident #36.-100 hall included the following residents: Resident #33, Resident #26, Resident #34, Resident #40, Resident #36, Resident #37, and Resident #38.- 300 hall included the following residents: Resident #32 and Resident #26.- Front desk/receptionist area included the following residents: Resident #32, Resident #26, and Resident #39. Photographic evidence obtained. On 2/17/26 at 3:47 p.m., a follow up interview and review of the 200 hall elopement binder was conducted with Staff C, LPN/UM. He said Resident #26 was added last week to the elopement binder. An observation of the back of the binder should three resident's information. He said Resident #36 and Resident #38 had discharged , and Resident #40 was not an elopement risk anymore, which is why they were in the back of the binder. On 2/17/26 at 4:09 p.m., an interview was conducted with the NHA and DON. The NHA said on 2/13/26 at approximately 3:01 p.m., Staff G, receptionist unlocked the front door for a food delivery person and Resident #26 followed him. The NHA said he was paged by Staff G, receptionist asking him to come to the front lobby. The DON said she heard the NHA was paged and that is what prompted her to go to the front. The said NHA said a therapy staff member was looking out the window and saw Resident #26 outside, then another therapy staff member got up to look as well. He said Staff H, staffing coordinator was returning from the store, parked in front of the facility, and saw Resident #26 exit the facility. The NHA said Staff H, staffing coordinator saw Staff D, PT assisting the resident as she was getting out of her car to walk towards the resident. The NHA said by the time he got to the front of the facility, he saw Staff D, PT and Staff E, PTA to right of the front door/at the end of the driveway as they were bringing Resident #26 back. The NHA said Resident #26 reached the end of the facility, by the north (100 unit) hall when therapy got to her. The DON said the resident did not have wander guard but had one placed as soon as she returned to the facility. The DON confirmed Resident #26 had an evaluation prior to 2/13/26 and was not an elopement risk. The DON said the resident's care plan was updated on 2/13/26 to include risk of exit seeking and interventions such as placement of wander guard and increased supervision. The DON and NHA said as soon as they placed the wander guard, Resident #26 cut it off. DON said staff completed a wander guard check to verify it was in place, they noticed it was not, notified her medical provider, and she was placed on 1:1 supervision. The NHA said he believed the resident used a plastic utensil to cut it. He stated, The strap is rubbery, she can cut it. The DON confirmed Resident #26 did not have a wander guard from 2/13/26 to 2/16/26. The NHA stated the facility is, Looking at alternative placement for memory care or secured unit, and she will continue to be on 1:1 supervision until then. The NHA stated Resident #26, Walks around with her purse, likes to lay in bed and watch tv [television]. She will shuffle around. The DON formed there is an elopement risk binder at the front desk and one at each unit. She stated the binder had, Anyone at risk of exit seeking. The NHA and DON initially said the residents in the elopement risk binders do not have a wander guard. They were both unsure if any residents in the facility had a wander guard. The DON confirmed a resident in the elopement risk binder would have a wander guard. She stated the criteria for a resident being in elopement risk binder was, Exit seeking behavior, low cognition, expressing they want to leave. The DON said all the elopement risk binders should be consistent with the same residents. She said the interdisciplinary (IDT) team collectively updated the elopement book as needed if a resident discharged or there was a change. The DON said Resident #26 had a room change on the day she exited and believed that cause disruption to her normal patterns. The DON said they moved Resident #26 to the long term care side as they wanted her to have a long term roommate she could talk to. The NHA said she walked from her new room to the previous room, then went to the lobby where she exited. On 2/18/26 at 9:55 a.m., a follow-up interview with the NHA and review of the facility's wander guard report revealed Resident #32 is the only resident with a wander guard. He said the other residents in the elopement binder do not have a wander guard. On 2/18/25 at 11:54 a.m., an interview was conducted with Staff H, staffing coordinator. She said on 2/13/26 she returned from the store and backed her car into a spot facing the front door of the facility. Staff H, staffing coordinator said she noticed Resident #26 was in the lobby as she could see her from the car. She said a food delivery person's vehicle was parked under the porch and observed him dropping off food/entering the facility. She stated, He was coming out the building, I saw her [Resident #26] leave behind him. She confirmed the delivery person did not hold the door; Resident #26 exited right behind him. Staff H, staffing coordinator stated, I was trying to hurry up, took my last bite, put my food down, locked the door and jumped out of the car. She said she had to put everything down and by the time she got to the resident, Staff D, PT was already there. She said the resident was at the end of the second row of cars in the parking lot. She described it as the curve of the driveway right in front of the therapy window on the north unit. When asked if she was supervising the resident she stated, I mean I was supposed to pay attention to the residents, but I was on a break. Staff H, staffing coordinator said she was not supposed to be supervising the resident but, It's just a natural reaction to watch. On 2/18/26 at 11:59 a.m., a follow up interview with the DON and NHA was conducted. The NHA said that night on 2/13/26 they made sure the binders were accurate with the residents' information who were at risk of elopement. He said that is when they added Resident #26. The DON stated, Whoever is putting the resident's information in the book is updating the binder. She said any staff member can add a resident to the elopement risk binder. The NHA said the risk of binders not matching/being accurate is they would not be able to identify the resident. The NHA said Staff F, BOA and Staff I, Regional Nurse Consultant (RNC) checked the binders last night and told him they matched. The DON and NHA said they did not check the binders themselves. The DON confirmed on 2/9/26 is when the resident was last seen by her primary medical provider and had not seen Resident #26 after 2/13/26. On 2/18/26 at 12:38 p.m., a second review of the facility's elopement binders showed the following:- 100 hall included the following residents: Resident #32 and Resident #26. Further review of the binder, under wander risk information, showed Resident #36, Resident #40, Resident #37, and Resident #38.- Front desk/receptionist area included the following residents: Resident #26, Resident #32, and Resident #39. A wander guard book was observed and included the following residents: Resident #32, Resident #26, and Resident #39.- 200 and 300 hall included the following residents: Resident #32 and Resident #26. Photographic evidence obtained. On 2/18/26 at 1:45 p.m., an observation of Resident #26's room, from the hallway, showed the door was open. A staff member was not sitting at the doorway and was not observed inside the room. Further observations of Resident #26's room revealed the resident's feet lying on the bed with the privacy curtain pulled which obscured the view of her upper body. From the nursing station Staff A, CNA stated, I'm here. She was observed standing against the nurses' station then started walking towards Resident #26's room. Staff A, CNA stated the resident was sleeping. On 2/18/26 at 3:05 p.m., Staff I, RNC said himself and the infection preventionist (IP) reviewed the elopement binders that morning. He said all four binders were reviewed to make sure they were accurate. He said two residents, Resident #32 and Resident #26, triggered for elopement risk and are the only ones in the binders. Staff I, RNC said there was a question about Resident #39 being in the binders, but he corrected that. He said he removed Resident #39's information from the elopement risk binders because he had never been exit-seeking. He said Resident #39 exhibited behaviors such as wandering but not exit seeking. He stated, Maybe staff need some clarification, when they completed the residents' elopement risk assessments. Staff I stated, Anyone can update the book, but the task for overseeing updates is for the nursing management team and is based on residents' assessment and risk evaluation. He said residents who were previously in the binder, who are not considered an elopement risk, could have been the staff being cautious. Staff I, RNC confirmed all the elopement binders should match. A review of the facility's policy titled Quality Assurance and Assessment Committee, with revised dates of 1/1/24 and 1/1/25, revealed the following: Standard: This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. Goals of the Committee The primary goals of the Quality Assessment and Assurance Committee are: . 5. To help departments, consultants and ancillary services implement plans to correct identified issues in quality of care; 6. To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals . Committee Audit Process . 2. The Quality Assessment and Assurance Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up.

Based on interview and record review the facility failed to provide notice of change in condition related to informing the resident's family regarding a fall and failed to follow-up with the Primary Provider after a fall for one resident (#3) of five sampled residents.Findings included: Resident #3 was admitted on [DATE], readmitted on [DATE] and discharged on 01/03/2026 to the hospital. Review of the admission record showed diagnoses included but not limited to diabetes, anemia, dementia, pancreatic cancer, depression, protein-calorie malnutrition, myocardial infarction, atrioventricular block first degree, nonrheumatic aortic valve stenosis, dysphagia, colostomy, history of breast cancer, atrial fibrillation, anxiety, history of falls, and hypotension.Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 meaning cognitively intact. Section GG showed the resident required supervision or touching assistance for toileting and bathing.Review of progress notes and SBARs (Situation, Background, Assessment, Recommendation) showed on 12/31/25 at 12:00 p.m. resident had a fall. Vital signs are documented but the date and time are not shown on the SBAR. Neurological Evaluation showed not clinically applicable to the change in condition being reported. Reminded to use call light for assist. Primary Care Clinician notified on 12/31/25 at 12:00 p.m., no new orders. Family/Health Care Agent Notified: self on 12/31/25 at 12:00 p.m. signed by Staff A.LPN (Licensed Practical Nurse)Review of a progress note dated 12/31/25, documented at 3:06 p.m. SBAR (from progress notes) for fall, Vital signs were as follows: BP (blood pressure) 130/72 on 12/31/25 at 9:14 a.m.; pulse 72 on 12/31/25 at 10:07 a.m.; respirations 18 on 12/31/25 at 10:07 a.m.; pulse oximetry of 97% on 12/31/25 at 12:08 p.m. (Per the Director of Nursing (DON) interview the fall occurred on 12/31/25 at 10:45 a.m.). The Primary Care Provider responded with recommendations of no new orders. Signed by Staff A LPN.A progress note on 12/31/25 at 10:59 p.m., showed this writer returned from lunch break and was made aware by staff of resident being on the floor, went to room and found resident laying on the floor with her head facing her bed and her feet facing the TV, observed small amount of blood on her back of her head, also noted a small raised open area was cleansed with normal saline (NS), patted dry and band aid applied, resident was able to move all her upper and lower extremities well on command with no grimacing in pain, however complained of slight pain on her ankle but stated it was just ok,. Left a message for NP (nurse practitioner) on call, also left a message for husband, neuro-checks initiated per facility protocol of unwitnessed falls. Staff B, LPNAn SBAR fall assessment dated [DATE] at 11:00 p.m. showed - vital signs showed BP 112/82, Pulse 87, respirations 20/ pulse oximetry 98%. Skin evaluation showed no changes observed. Pain Evaluation showed resident did not have any pain. Reminded to use call light for assistance. Primary Care Clinician notified on 12/31/25 at 10:30 p.m., no orders / awaiting for call back. Husband notified on 12/31/25 at 11:00 p.m. Signed by Staff B, LPN01/02/26, 8:44 a.m., IDT (Interdisciplinary Team) note: Review of fall from 12/31/25. Resident observed on the floor beside her bed. Resident reported that she took medication from outside facility that increased drowsiness. New intervention: Education provided to resident and family about not bringing medications from outside the facility. Resident and family verbalized understanding.Review of the care plans showed Resident #3 was at risk for falls related to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medication usage as of 04/10/2024. Interventions included but not limited to: educate family to not provide resident with outside medications, educate the resident to not take medication that is not provided by facility nursing staff as of 01/01/2026. Educate the resident to wait for assistance with transfers as of 01/01/2026. Labs to be obtained for acute change as of 01/02/2026.On 01/16/26 at 11:00 a.m. an interview with the DON and regional nurse consultant revealed Resident #3 had a fall on 12/31/25 at 10:45 a.m. The DON verified the SBAR only stipulated in the morning. The DON verified the resident herself was notified of the fall and the family should have been notified. The DON stated Resident #3 had another fall that evening. The DON stated the resident fell at 10:00 p.m. The DON stated Staff B, LPN put in a note that when he returned from his break the staff made him aware the resident was found on the floor. The DON verified the exact time of the fall was not in the progress note. The DON stated the vitals signs were done after the fall, per the documentation. The DON verified the SBAR (for the second fall) showed they were awaiting a call back from the medical provider. The DON verified there was no documentation the medical provider called back after the notification and no follow up was documented even though the resident hit her head in the fall. The DON stated the expectation was to find documentation they spoke to a doctor about the fall and her hitting her head. The DON verified the IDT note showed the resident had a family member bring medication from the outside. The DON stated they believe the family brought in Benadryl. The DON verified the documentation showed they spoke with the family but she was not sure who did, maybe the Unit Manager. The DON stated she expected to see neurological checks after the first fall. Review of the facility's policy, Change in Resident Condition or Status-Resident Rights, revised on 6.2023 showed Facility shall notify the resident, his or her Attending Physician, and representative of changes in their resident's medical / mental condition and / or status.Guideline: To ensure the facility provides timely notification in accordance with State and Federal regulations as it pertains to residents' rights.Procedure:1. The nurse will notify the resident's Attending Physician or physician on call when there has been a:A. Accident or incident involving the resident;D. Significant change in the resident's physical / emotional / mental condition;E. Need to alter the resident's medical treatment significantly;G. Need to transfer the resident to a hospital / treatment center;I. Specific instruction to notify the physician of physician of changes in the resident's condition.2. A significant change of condition is a major decline or improvement in the resident's status that:C. Requires interdisciplinary review and / or revision to the care plan;D. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument.3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. The resident is involved in an accident or incident that results in an injury including injuries of an unknown origin;E. It is necessary to transfer the resident to a hospital / treatment center.5. The nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status.

Based on observations and interviews the facility failed to ensure a safe and clean environment related to soiled/stained privacy curtains in two resident rooms (#206 and #325) out of three rooms observed. Findings included: On 1/15/26 at 9:16a.m., an observation of room [ROOM NUMBER]'s privacy curtain revealed multiple brown stains smeared along the length of the curtain.On 1/15/26 at 12:33p.m., an observation of room [ROOM NUMBER]'s privacy curtain revealed a large brown stain smeared on the curtain.On 1/15/26 at 11:45a.m., an interview with the Nursing Home Administrator (NHA) revealed it is the responsibility of housekeeping to put in orders for new privacy curtains.On 1/15/26 at 11:51a.m., an interview with the Housekeeping Manager (HM) revealed if a privacy curtain has any stains, it is addressed and swapped out right away. The HM stated the Certified Nursing Assistants (CNAs) or housekeeping staff will advise the HM of any stained or dirty privacy curtains, but the HM will try to check all curtains once a week. The HM said that he does not keep a log of changed privacy curtains, but will write on his notepad or a piece of paper for which rooms need to be changed. The HM stated majority of the curtains are stained and not actually dirty.On 1/15/26 at 12:15p.m., an interview with the Director of Operations (DOO), District Manager (DM), and the HM revealed that housekeeping does not do the orders for privacy curtains, but central supply is responsible for the privacy curtain orders after the HM advises of how many are needed. Participants in the interview revealed there is no formal tracking of the number of privacy curtains needed, and that needed privacy curtains can be written simply on a piece of scratch paper if it is what is available.On 1/15/26 at 12:34a.m., an interview with Staff K, Central Supply (CS) revealed it is not CS's responsibility to make privacy curtain orders, and calls are put out to the regional company, housekeeping, or maintenance.On 1/15/26 at 2:38pa.m., an interview with Staff L, CNA revealed that sometimes privacy curtains are not changed right away despite requests for them to be changed being made.On 1/16/26 at 10:13a.m., an interview with the Director of Nursing (DON) revealed it is expected for housekeeping to be notified right away when privacy curtains appear to be dirty so they can be switched out right away, and that housekeeping should be notified right away. After viewing photo evidence the DON admitted it is not expectation for privacy curtains to be or appear dirty, and the risk of dirty privacy curtains could be infections for all residents present in the room. The DON stated there is no way to determine when a curtain is stained compared to soiled.A review of the facility's Environmental - Cleaning policy revealed a standard: It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home-like environment as outlined below: Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust, and safety hazards. Walls and ceilings are maintained free from dirt or other matters. Fresh, clean and odor-free linen and pillows should be provided to the residents daily or as needed.Photographic Evidence Obtained.

Based on observation, record review, and interview, the facility failed to effectively implement the Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy and procedure for 2 (#2 and #8) of fifteen sampled residents. Resident #8 complained on 12/11/25 about customer service which was not investigated or reported; subsequently Resident #2 reported an allegation of mental / verbal abuse on 12/27/2025 which was verified.Findings included: A review of Resident #8's clinical chart, the admission record, documented an admission of 12/05/2025. The diagnosis information included but not limited to Necrotizing Fasciitis, Type 2 Diabetes Mellitus without complications; chronic combined systolic (congestive) and diastolic (congestive) heart failure; difficulty in walking; muscle weakness; and colostomy status. A review of a Brief Interview for Mental Status (BIMS), dated 12/08/2025, and 01/15/2026, documented a score of 15, which indicated the resident was cognitively intact.A review of Resident #8's care plan included the following:Focus: Resident has colostomy, r/t (related to) large buttock wound, divergent colostomy, initiated 12/07/2025. Interventions included: Apply skin barrier around stoma to protect from excoriation secondary to urine feces, initiated 12/07/2025. Ostomy care daily and PRN (as needed), initiated 12/07/2025.Focus: Resident has an [sic] potential for ADL(Activities of Daily Living) self-care deficit r/t ADL needs and participation vary, fatigue, chronic medical conditions, initiated 12/07/2025. Interventions included: ADL Care: The resident may need limited to extensive assistance X 1 or X 2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status, initiated 12/07/2025. Bed Mobility: The resident needs extensive help to move and reposition the bed (sic). Will need one-or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts., initiated 12/07/2025.A review of the facility grievance log revealed the following entries: For Resident #8, a grievance filed by Resident #8, dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated by the Assistant Director of Nursing (ADON) and resolved on 12/12/2025.For Resident #8, a 2nd grievance, filed by Resident #8, dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated and resolved on 12/12/2025.On 1/15/2025 at 1:58 p.m., an interview was conducted with Resident #8. He was observed to be in bed, sheet up mid torso. He agreed to answer questions. He was alert and oriented. When asked about his 12/11/2025 grievance about call bell light response time, he stated, oh ya, that was when my colostomy bag had broken open and I had feces on my stomach. It took three hours for them to answer the call bell light. I thought that was a little excessive. The interview continued at 2:20 p.m., Resident #8 stated the colostomy bag broke during the 3p-11p shift. They kept coming and telling me they were going to get to it. The Certified Nursing Assistants (CNAs) can't provide service; broke about 9p.m., I cannot be sure, but it was around that time. They got it on at 11:00 p.m. He said, the colostomy is supposed to be changed as needed. It was coming away from the skin with feces on it. I was worried about the integrity of the wound. I had to wait for the nurse. The nurse had three admissions that night. That is why I filed the grievance. I filed it, and that is as far as it went. No one came and talked to me about it. For the phone call complaint. He stated that one I submitted because my POA (power of attorney) tried to call the nursing desk 5-6 times to address an issue and he got hung up on. He was pissed. The nursing home administrator came and talked to both of us about that one. When asked if he had been abused or neglected, he stated no. He stated there had been an aid on the 3-11 shift. In December. I do not remember her name, but she had attitude; she is gone now. I do not know her name, they do not wear name tags. If they wore name tags I would know the name.An interview was conducted on 01/15/2026 at 3:41 p.m. with the Director of Nursing (DON). Resident #8's grievance form, dated 12/11/2025, waited too long for call light to be answered was reviewed with the DON. She stated the Assistant Director of Nursing (ADON) took care of the grievance. When the DON was asked if she was aware of the grievance, she stated it looks like it was a customer service issue. When asked how long Resident #8 waited to have his call light answered, she stated I do not know how long he waited. When asked if she should know, she stated, not necessarily. The DON confirmed she was the Abuse Coordinator. She stated the grievance was talked about in the morning meeting the day following the submission of the grievance. She stated she recalled the grievance was about the staff came in and were rude. When asked if a resident had waited three hours for the call bell light to be responded to, she stated, three hours, that would be a problem. No patient should have to wait for an extended period of time. The DON confirmed no resident interview was attached to the grievance as part of the investigation. When asked how an investigation could be conducted without an interview with the resident voicing the concern, the DON stated, call light response times are something we are educating staff on. For Resident #8's 2nd grievance, the 12/11/2025, Resident voiced concern about customer service, the DON confirmed no statement from the resident was available to review for the grievance.A second interview with DON was conducted on 01/15/2026 at 4:34 p.m. The DON stated they were going to go ahead and file a report for neglect for Resident #8. He states his call light was on for 3 hours. He states he was having issues with his colostomy. He said he thought it had ruptured on one side. The DON said she believed the event occurred on 12/11. A review of Resident #2's clinical chart, the admission record, documented an admission of 12/04/2025. The diagnosis information included but not limited to chronic pain syndrome; heart failure; bipolar disorder, muscle weakness (generalized) and neuromuscular dysfunction of bladder. A review of a Brief Interview for Mental Status (BIMS), dated 12/08/2025, documented a score of 15, which indicated the resident was cognitively intact.A review of Resident #2's care plan included the following focus areas:Focus: The resident is at risk for skin impairment r/t (due to) weakness/ decreased mobility, episodes of incontinence, initiated 12/05/2025.Focus: The resident has a pressure ulcer to sacrum/ coccyx friction shear and DTI (deep tissue injury) on admission.Focus: Resident has an (sic) potential for ADL (Activities of Daily Living) self-care deficit r/t ADL needs and participation vary, fatigue, chronic medical conditions, chronic back pain, initiated 12/05/2025. Interventions included: ADL Care: The resident may need limited to extensive assistance X 1 or X 2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status, initiated 12/05/2025. Bed Mobility: The resident is supervision to limited assistance and may need guided maneuvering for reposition in the bed but check with the resident every few hours to remind and assist if needed, initiated 12/05/2025.On 01/15/2026 at 9:15 a.m. an observation was conducted of Resident #2, in bed, on a specialized mattress, and clean in appearance. Resident #2 was holding her phone; she agreed to an interview. She was interviewed about an allegation of mental / verbal abuse that had been submitted by the facility on 12/27/2025. Resident #2 stated, the person (Staff I, Certified Nursing Assistant (CNA)) would speak to me disrespectfully, in a bad way. I have her on video. The aide worked on the 11 p.m.-7 a.m. shift. It went on for about a month. I did not let anyone know. I would just dread her coming in. For the day Resident #2 reported the aide, she said, I sent him (name / Registered Nurse Consultant (RNC)) the video I had taken on my phone. As far as I know, she no longer works here. The next day, they came in and questioned me and others. I assumed they fired her. No one let me know. Resident #2 was observed to review her phone, she said she was locating the video. Resident #2 showed the surveyor her phone and the video was reviewed. The video had no persons pictured, but a plain background of the resident room. Voices could be heard on the recording. The person (aide), female voice, could be heard in the exchange with Resident #2, an incontinence care procedure was being performed. The female staff member was heard to say three times, I do not give a damn. During the episode, the resident was heard to request a gown replacement. The staff member was heard to say, no. Resident #2 was interviewed about the gown, and she confirmed she was not provided a replacement gown during the care.A review of the facility SNF (Skilled Nursing Facility) Risk Management Tracking Tool (the abuse/ neglect log), revealed an entry for Resident #2, dated 12/27/2025, an allegation of verbal abuse.An interview was conducted on 01/16/2025 at 11:39 a.m. with the Director of Nursing (DON) and Registered Nurse Consultant (RNC) regarding Resident #2's 12/27/2025 allegation. The RNC stated he became are of the allegation about 7:00 a.m. on 12/27/2025. He stated he had provided his contact information to the resident, she had a previous allegation, and I wanted to help with the follow up with her. She contacted me by phone. She sent me a recording. It was a verbal interaction, and you can hear her (presumed to be the resident). The verbal interaction sounded to me a negative interaction. The resident was saying, like are you going to change me. The CNA was pretty much discarding the resident, telling the resident she did not care what the resident was telling her. The RNC stated he contacted the DON and the Nursing Home Administrator (NHA) about 10-15 minutes after receiving the recording. He stated, then, they began an investigation immediately.The DON stated, I came to the facility. When asked when, she stated, I showered and I am 45 minutes away, maybe an hour and 1/2 after I was made aware. We suspended the CNA, Staff I on 12/27. The DON said she would have to look up the time Staff I had been suspended. The DON said, first we got her statement and then we suspended her. I had the Unit Manager, Staff J, Licensed Practical Nurse (LPN), make the phone call to suspend her. Yes, she had left for the day. The DON presented a statement, I (Staff I) can not recall the exact word that I used. I was frustrated and do not recall. The statement was not signed by the staff member but documented via (by way of) phone, signed by the NHA and the DON. The statement did not have a time or date on it. Also provided was an Education/ In-service form, dated 12/27/2025, with no time mark, signed by the DON, that documented she had provided the in-service via phone to Staff I for verbal abuse, providing customer service of quality, professionalism, challenging patients, and resident rights. The DON stated the Assistant Director of Nursing (ADON) assessed the resident's skin at 12:12 p.m.; her pain; her psychosocial base line; and followed up with psych. The allegation was verified. There was no update to Resident #2's care plan.A review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy and procedure, last revised 03/2025, documented the standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.Definitions included: Abuse, .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect, .means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 7. Mistreatment, means inappropriate treatment or exploitation of a resident.Reporting:Staff are required to report any allegation of ANEMMI to the facility risk manager, direct supervisor, and/ or abuse coordinator immediately upon knowledge of the allegation.Allegations of possible ANEMMI will be reported to state agencies per the federal regulation timeframe. State agencies may include (but are not limited to):Abuse Hotline (Department of Children and Families);State Agencies (Agency for Health Care Administration)Local Law enforcement.The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include, but is not limited to:Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and alleged victim and/ or other residents, and interactions/ relations between resident to other residents.Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from Advance Copy outside agencies such as other investigatory agencies, and hospital or emergency room personnel.Conducting record review for pertinent information related to the alleged violation.Initial Reporting:In accordance with (Code of Federal Regulation) CFR483.12(c)(1), with response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the vents (sic)that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures.Follow-up Investigation Report.Within 5 working days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report, so that State agencies can initiate action necessary to oversee the protection of nursing home residents.Investigation:In response to allegations of abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknow origin the facility must: a). Have evidence that all alleged violations are thoroughly investigated.Prevent further potential abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknown origin while the investigation is in progress e). Conduct interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, .Residents will be protected from harm during an investigation.4. Staff person(s) suspected of ANEMMI will be suspended immediately pending results of the investigation.

Based on observation, record review and interview, the facility failed to ensure an allegation of neglect regarding untimely care and services was investigated and reported within 24 hours to the State Survey Agency and adult protective services for one resident (#8) of fifteen sampled residents. Findings included: A review of Resident #8's clinical chart, the admission record, documented an admission of 12/05/2025. The diagnosis information included but not limited to Necrotizing Fasciitis, Type 2 Diabetes Mellitus without complications; chronic combined systolic (congestive) and diastolic (congestive) heart failure; difficulty in walking; muscle weakness; and colostomy status. A review of a Brief Interview for Mental Status (BIMS), dated 12/08/2025, and 01/15/2026, documented a score of 15, which indicated the resident was cognitively intact. A review of Resident #8's care plan included the following:Focus: Resident has colostomy, r/t (due to) large buttock wound, divergent colostomy, initiated 12/07/2025. Interventions included: Apply skin barrier around stoma to protect from excoriation secondary to urine feces, initiated 12/07/2025. Ostomy care daily and PRN (as needed), initiated 12/07/2025.Focus: Resident has an [sic] potential for ADL(Activities of Daily Living) self-care deficit r/t ADL needs and participation vary, fatigue, chronic medical conditions, initiated 12/07/2025. Interventions included: ADL Care: The resident may need limited to extensive assistance X 1 or X 2 for ADL care. This may fluctuate with weakness, fatigue, and weight bearing status, initiated 12/07/2025. Bed Mobility: The resident needs extensive help to move and reposition the bed (sic). Will need one-or two-person assistance to change position or scoot up in the bed. This may involve some lifting of the legs or boosts., initiated 12/07/2025. A review of the facility grievance log revealed the following entries: For Resident #8, a grievance filed by Resident #8, dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated by the Assistant Director of Nursing (ADON) and resolved on 12/12/2025.For Resident #8, a 2nd grievance, filed by Resident #8, dated as received on 12/11/2025, date of incident 12/11/2025, documented as investigated and resolved on 12/12/2025. On 1/15/2025 at 1:58 p.m., an interview was conducted with Resident #8. He was observed to be in bed, sheet up mid torso. He agreed to answer questions. He was alert and oriented. When asked about his 12/11/2025 grievance about call bell light response time, he stated, oh yea, that was when my colostomy bag had broken open and I had feces on my stomach. It took three hours for them to answer the call bell light. I thought that was a little excessive. The interview continued at 2:20 p.m., Resident #8 stated the colostomy bag broke during the 3p-11p shift. They kept coming and telling me they were going to get to it. The Certified Nursing Assistants (CNAs) can't provide service; broke about 9 p m, I cannot be sure, but it was around that time. They got it on at 11:00 p.m. He said, the colostomy is supposed to be changed as needed. It was coming away from the skin with feces on it. I was worried about the integrity of the wound. I had to wait for the nurse. The nurse had three admissions that night. That is why I filed the grievance. I filed it, and that is as far as it went. No one came and talked to me about it. For the phone call complaint. He stated that one I submitted because my POA (power of attorney) tried to call the nursing desk 5-6 times to address an issue and he got hung up on. He was pissed. The nursing home administrator came and talked to both of us about that one. An interview was conducted on 01/15/2026 at 3:41 p.m. with the Director of Nursing (DON). Resident #8's grievance form, dated 12/11/2025, waited too long for call light to be answered was reviewed with the DON. She stated the ADON took care of the grievance. When the DON was asked if she was aware of the grievance, she stated it looks like it was a customer service issue. When asked how long Resident #8 waited to have his call light answered, she stated I do not know how long he waited. When asked if she should know, she stated, not necessarily. The DON confirmed she was the Abuse Coordinator. She stated the grievance was talked about in the morning meeting the day following the submission of the grievance. She stated she recalled the grievance was about the staff came in and were rude. When asked if a resident had waited three hours for the call bell light to be responded to, she stated, three hours, that would be a problem. No patient should have to wait for an extended period of time. The DON confirmed no resident interview was attached to the grievance as part of the investigation. When asked how an investigation could be conducted without an interview with the resident voicing the concern, the DON stated, call light response times are something we are educating staff on. For Resident #8's second grievance, the 12/11/2025, Resident voiced concern about customer service, the DON confirmed no statement from the resident was available to review for the grievance.A second interview with DON was conducted on 01/15/2026 at 4:34 p.m. The DON stated they were going to go ahead and file a report for neglect for Resident #8. He states his call light was on for 3 hours. He states he was having issues with his colostomy. He said he thought it had ruptured on one side. The DON said she believed the event occurred on 12/11. A review of the facility's Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy and procedure, last revised 03/2025, documented the standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.The Definitions included: Abuse, .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect, .means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Reporting. b. Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.4. Allegations of possible ANEMMI will be reported to state agencies per the federal regulation timeframe. State agencies may include (but are not limited to): Abuse Hotline (Department of Children and Families; State Agencies (Agency for Health Care Administration); Local Law Enforcement.

Based on observations, interviews, and record review, the facility failed to ensure updates of care plans for two out of four residents reviewed (Resident #1 and #231B). Findings included: A review of the facility policy titled Comprehensive MDS Assessment and Care Plan, Revised 2/2024, revealed - It will be standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS . The plan of care will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The plan of care will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally competent and trauma informed.On 1/15/26 at 9:17 a.m., an observation of Resident #1 revealed orange and brown build up underneath the resident's nails.A review of Resident #1's admissions record revealed an admission date of 11/18/22 with diagnoses to include chronic obstructive pulmonary disease, Parkinson's disease, ataxia and tremors.A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/10/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 07, severe impairment. A review of Section E- Behavior for Resident #1's Rejection of Care- Presence and Frequency scored a 0-behavior not exhibited.A review of Resident #1's original Care Plan dated 12/25/25 revealed Resident #1 has a ADL, self-care deficit related to their Parkinson's diagnosis, and the resident should be encouraged and assisted with all ADL tasks including but not limited to personal hygiene. Resident #1 may need limited to extensive assistance x1 or x2 for ADL care.A review of Resident #1's progress notes dated 11/16/25 reveal no documentation of the resident's refusal of ADLs, including nail care.A review of Resident #1's shower sheets revealed Resident #1 receives showers on Wednesdays and Saturdays, documentation was provided and read as for dates:11/26/25 no nail care documented or refused.12/10/25 no nail care documented or refused.12/27/25 no nail care documented or refused.1/14/26 both bed bath and shower are marked, and nail care originally marked as Clean, but then crossed out and marked as Refused, signed by Staff L, Certified Nursing Assistant (CNA).On 1/15/26 at 2:38 p.m., an interview was conducted with Staff L, certified nursing Assistant (CNA) and revealed when Resident #1 refuses nail care, they talk to the resident's family member, and the family member is able to convince Resident #1 to complete the task. Staff L, CNA stated nail care will be provided to resident on non-shower days if it is needed, and a shower sheet will be filled out and completed for these additional attempts at the task each time.On 1/15/26 at 1:10 p.m. and on 1/16/26 at 9:40 a.m., an observation of Resident #13 revealed brown and dark-colored build-up underneath the resident's nails.A review of Resident #13's admissions record revealed an original admission date of 7/12/25 and a re-admission date of 12/7/25 with diagnoses to include Type 2 diabetes, chronic obstructive pulmonary disease and hypertensive heart disease.A review of Resident #13's quarterly Minimum Data Set (MDS) assessment, dated 12/11/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 99, meaning the resident was unable to complete interview. A review of Section E- Behavior for Resident #Resident #13's Rejection of Care- Presence and Frequency scored a 0-behavior not exhibited.A review of Resident #13 's original Care Plan dated 12/7/25 revealed Resident #13 has an ADL self-care deficit related to ADL needs, and the resident should be encouraged and assisted with all ADL tasks including but not limited to personal hygiene. Resident #13 may need dependent assistance x1 or x2 for ADL care.A review of Resident #13 's progress notes dated 11/16/25 reveal there was no documentation of the resident's refusal of ADL nail care.A review of Resident #13 's shower sheets revealed Resident #13 receives showers on Wednesdays and Saturdays, documentation was provided and read as for dates:12/21/25 no nail care documented or refused.12/29/25 no nail care documented or refused.On 1/15/26 at 2:44 p.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN) revealing shower sheets are to be filled out for any kind of hygienic care and/or refusals for each attempt. Staff G, LPN stated Resident #13 does not usually refuse care.On 1/15/26 at 2:59 p.m., an interview was conducted with Staff J, LPN Unit Manager (UM) revealing Resident #1 and 13's care plan should have been updated to reflect needing nail care often.On 1/16/26 at 10:13 a.m., an interview with the Director of Nursing (DON) revealed the expectation is for hygienic care to be provided to residents even if it is not their designated shower day, and all residents have the right to ask and be provided with care outside of those shower days. The DON revealed Resident #13's nails were not acceptable and should have been taken care of by staff. The DON stated Resident #1 and 13's care plan should have been updated to reflect needing nail care often. The DON stated that residents who do not get proper nail care are at risk for infection if they are not cleaned properly and regularly.

Based on observations, interviews, and record review, the facility failed to ensure ADLs (activities of daily living) related to nail care was provided for two residents (#1, #13) out of four residents sampled.Findings included: On 1/15/26 at 9:17 a.m., an observation of Resident #1 revealed orange and brown build up underneath the resident's nails.A review of Resident #1's admissions record revealed an admission date of 11/18/22 with diagnoses to include chronic obstructive pulmonary disease, Parkinson's disease, ataxia and tremors.A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/10/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 07, severe impairment. A review of Section E- Behavior for Resident #1's Rejection of Care- Presence and Frequency scored a 0-behavior not exhibited.A review of Resident #1's original Care Plan dated 12/25/25 revealed Resident #1 has a ADL, self-care deficit related to their Parkinson's diagnosis, and the resident should be encouraged and assisted with all ADL tasks including but not limited to personal hygiene. Resident #1 may need limited to extensive assistance x1 or x2 for ADL care.A review of Resident #1's progress notes dated 11/16/25 reveal no documentation of the resident's refusal of ADLs, including nail care.A review of Resident #1's shower sheets revealed Resident #1 receives showers on Wednesdays and Saturdays, documentation was provided and read as for dates:11/26/25 no nail care documented or refused.12/10/25 no nail care documented or refused.12/27/25 no nail care documented or refused.1/14/26 both bed bath and shower are marked, and nail care originally marked as Clean, but then crossed out and marked as Refused, signed by Staff L, Certified Nursing Assistant (CNA).On 1/15/26 at 2:38 p.m., an interview was conducted with Staff L, certified nursing Assistant (CNA) and revealed when Resident #1 refuses nail care, they talk to the resident's family member, and the family member is able to convince Resident #1 to complete the task. Staff L, CNA stated nail care will be provided to resident on non-shower days if it is needed, and a shower sheet will be filled out and completed for these additional attempts at the task each time.On 1/15/26 at 1:10 p.m. and on 1/16/26 at 9:40 a.m., an observation of Resident #13 revealed brown and dark-colored build-up underneath the resident's nails.A review of Resident #13's admissions record revealed an original admission date of 7/12/25 and a re-admission date of 12/7/25 with diagnoses to include Type 2 diabetes, chronic obstructive pulmonary disease and hypertensive heart disease.A review of Resident #13's quarterly Minimum Data Set (MDS) assessment, dated 12/11/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 99, meaning the resident was unable to complete interview. A review of Section E- Behavior for Resident #Resident #13's Rejection of Care- Presence and Frequency scored a 0-behavior not exhibited.A review of Resident #13 's original Care Plan dated 12/7/25 revealed Resident #13 has an ADL self-care deficit related to ADL needs, and the resident should be encouraged and assisted with all ADL tasks including but not limited to personal hygiene. Resident #13 may need dependent assistance x1 or x2 for ADL care.A review of Resident #13 's progress notes dated 11/16/25 reveal there was no documentation of the resident's refusal of ADL nail care.A review of Resident #13 's shower sheets revealed Resident #13 receives showers on Wednesdays and Saturdays, documentation was provided and read as for dates:12/21/25 no nail care documented or refused.12/29/25 no nail care documented or refused.On 1/15/26 at 2:44 p.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN) revealing shower sheets are to be filled out for any kind of hygienic care and/or refusals for each attempt. Staff G, LPN stated Resident #13 does not usually refuse care.On 1/15/26 at 2:59 p.m., an interview was conducted with Staff J, LPN Unit Manager (UM) revealing Resident #1 and 13's care plan should have been updated to reflect needing nail care often.On 1/16/26 at 10:13 a.m., an interview with the Director of Nursing (DON) revealed the expectation is for hygienic care to be provided to residents even if it is not their designated shower day, and all residents have the right to ask and be provided with care outside of those shower days. The DON revealed Resident #13's nails were not acceptable and should have been taken care of by staff. The DON stated Resident #1 and 13's care plan should have been updated to reflect needing nail care often. The DON stated that residents who do not get proper nail care are at risk for infection if they are not cleaned properly and regularly.Review of the facility policy titled ADL Care and Services, revised 01/2024, revealed residents will be provided care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.4. Appropriate care and services will be provided for residents who are unable to carry put ADLs independently with the consent of the resident in accordance with the plan of care, including appropriate supports and assistance with, including but not limited to: a.) .nail care. Photographic evidence Obtained.

Based on observations, interviews and record review, the facility did not ensure equipment was safe, sanitary and operational, and failed provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas. Findings included: On 6/11/2025 at 10:45 a.m., an observation and interview were conducted with Resident #5 in his room. Resident #5 stated his overhead light does not work very well, and stated, it flickers on and off, and stated his roommate's [Resident #6] light, does not work at all. Staff P, Certified Nurse Assistant (CNA), entered the room and agreed the lights were not working properly. Staff P, CNA stated this was not her assignment. She stated she will notify their nurse. On 6/11/2025 at 10:52 a.m., an interview was conducted with Resident #7. Resident #7 stated she received a new bed this morning because the other bed was not working but stated, this bed's head will not go up and down. The resident stated she will have to start the whole process of requesting a new bed all over again. On 6/11/2025 at 10:11 a.m., an observation was made of the activities room on the south hallway. Inside the activities room ceiling was a ceiling tile to the left upon entry with scattered areas of small gray/black circles, then concentric circles of various shades of tan, rusty brown. During observation, Staff P, CNA stated, that's been there for a while.' Staff P, CNA stated over the weekend there was water on the floor in the activity room when she came to work. An observation was made of loose baseboards along the perimeter of the activities room. An observation was made of thick green bio growth substance outside the sliding glass door to the left of the activities room exiting to a courtyard. Directly outside the activities room adjacent to the ceiling tile, there was black bio growth substance and peeling paint with a heavy color of dark brown/black substance. Some missing ceiling texture were observed with light brown discoloration and dark heavy collection of black bio growth at the area where the wall meets the ceiling. A tall white garbage can was observed underneath this area with a collection of lightly discolored water inside garbage can approximately six inches. On 6/11/2025 at 10:30 a.m., an observation and interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) during tour of south hallway in the activities room. The NHA and the DON stated they had not seen these two areas before. On 6/11/2025 at 11:03 a.m., an observation and interview was conducted with Resident #11. Resident #11 stated her overhead bed light does not work. Staff P, CNA arrived in the room and stated her light works, She said, you don't have the switch. Staff P, CNA turned the light switch on by the doorway of Resident #11's room, then went to the bedside to pull the cord to turn on the overhead light. The light did not go on, and Staff P, CNA pulled the cord multiple times until the light flickered, and stated, see it works. Staff P, CNA had to pull the cord aggressively again to turn off the light. Resident #11 stated she did not think she could pull the cord the same way Staff P, CNA pulled the cord. On 6/11/2025 at 1:20 p.m., an observation was made of the pantry room in the east hallway. The refrigerator for the residents in the east hall had a temperature log on the outside door. A documented entry for 6/11/2025 showed a reading for the refrigerator at 50 degrees Fahrenheit and the freezer was documented at 28 degrees Fahrenheit. No documented entries were entered for 6/10/2025. The current refrigerator temperature reading was 58-60 degrees Fahrenheit, and the freezer temperature reading was 36-40 degrees Fahrenheit. Staff J, CNA was witness to the current temperatures for the refrigerator. Inside the refrigerator there were four quarts of milk with a resident's name on them. The milk was lukewarm to touch. In the freezer, there were three half gallons of orange sherbert ice cream, a box of ice cream sandwiches and a box of popsicles. All of the freezer items were observed to be thawed. Staff J, CNA agreed the items were soft to touch and not frozen. Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) for the east hallway was made aware of the refrigerator temperature readings. Staff D, LPN/UM stated according to the temperature log on the refrigerator, the temperature for the refrigerator had been adjusted but agreed the temperature reading were out of normal range. An observation was made of the inside of the cupboard under the sink of the east pantry room. Under the sink there was a large collection of dark brown/black bio growth matter throughout the underside inside the pantry cabinet. An observation was made of the ceiling tile directly above the door partially hanging down. Directly across the entry doorway, was a fan in the wall with a collection of leaves and debris and an opening to the outside environment approximately one inch wide. Staff D, LPN/UM acknowledged these findings. On 6/11/2025 at 3:15 p.m., an observation was made of room [ROOM NUMBER] with open areas of flooring visualized from the hallway. The resident in the room allowed further observation revealing the flooring could be lifted with a slide of the foot. On 6/11/2025 at 3:20 p.m., an observation was made in Residents #12 and #13. The room was designed for a three-resident occupancy. The room was noticeably warmer. Resident #12 stated his roommate #13's AC does not work but his works. Resident #12 had his headboard directly next to his AC unit with his privacy curtain over his headboard where he could receive a direct flow of air from his AC personal unit. Resident #12 stated he moved the curtain because he gets better direct airflow from his AC unit. Resident #12 stated, they know about his AC unit not working. Resident #13's AC unit was powered on, set at 61 degrees Fahrenheit. No air flow was noted. AC filters were observed with a heavy black bio growth. Resident #13 stated he felt his room was hot. A hygrometer reading of 80 degrees Fahrenheit was obtained. Photographic evidence obtained On 6/11/25 at 3:36 p.m., observation was conducted of the bathroom for Resident's #12 and #13. A ceiling tile was observed to be missing with exposed pipes present. On 6/11/2025 at 3:40 p.m., an observation was made of loose flooring on the east hallway. An unidentified resident was walking the hallway with her walker and stated, be careful, you can trip over the loose floor. during this tour, numerous observations were made of loose flooring. The flooring easily would come up when sliding foot over the areas. On 6/11/2025 at 4:46 p.m., a walking tour was conducted with the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM. The NHA became aware of the loose flooring, especially in the 200 hallways. The team acknowledged the refrigerator was removed in the east hallway pantry. The team acknowledged the ceiling tile directly above the entry door, the heavy dark brown/black bio growth under the sink cabinet, and the exposed area to the outside environment along the wall fan/vent. The team toured Resident #13's room to witness a non-functioning A/C (Air Conditioning) unit, with dark black bio growth substance on the A/C filter. The administration team confirmed the observations and the missing bathroom ceiling tile with exposed pipes. During the tour on 6/11/2025 at 5:20 p.m., the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM confirmed these areas of concerns and stated they would be addressed immediately. Review of a facility policy titled, Standards and Guidelines: General cleaning dated 01/2024 showed a standard: It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home like environment as outlined below: 1. Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. 2. Floors and horizonal surfaces are cleaned routinely. Finishes on floors provide an appropriate finish and disinfectants are used where required. 3. Walls and ceilings are maintained free from dirt or other matters. 4. Entrances, exits, walkways, driveways and other outside or entry areas are kept free from debris and dirt. 5. Beds, bedside tables, chairs overbed tables, nightstands and dressers should be cleaned with a germicidal and allowed to air dry. 6. Dry dusting is used on items such as pictures, plaques, mirrors, bulletin boards, tops of partitions, vents, tops of cabinets, coat racks and window/door frames. Damp dusting may be used as needed. (Photographic Evidence Obtained.)

Based on interviews and record review, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#3) out of four residents sampled. Findings included: Review of Resident #3's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of displaced fracture of upper end of right humerus, with routine healing, asthma, dysphagia, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle weakness, major depressive disorder, post traumatic stress disorder (PTSD), and generalized anxiety disorder. An interview was conducted on 6/11/25 at 11:03AM with Resident #3. She said it was a Saturday around the last week of May 2025; she came out of the bathroom and was in a towel. She said Staff C, Occupational Therapist Assistant (OTA) knocked, came into her room, and she realized it was a male, so she said, I'm not dressed get out! She said Staff C, OTA said to her I can walk in anytime I want to I'm with physical therapy. She said she told him again to get out of her room, and he left. She said he tried to come into her room the next day for therapy, but she refused therapy because she did not want to work with Staff C, OTA. Resident #3 said she did not have any problems with him leaving her room that day. She said she felt sexually harassed and abused. She said on the Monday after it happened, she told a female supervisor what happened and she told the Director of Nursing (DON) she did not want Staff C, OTA in her room anymore and told her what happened over the weekend as well. Review of Resident #3's admission Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating she is cognitively intact. Review of the facility's state agency reportable log did not reveal evidence a report was filed to stage agencies, or an investigation was conducted related to Resident #3. An interview was conducted on 6/12/25 at 9:56AM with the Director of Rehabilitation. She said it was around Memorial Day (the last Monday in May) Resident #3 came to her and said Staff C, OTA came into her room and she was in the bathroom and he knocked on the door and she said enter, she saw it was a man and she said oh my god I'm naked get out! The Director of Rehabilitation said Resident #3 told her Staff C, OTA said something back to her but the Director of Rehabilitation could not remember what Resident #3 told her Staff C, OTA said But then he left the room. The Rehabilitation Director said Resident #3 told her Staff C, OTA came back on Sunday to work with her, but she kicked him out of her room. However, he did not come back on Sunday because no one was on the schedule on Sunday. The Director of Rehabilitation said she went to talk to Staff C, OTA the same day Resident #3 told her what happened. The Director of Rehabilitation said Staff C, OTA told her he knocked on the door heard enter, he poked his head in the bathroom, and she said, oh my god I'm naked get out! and he said, no you're dressed and she said, no I'm not get out. The Director of Rehabilitation said Resident #3 had also told her Therapy was sexually harassing her but she changed the story, it wasn't about Staff C, OTA anymore. The Director of Rehabilitation said after Resident #3 told her what happened, and she interviewed Staff C, OTA, she told the DON what Resident #3 had said and what Staff C, OTA had said. The Director of Rehabilitation said she could not remember what the DON told her, but she thinks she said she'd look into it. I'm sure they took action. The Director of Rehabilitation said she reported it to the DON because the DON was the abuse coordinator and Resident #3 reported a serious allegation of Sexual Harassment. An interview was conducted on 6/12/25 at 11:07 AM with the DON and the Nursing Home Administrator (NHA). The DON said the Director of Rehabilitation did not come to her with sexual harassment concerns related to Resident #3 and Staff C, OTA. The DON said Resident #3 came to her and said when the therapist went into her room she said she was not ready for therapy, so he left. The DON said to Resident #3 well maybe we can come up with a schedule, so she was ready for therapy, and she said well who is going to be my therapist, and she said she didn't want it to be this person and that person. The DON said she does not recall Resident #3 saying any specific therapist names. So, the DON went to the Director of Rehabilitation and asked if Resident #3 could have a therapy schedule so she could be ready for therapy. The Director of Rehabilitation said, okay I'll take care it. The DON said the Director of Rehabilitation never came to her and told her there was a sexual harassment allegation against Staff C, OTA. If there was, she would have suspended the staff member, reported the allegation and carried out an investigation. The DON said if a resident tells any staff member of an allegation of abuse or sexual harassment, they are to report the allegation to her immediately so it could be reported and investigated. The DON reviewed the reportable events log and confirmed there was not a report, or an investigation conducted related to Resident #3's allegation. A phone interview was conduncted on 6/12/25 at 11:24PM with Staff C, He said Resident #3 is hard to forget because she confabulates a lot, you have to redirect her into what is actually going on. He said about three weeks ago, he knocked on Resident #3's door, someone said come in, so he walked in, Resident #3 said get out of here I'm not dressed, and he said you're dressed and she said no I'm not, and he said you are fully dressed, shirt, pants, and she no I'm not, get out of here and so he left the room. Staff C, OTA said no one talked to him or asked him what happened except for another therapist told him Resident #3 was very mad at him and all he said was okay sorry. He said he went to the Director of Rehabilitation and asked not to be assigned to Resident #3 anymore and the Director of Rehabilitation said she wouldn't assign her to him anymore. Review of the facility's policy Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 3/2025 revealed Standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart . Definitions: 1. Abuse, is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 4. Willful, . in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Reporting: The facility must develop and implement written policies and procedures that: 1. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. 3. Staff are required to report any allegation of NEMMI to the facility risk manager, direct supervisor, and/or abuse coordinator immediately upon knowledge of the allegation. 4. Allegations of possible ANEMMI will be reported to state agencies per the federal regulation timeframe. State agencies may include (but are not limited to): - Abuse Hotline (Department of Children and Families) - State Agencies (Agency for Health Care Administration) - Local Law Enforcement .

Based on interview and record review, the facility failed to thoroughly investigate a resident-to-resident allegation of abuse involving two residents (#14 and #15) out of four reportable events sampled. Findings included: Review of the facility's state agency reportable log revealed on 5/22/25 a resident to resident report was made involving Resident #14 and Resident #15. An interview was conducted on 6/11/25 at 1:21 PM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 6/11/25 at 1:21PM. The DON said she was the one who reported and investigated the event and the NHA said she was not working at the facility at the time the event occurred. The DON said the event occurred on 5/22/25 around 6:00 PM and she reported the event the state agencies on 5/22/25 at 6:00 PM. The DON said staff reported to Staff D, Eat Wing Unit Manager (UM) that Resident #14 made contact with Resident #15 to the back of his head. Staff were noted to be within close immediate proximity with both residents and intervened immediately and placed Resident #14 on one-to-one supervision monitoring. Resident #15 was immedieitly assessed by nursing, vitals were within normal limits, they notified the physician and out of the abundance of caution Resident #15 was sent to the emergency department where a computed tomography (CT) scan was conducted, and the results were negative. Resident #14 did not say what caused the interaction to happen and he was unable to state what he was attempting to do. The DON said from staff interviews Resident #14 grazed the back of Resident #15's head with a white plastic tube (The DON clarified the white plastic tube was a polyvinyl chloride (PVC) pipe). The DON said Resident #15 returned to the facility the same day. The DON said Resident #14 was sent to the hospital for increased agitation. The DON said at the time of the incident both residents were under adequate supervision on the smoking patio. And staff responded immediately to the residents change in behavior. Other alert and oriented residents were interviewed without concerns for care, safety, or supervision. The DON said, after a thorough investigation the allegation of abuse was not substantiated. The DON said she obtained statements as part of her investigation and said Staff B, Licensed Practical Nurse (LPN) statement was collected and said, she was sitting at the nurse's station when she heard yelling coming from one of the CNA's. Resident #14 had made contact with the CNA. After making contact with the CNA the resident was placed on one-on-one supervision. Resident #14 had increased agitation after being placed on one-on-one supervision, so the resident was then placed on 15-minute checks and within the first 15 minutes, he was noted outside in the smoking area pacing but not showing aggressive behaviors at that time. The DON said Staff D, East wing UM statement said on 5/22/25 I was notified that [Resident #14] was outside on the smoking area and made contact with [Resident #15's] head. The residents were immedieitly separated Resident #15 was assessed and he had a reddened raised area which was observed on Resident #15's posterior scalp. He denied pain. He notified DON. [Physician] was notified, and new orders were received to send the resident to the ER [emergency room] for further eval [evaluation]. Resident #14 was assisted to his room and [Physician] was notified to send the resident to the ER for further eval [evaluation] and treatment. The DON said the facility's Psychologist initiated an involuntary hospitalization for Resident #14. They attempted medication to manage his behaviors, but his behaviors continued to escalate. The DON said Resident #14 was emergently transferred related to the incident because they could not redirect him. The DON said Staff T, CNA was the CNA who was out on the smoking patio at the time of the event and his statement was, he was sitting in the smoking patio when he saw Resident #14 behind Resident #15. He said Resident #14 had his hand behind his back and he kept walking closer to Resident #15. He said Resident #14 pulled his hand out from behind his back and he had a PVC pipe in his hand, the CNA said he yelled at Resident #14 to drop it, and Staff T, CNA said he got closer to Resident #14 and when he got closer to Resident #14, he swung at Resident #15 with it. The DON said there are no cameras on the smoking patio therefore there was no video footage to review. An interview was conducted on 6/11/25 at 11:03AM with Resident #3. Resident #3 said she has not seen Resident #14 since he left when he hit another resident over the head with a pipe. 1. Review of Resident #14's admission Record revealed he was admitted to the facility on [DATE] and discharged on 5/22/25. His medical diagnoses included Major depressive disorder, Post Traumatic Stress Disorder (PTSD), generalized anxiety disorder, insomnia, Parkinsons disease, and dementia without behavioral disturbances, psychotic disturbances, mood disturbance, and anxiety. Review of Resident #14's care plan with an initiated date of 12/13/25 and a revision date of 5/22/25 revealed a focus of [Resident #14] has a history of exhibiting the following behaviors: Confabulation, verbally aggressive. Pacing. removing wander guard, combative at times. The goal revealed [Resident #14] will have fewer episodes of the identified behavior through the next review date. The intervention dated 12/13/2023 revealed Acknowledge/commend the resident's progress/improvement in behavior. Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage and assist the resident to develop more appropriate methods of coping and interacting as able. Encourage the resident to express feelings as needed. Encourage resident to interact with staff members as tolerated. Explain procedures to the resident before starting and allow the resident time to adjust to changes as needed. If reasonable/appropriate, discuss the behavior with the resident. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene and/or redirect resident behavior as necessary. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention/redirect behavior as indicated. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Offer Psychology/Psychiatry services as needed. Provide a program of activities that is of interest and accommodates residents status. Social Services will offer education for the resident/family member on successful coping and interaction strategies specific to individual resident needs. Review of the intervention with an initiated date of 5/22/25 revealed Intervene and/or redirect resident behavior as necessary. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of Resident #14's Crisis Intervention Note with a service date of 5/22/25 at 6:49PM revealed Summary Narrative of Session: Staff reported that the patient has unpredictable episodes of aggression towards others. Another provider attempted medication earlier today to manage aggressive behaviors after the patient hit a CNA with his hands, pushing her face and later hitting her arms. This afternoon, the patient managed to remover [sic] forcefully a PVC pipe from the courtyard area of the facility and hit another patient with the pipe on their head. Attempts to use behavioral redirection and psychotropic medication failed. [involuntary hospitalization] initiated. 2. Review of Resident #15 admission Record revealed he was admitted on [DATE] with medical diagnoses of Dementia with mild agitation, spinal stenosis, lumber region without neurogenic claudication, muscle wasting and atrophy. An interview was conducted on 6/11/25 at 4:07pm with Resident #15. He said about two weeks ago a guy hit him on my head, [explicit] yes it hurt. Review of Resident #15's Annual, Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Review of Resident #15's change in condition dated 5/22/25 at 9:57PM revealed the change in condition, symptoms or signs was: .head injury. This started on 5/22/25 in the afternoon. Is a skin assessment relevant to the change in condition been reported? Not clinically applicable to the change in condition being reported. Were the change in condition and notifications reported to the primary care clinical? No . Review of Resident #15's Progress notes revealed on 5/22/25 at 9:57PM a Situation Background Assessment Recomendation (SBAR) summary for providers revealed a change in condition other change in condition outcome of physical assessment: Positive findings reported on the residents evaluation for this change in condition were: no changes in mental status observed, no changes in functional status observed, no documentation for a skin status evaluation, no documentation for a pain status evaluation and there was no documentation the physician was notified of the change in condition. Review of Resident #15's medical record did not reveal documentation of a skin assessment from the time of the event. Review of Resident #15's transfer form dated 5/22/25 revealed he was being transferred to a hospital for an unplanned CT of the head. Review of Resident #15's progress note dated 5/22/25 at 10:00PM, written by the DON, revealed Resident returned from [Hospital] after being sent out in the abundance of caution for ED [Emergency Department] evaluation. CT of head completed with no acute findings, no intracranial hemorrhage. Skin assessment completed skin remains intact, resident denies pain at this time. MD [Medical Doctor] made aware of return, NNO [no new orders.] An interview was conducted on 6/11/25 at 3:46pm with Staff D, East Wing Unit Manager (UM). He said Staff T, CNA came to him and told him Resident #14 hit Resident #15 in the back of the head with a PVC pipe. Staff D, UM said Resident #15 did not have any injures but he was sent out to the hospital to get evaluated. He said Resident #14 definitely got hit by the PVC pipe on his head. An interview was conducted on 6/12/205 at 1:17PM with Staff B, Licensed Practical Nurse (LPN) she confirmed she was familiar with Resident #14, and she was his nurse on 5/22/25. Staff B, LPN said shortly after the start of the 3:00 PM to 11:00PM shift Resident #14 started to sundown. She said when it comes to sundowning time Resident #14 is a whole different person. On 5/22/25 around the start of the 3:00PM-11:00PM shift we heard his CNA yelling and when we went in there, he was hitting her, and she was covering her face. So, she separated him from the CNA and placed Resident #14 on one-to-one supervision. Staff B, LPN said they called his physician and his psychiatrist to get as needed medications to calm him down they ordered an extra dose of Rexulti and Vistaril and labs for the next day. Staff B, LPN said she gave him his as needed Ativan and the other medications, but nothing worked. So, they put him on one-to-one supervision. Staff B, LPN said Resident #14 wasn't too comfortable with the one-to-one supervision and he was very annoyed with someone being close by him. Staff B, LPN said either Staff D, UM or The DON gave her directive to place Resident #14 on 15-minute checks because he was getting agitated with the one-to-one supervision and we didn't want to make things worse. She said she was the one who completed the 15-minutes checks, and he was observed to be outside on the smoking patio pacing with his hands behind his back but that's just how he walks. Staff B, LPN said Staff T, CNA was the smoking aide that day and he brought Resident #14 to her and Staff T, CNA told her he just hit a resident in the back of his head with some kind of pole. Staff B, LPN said she escorted Resident #14 to his room, he was agitated because it had just happened. Staff B, LPN said she sat with him for a little bit and started to talk to him he calmed down a little bit but you could tell he was still a little agitated because he started to run down the hall so we ran down the hall with him and then he ran back down the hall and into his room. Staff B, LPN said she continued to sit with him and shortly after, the Emergency Medical Technicians (EMT) came and got him. She said from the CNA got hit by Resident #14 to the time Resident #14 hit Resident #15 with the PVC pipe was about two hours. She confirmed she was told by Staff T, CNA Resident #14 hit Resident #15 with the PVC pipe on his head. An interview was conducted on 6/12/25 at 9:03AM with the DON she stated she reported to the State Agency Resident #14 attempted to make contact with Resident #15 with a white tube which she clarified was a PVC pipe. She said she reported Resident #14 attempted to hit Resident #15 because since Resident #15 did not have any injuries to his head and the CT scan results did not show any injuries she could not prove he was actually hit by the PVC pipe therefore she did not substantiate the allegation of abuse. Review of the facility's policy Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) revised on 3/2025 revealed Standard: The resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and exploitation as defined in this subpart . Definitions: 1. Abuse, is defined .as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. .4. Willful, . in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Follow-up investigation Report 1. Within 5 working days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of the submission of the report, so that State agencies can initiate action necessary to oversee the protection of the nursing home residents . The facility should include any updates to information provided in the initial report. .Investigation: 1.In response to allegations of abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknown origin the facility must: . a. Have evidence that all alleged violations are thoroughly investigated . b. Prevent further potential abuse, neglect, exploitation, misappropriation, mistreatment, or injury of unknown origin while the investigation is in progress . c. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. d. Conduct observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to the other residents; e. Conduct interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witness, practitioner, interviews with personnel from outside agencies such as other investigatory agencies, and hospital or emergency room personnel. f. Conduct record review for pertinent information related to the alleged violation, as appropriate, such as progress notes (Nurse, social services, physician, therapist, consultants as appropriate, etc.), financial records incident reports (if used), reports from hospital/emergency room records, laboratory or x-ray reports, medication administration records, photographic evidence, and reports from other investigatory agencies.

Based on observations, interviews and record review, the facility did maintain an effective pest control program related to roaches for their residents. Findings include: On [DATE] at 10:11 a.m., an observation was made in front of Resident #4's room of a large moving roach on its back swept up in a pile of debris from Staff A, housekeeping. An interview was conducted with Resident #4 in his room. Resident #4 stated roaches are a problem and he sees them all the time in his room. Upon observation, live roaches were seen on the windowsill, walls and dressers. An observation was made behind Resident #4's dresser of a heavy growth of dark brown/black dusty-like debris on the floor by the baseboards behind his dresser. Staff A, housekeeping, returned to the room and was witnessed moving the dresser to sweep the debris on the floor. Staff A, housekeeping through an interpreter's phone, stated she sees roaches all the time. Photographic evidence obtained. On [DATE] at 10:52 a.m., an interview was conducted with Resident #7. Resident #7. Resident #7 stated, roaches are definitely a problem here. Resident #7 stated, I don't think they come in my room to spray for bugs. On [DATE] at 11:03 a.m., an interview was conducted with Resident #3. Resident #3 said she sees roaches in her room all the time and pointed to a roach located under her dresser. She said the roach was dead but it had been there for longer than she can remember. She said she had told staff about the roaches in her room. She said she had never seen a pest control company come into her room to treat the roaches. (Picture evidence obtained) On [DATE] at 11:03 a.m., an interview was conducted with Resident #11 in her room. Resident #11 stated she sees roaches all the time but has not witnessed anyone coming into her room to spray for them. On [DATE] at 11:20 a.m., an interview was conducted with Resident #8 in his room. Resident #8 stated he sees roaches all the time and stated, I saw two big one's last night. Resident #8 allowed observations to be made of his dresser drawers and a large live roach moving quickly was witnessed in one of the drawers. Resident #8 stated he has never seen anyone come in his room to spray for bugs. On [DATE] at 2:40 p.m., an observation was made of the pantry room in the north hallway. On the right side of the refrigerator were various dead body parts of roaches on the ground. An interview was conducted with the nursing staff at the nurses' station related to roaches. An unidentified staff member stated, they have taken residency here. All staff were aware of the pest control log. Photographic evidence obtained. On [DATE] at 3:17 p.m., an observation and interview were conducted with two residents in a room designed for three residents. Residents #12 and #13 stated they see roaches in their room all the time. Resident #12 stated he can walk to his bathroom and stated he sees live roaches on a frequent bases especially at nighttime. Resident #13 pointed to his overhead fluorescent light fixture over his bed and stated, I watched that roach for a while until he flipped over and died. An observation was made of a large dead roach on its back in the overhead fluorescent light. On [DATE] at 9:42 a.m., an interview was conducted with Staff E, Certified Nurse Assistant (CNA). Staff E, CNA stated she sees numerous roaches, dead and alive, in residents' rooms and will place concerns in the pest control log book. On [DATE] at 9:55 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN stated roaches are a concern but stated it was worse two months ago. On [DATE] at 10:09 a. m., an interview was conducted with Staff H, housekeeping, with Staff I, CNA, utilized for interpretation. Staff H, housekeeping, stated she sees lots of roaches dead and alive. Staff H, housekeeping, stated she just kills the live ones when she can. On [DATE] at 10:16 a.m., an interview was conducted with Staff I, CNA. Staff I, CNA stated sees roaches all the time and they are worse on the east hallway. Staff I, CNA stated she just kills the roaches herself. On [DATE] at 10:33 a.m., an interview was conducted with Staff J, CNA. Staff J, CNA stated he sees alive roaches every other day during his shift. On [DATE] at 10:30 a.m., an interview was conducted with Staff K, CNA and Staff L, CNA. Both staff members stated they see roaches. Staff K, CNA stated she sees all kinds of roaches, big, small, dead and alive. Staff K, CNA stated there are lots of holes in the building, that's how they are getting in. Staff K, CNA stated she just kills them when she sees them and cleans up the mess. Staff L, CNA stated she has put pest concerns in the pest control log. On [DATE] at 11:09 a.m., an observation and interview were conducted with Staff M, housekeeping. An observation was made by Staff M, housekeeping, servicing Residents #12 and #13's room. Staff M, housekeeping, was in the room mopping the floor and, in the doorway entrance, was a swept-up pile of dead roaches. An interview was conducted with Staff M through her phone utilized for interpretation. Staff M, housekeeping, stated she sees lots of roaches, dead and alive. She said she tries to kill the lives one as best as she can. On [DATE] at 11:13 a.m., an interview was conducted with Staff N, LPN. Staff N, LPN stated she sees roaches dead and alive, and she will use the pest control log and added, we make morning rounds every morning and they will take care of it. On [DATE] at 11:20 a.m., an interview was conducted with the representative servicemen for the facility contracted commercial pest control service company(pest control serviceman). The pest control serviceman stated he has been servicing the facility on and off for the past 8-9 years but more on a continually basis for the past one and one-half years. The pest control serviceman stated his point of contact for the facility has always been Staff O, maintenance assistant. The pest control serviceman stated he will contact Staff O upon arrival and they will review the pest logs from each nurses' station and other concerns Staff O would bring to his attention. The pest control serviceman stated he comes every Thursday. The pest control serviceman stated he will make his rounds and then provide a verbal and written report to Staff O, maintenance assistant, of his findings. The pest control serviceman stated he would make suggestions in his report such as fixing holes in the facility to minimize entrance of pests. The pest control serviceman stated, Staff O has too much on his plate. The pest control serviceman stated points of entry include such places as air conditioning units, pipes and dead foliage around the facility The pest control serviceman stated the pest log is not utilized appropriately and added sometimes he will come in for service and there would be very little rooms on the pest control ledger and then next week the ledger will be a full page. The pest control serviceman stated he sees American roaches and German roaches. He stated German roaches are not good to have in a facility and are difficult to maintain once you have an outbreak. The pest control serviceman stated another job duty while in the facility is to maintain the numerous ultraviolet pest control lights. The pest control serviceman stated he cleans and changes out the filters monthly but stated two are in need of new bulbs with one located in the east nurses' stations, out for four months, and the other in the kitchen, out for two months. The pest control serviceman stated Staff O, maintenance assistant was aware. On [DATE] at 12:26 p.m., an interview was conducted with Staff O, maintenance assistant, a maintenance director from another facility and the Nursing Home Administrator (NHA). Staff O, maintenance assistant, stated he will meet up with the pest control serviceman every Thursday to review the pest logs at each nurses' station. Staff O stated he does not get the emailed written reports. The maintenance director from another facility stated she thinks the former Maintenance Director was getting them. The maintenance director from another facility stated she printed the emails yesterday to be viewed during the survey. The NHA stated she has not received any emails but will rectify the issue. Staff O, maintenance assistant, stated he was aware of the holes outside in need of repair to minimize entry but the NHA, newly hired, stated she was not aware. Staff O stated the facility has a lawn service but it would need approval to have the perimeter cleared from the facility. The NHA stated Staff O, maintenance assistant, is doing the work of three at this time and attempts have been made to hire more staff for maintenance. A review of the facility's policy titled, Pest Control, revised on 7/2024 stated the following standard statement: Our facility shall maintain an effective pest control program. . 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, record review, interviews, and review of the Plan of Correction (PoC) the facility failed to ensure it had a functioning Quality Assurance Performance Improvement (QAPI) plan. The facility was actively involved in the creation, implementation, and monitoring of their PoC for deficient practice identified during a complaint survey on 05/13/2025. The plan was ineffective resulting in citation F908 being recited related to ensuring timely repairs of essential equipment, for one roof-top Air-Conditioning (A/C) unit (#11) of 19 roof- top A/C units and F908 being recited related to failure to ensure equipment was safe, sanitary and operational, and failure to provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas. Findings included: A review of an undated facility policy titled, Quality Assurance and Performance Improvement (QAPI), showed a policy statement: This facility shall develop, implement, and maintain on ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for out residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions. Authority: 1. The owner and/ or governing board body of our facility is ultimately responsible for the QAPI program 2. The governing board/owner evaluates the effectiveness of its QAPI program at least annually and presents findings to the QAPI committee. 3. The administrator is responsible for assuring that this facilities QAPI program complies with federal, state, and local Regulatory agency requirements. 4. The QAPI committee reports directly to the administrator Implementation: 1. The QAPI Committee overseas implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance. b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities and f. Monitoring or evaluating the effectiveness of corrective action performance improvement activities, and revising is needed. Coordination: 1. The QAPI Coordinator coordinates QAPI Committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as a liaison between the QAPI committee and the individuals, services, and/or department regarding QAPI activities 1. On 6/11/2025 at 10:45 a.m., an observation and interview were conducted with Resident #5 in his room. Resident #5 stated his overhead light does not work very well, and stated, it flickers on and off, and stated his roommate's [Resident #6] light, does not work at all. Staff P, Certified Nurse Assistant (CNA), entered the room and agreed the lights were not working properly. Staff P, CNA stated this was not her assignment. She stated she will notify their nurse. On 6/11/2025 at 10:52 a.m., an interview was conducted with Resident #7. Resident #7 stated she received a new bed this morning because the other bed was not working but stated, this bed's head will not go up and down. The resident stated she will have to start the whole process of requesting a new bed all over again. On 6/11/2025 at 10:11 a.m., an observation was made of the activities room on the south hallway. Inside the activities room ceiling was a ceiling tile to the left upon entry with scattered areas of small gray/black circles, then concentric circles of various shades of tan, rusty brown. During observation, Staff P, CNA stated, that's been there for a while.' Staff P, CNA stated over the weekend there was water on the floor in the activity room when she came to work. An observation was made of loose baseboards along the perimeter of the activities room. An observation was made of thick green bio growth substance outside the sliding glass door to the left of the activities room exiting to a courtyard. Directly outside the activities room adjacent to the ceiling tile, there was black bio growth substance and peeling paint with a heavy color of dark brown/black substance. Some missing ceiling texture were observed with light brown discoloration and dark heavy collection of black bio growth at the area where the wall meets the ceiling. A tall white garbage can was observed underneath this area with a collection of lightly discolored water inside garbage can approximately six inches. On 6/11/2025 at 10:30 a.m., an observation and interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) during tour of south hallway in the activities room. The NHA and the DON stated they had not seen these two areas before. On 6/11/2025 at 11:03 a.m., an observation and interview was conducted with Resident #11. Resident #11 stated her overhead bed light does not work. Staff P, CNA arrived in the room and stated her light works, She said, you don't have the switch. Staff P, CNA turned the light switch on by the doorway of Resident #11's room, then went to the bedside to pull the cord to turn on the overhead light. The light did not go on, and Staff P, CNA pulled the cord multiple times until the light flickered, and stated, see it works. Staff P, CNA had to pull the cord aggressively again to turn off the light. Resident #11 stated she did not think she could pull the cord the same way Staff P, CNA pulled the cord. On 6/11/2025 at 1:20 p.m., an observation was made of the pantry room in the east hallway. The refrigerator for the residents in the east hall had a temperature log on the outside door. A documented entry for 6/11/2025 showed a reading for the refrigerator at 50 degrees Fahrenheit and the freezer was documented at 28 degrees Fahrenheit. No documented entries were entered for 6/10/2025. The current refrigerator temperature reading was 58-60 degrees Fahrenheit, and the freezer temperature reading was 36-40 degrees Fahrenheit. Staff J, CNA was witness to the current temperatures for the refrigerator. Inside the refrigerator there were four quarts of milk with a resident's name on them. The milk was lukewarm to touch. In the freezer, there were three half gallons of orange sherbert ice cream, a box of ice cream sandwiches and a box of popsicles. All of the freezer items were observed to be thawed. Staff J, CNA agreed the items were soft to touch and not frozen. Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) for the east hallway was made aware of the refrigerator temperature readings. Staff D, LPN/UM stated according to the temperature log on the refrigerator, the temperature for the refrigerator had been adjusted but agreed the temperature reading were out of normal range. An observation was made of the inside of the cupboard under the sink of the east pantry room. Under the sink there was a large collection of dark brown/black bio growth matter throughout the underside inside the pantry cabinet. An observation was made of the ceiling tile directly above the door partially hanging down. Directly across the entry doorway, was a fan in the wall with a collection of leaves and debris and an opening to the outside environment approximately one inch wide. Staff D, LPN/UM acknowledged these findings. On 6/11/2025 at 3:15 p.m., an observation was made of room [ROOM NUMBER] with open areas of flooring visualized from the hallway. The resident in the room allowed further observation revealing the flooring could be lifted with a slide of the foot. On 6/11/2025 at 3:20 p.m., an observation was made in Residents #12 and #13. The room was designed for a three-resident occupancy. The room was noticeably warmer. Resident #12 stated his roommate #13's AC does not work but his works. Resident #12 had his headboard directly next to his AC unit with his privacy curtain over his headboard where he could receive a direct flow of air from his AC personal unit. Resident #12 stated he moved the curtain because he gets better direct airflow from his AC unit. Resident #12 stated, they know about his AC unit not working. Resident #13's AC unit was powered on, set at 61 degrees Fahrenheit. No air flow was noted. AC filters were observed with a heavy black bio growth. Resident #13 stated he felt his room was hot. A hygrometer reading of 80 degrees Fahrenheit was obtained. Photographic evidence obtained On 6/11/25 at 3:36 p.m., observation was conducted of the bathroom for Resident's #12 and #13. A ceiling tile was observed to be missing with exposed pipes present. On 6/11/2025 at 3:40 p.m., an observation was made of loose flooring on the east hallway. An unidentified resident was walking the hallway with her walker and stated, be careful, you can trip over the loose floor. during this tour, numerous observations were made of loose flooring. The flooring easily would come up when sliding foot over the areas. On 6/11/2025 at 4:46 p.m., a walking tour was conducted with the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM. The NHA became aware of the loose flooring, especially in the 200 hallways. The team acknowledged the refrigerator was removed in the east hallway pantry. The team acknowledged the ceiling tile directly above the entry door, the heavy dark brown/black bio growth under the sink cabinet, and the exposed area to the outside environment along the wall fan/vent. The team toured Resident #13's room to witness a non-functioning A/C (Air Conditioning) unit, with dark black bio growth substance on the A/C filter. The administration team confirmed the observations and the missing bathroom ceiling tile with exposed pipes. During the tour on 6/11/2025 at 5:20 p.m., the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM confirmed these areas of concerns and stated they would be addressed immediately. Review of a facility policy titled, Standards and Guidelines: General cleaning dated 01/2024 showed a standard: It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home-like environment as outlined below: 1. Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. 2. Floors and horizonal surfaces are cleaned routinely. Finishes on floors provide an appropriate finish and disinfectants are used where required. 3. Walls and ceilings are maintained free from dirt or other matters. 4. Entrances, exits, walkways, driveways and other outside or entry areas are kept free from debris and dirt. 5. Beds, bedside tables, chairs overbed tables, nightstands and dressers should be cleaned with a germicidal and allowed to air dry. 6. Dry dusting is used on items such as pictures, plaques, mirrors, bulletin boards, tops of partitions, vents, tops of cabinets, coat racks and window/door frames. Damp dusting may be used as needed. (Photographic Evidence Obtained.) 2. On 6/11/2025 at 11:38 a.m., an interview was conducted with Staff O, Maintenance Assistant and a Maintenance Director from another facility. Staff O stated the Air Conditioner (A/C) unit #11 was not functioning properly and stated there was a bent blade in the A/C fan causing the issue. Staff O stated the issue had been going on since October 2024. The maintenance director from another facility stated they were contacting the A/C company to have the A/C fixed. An unidentified nursing staff member was witnessed standing in the south hallway close to the nurses' station down the hallway to the right, fanning her face with her hand and stated, I found a cool spot. During a tour on 6/11/2025 at 4:46 p.m. with the administrative team - Nursing Home Administrator (NHA), the director of Nursing (DON) and Staff O, Maintenance Assistant, Maintenance Director from another facility and Staff D, Licensed Practical Nurse/Unit manager (LPN/UM) of the east hallway. The NHA stated the A/C company was up on the roof today taking measurements to fix A/C unit #1 in the physical therapy gym) and A/C unit #19 (north nurses' station and hallway). The NHA stated A/C unit #11 was a new request. Staff O, Maintenance Assistant confirmed A/C unit #11 in the south hallway/activities room area had been an on-going problem since October 2024. On 6/12/2025 at 12:11 p.m., an interview was conducted with the administrative team. The NHA stated the A/C company took measurements yesterday, (6/11/2025) during the revisit survey to fix the A/C concerns identified previously. The NHA could not confirm a payment had been made to the A/C company for the original requests, but provided a new quote dated 6/11/2025 for repairs of A/C unit #11. The NHA stated she was unaware of the issues with A/C unit #11 until yesterday, but the maintenance assistant stated it had been an ongoing issue since October 2024. The facility did not have a policy on A/C units maintenance and repairs.

Based on observation, record review, interviews, and review of the Plan of Correction (PoC) the facility failed to ensure it had a functioning Quality Assurance Performance Improvement (QAPI) plan. The facility was actively involved in the creation, implementation, and monitoring of their PoC for deficient practice identified during a complaint survey on 05/13/2025. The plan was ineffective resulting in citation F908 being recited related to ensuring timely repairs of essential equipment, for one roof-top Air-Conditioning (A/C) unit (#11) of 19 roof- top A/C units and F908 being recited related to failure to ensure equipment was safe, sanitary and operational, and failure to provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas. Findings included: A review of an undated facility policy titled, Quality Assurance and Performance Improvement (QAPI), showed a policy statement: This facility shall develop, implement, and maintain on ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for out residents. The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions. Authority: 1. The owner and/ or governing board body of our facility is ultimately responsible for the QAPI program 2. The governing board/owner evaluates the effectiveness of its QAPI program at least annually and presents findings to the QAPI committee. 3. The administrator is responsible for assuring that this facilities QAPI program complies with federal, state, and local Regulatory agency requirements. 4. The QAPI committee reports directly to the administrator Implementation: 1. The QAPI Committee overseas implementation of our QAPI plan, which is the written component describing the specifics of the QAPI program, how the facility will conduct its QAPI functions, and the activities of the QAPI committee. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: a. Tracking and measuring performance. b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities and f. Monitoring or evaluating the effectiveness of corrective action performance improvement activities, and revising is needed. Coordination: 1. The QAPI Coordinator coordinates QAPI Committee activities and changes to the QAPI plan. 2. The QAPI coordinator assists other committees, individuals, departments, and/or services in developing quality indicators, monitoring tools, assessment methodologies and documentation, and in making adjustments to the plan. 3. The QAPI coordinator serves as a liaison between the QAPI committee and the individuals, services, and/or department regarding QAPI activities 1. On 6/11/2025 at 10:45 a.m., an observation and interview were conducted with Resident #5 in his room. Resident #5 stated his overhead light does not work very well, and stated, it flickers on and off, and stated his roommate's [Resident #6] light, does not work at all. Staff P, Certified Nurse Assistant (CNA), entered the room and agreed the lights were not working properly. Staff P, CNA stated this was not her assignment. She stated she will notify their nurse. On 6/11/2025 at 10:52 a.m., an interview was conducted with Resident #7. Resident #7 stated she received a new bed this morning because the other bed was not working but stated, this bed's head will not go up and down. The resident stated she will have to start the whole process of requesting a new bed all over again. On 6/11/2025 at 10:11 a.m., an observation was made of the activities room on the south hallway. Inside the activities room ceiling was a ceiling tile to the left upon entry with scattered areas of small gray/black circles, then concentric circles of various shades of tan, rusty brown. During observation, Staff P, CNA stated, that's been there for a while.' Staff P, CNA stated over the weekend there was water on the floor in the activity room when she came to work. An observation was made of loose baseboards along the perimeter of the activities room. An observation was made of thick green bio growth substance outside the sliding glass door to the left of the activities room exiting to a courtyard. Directly outside the activities room adjacent to the ceiling tile, there was black bio growth substance and peeling paint with a heavy color of dark brown/black substance. Some missing ceiling texture were observed with light brown discoloration and dark heavy collection of black bio growth at the area where the wall meets the ceiling. A tall white garbage can was observed underneath this area with a collection of lightly discolored water inside garbage can approximately six inches. On 6/11/2025 at 10:30 a.m., an observation and interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) during tour of south hallway in the activities room. The NHA and the DON stated they had not seen these two areas before. On 6/11/2025 at 11:03 a.m., an observation and interview was conducted with Resident #11. Resident #11 stated her overhead bed light does not work. Staff P, CNA arrived in the room and stated her light works, She said, you don't have the switch. Staff P, CNA turned the light switch on by the doorway of Resident #11's room, then went to the bedside to pull the cord to turn on the overhead light. The light did not go on, and Staff P, CNA pulled the cord multiple times until the light flickered, and stated, see it works. Staff P, CNA had to pull the cord aggressively again to turn off the light. Resident #11 stated she did not think she could pull the cord the same way Staff P, CNA pulled the cord. On 6/11/2025 at 1:20 p.m., an observation was made of the pantry room in the east hallway. The refrigerator for the residents in the east hall had a temperature log on the outside door. A documented entry for 6/11/2025 showed a reading for the refrigerator at 50 degrees Fahrenheit and the freezer was documented at 28 degrees Fahrenheit. No documented entries were entered for 6/10/2025. The current refrigerator temperature reading was 58-60 degrees Fahrenheit, and the freezer temperature reading was 36-40 degrees Fahrenheit. Staff J, CNA was witness to the current temperatures for the refrigerator. Inside the refrigerator there were four quarts of milk with a resident's name on them. The milk was lukewarm to touch. In the freezer, there were three half gallons of orange sherbert ice cream, a box of ice cream sandwiches and a box of popsicles. All of the freezer items were observed to be thawed. Staff J, CNA agreed the items were soft to touch and not frozen. Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM) for the east hallway was made aware of the refrigerator temperature readings. Staff D, LPN/UM stated according to the temperature log on the refrigerator, the temperature for the refrigerator had been adjusted but agreed the temperature reading were out of normal range. An observation was made of the inside of the cupboard under the sink of the east pantry room. Under the sink there was a large collection of dark brown/black bio growth matter throughout the underside inside the pantry cabinet. An observation was made of the ceiling tile directly above the door partially hanging down. Directly across the entry doorway, was a fan in the wall with a collection of leaves and debris and an opening to the outside environment approximately one inch wide. Staff D, LPN/UM acknowledged these findings. On 6/11/2025 at 3:15 p.m., an observation was made of room [ROOM NUMBER] with open areas of flooring visualized from the hallway. The resident in the room allowed further observation revealing the flooring could be lifted with a slide of the foot. On 6/11/2025 at 3:20 p.m., an observation was made in Residents #12 and #13. The room was designed for a three-resident occupancy. The room was noticeably warmer. Resident #12 stated his roommate #13's AC does not work but his works. Resident #12 had his headboard directly next to his AC unit with his privacy curtain over his headboard where he could receive a direct flow of air from his AC personal unit. Resident #12 stated he moved the curtain because he gets better direct airflow from his AC unit. Resident #12 stated, they know about his AC unit not working. Resident #13's AC unit was powered on, set at 61 degrees Fahrenheit. No air flow was noted. AC filters were observed with a heavy black bio growth. Resident #13 stated he felt his room was hot. A hygrometer reading of 80 degrees Fahrenheit was obtained. Photographic evidence obtained On 6/11/25 at 3:36 p.m., observation was conducted of the bathroom for Resident's #12 and #13. A ceiling tile was observed to be missing with exposed pipes present. On 6/11/2025 at 3:40 p.m., an observation was made of loose flooring on the east hallway. An unidentified resident was walking the hallway with her walker and stated, be careful, you can trip over the loose floor. during this tour, numerous observations were made of loose flooring. The flooring easily would come up when sliding foot over the areas. On 6/11/2025 at 4:46 p.m., a walking tour was conducted with the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM. The NHA became aware of the loose flooring, especially in the 200 hallways. The team acknowledged the refrigerator was removed in the east hallway pantry. The team acknowledged the ceiling tile directly above the entry door, the heavy dark brown/black bio growth under the sink cabinet, and the exposed area to the outside environment along the wall fan/vent. The team toured Resident #13's room to witness a non-functioning A/C (Air Conditioning) unit, with dark black bio growth substance on the A/C filter. The administration team confirmed the observations and the missing bathroom ceiling tile with exposed pipes. During the tour on 6/11/2025 at 5:20 p.m., the NHA, DON, maintenance assistant, maintenance director from another facility and Staff D, LPN/UM confirmed these areas of concerns and stated they would be addressed immediately. Review of a facility policy titled, Standards and Guidelines: General cleaning dated 01/2024 showed a standard: It is the policy of this facility to provide a clean, safe, orderly, comfortable and attractive home-like environment as outlined below: 1. Accepted practices and procedures are used to keep the facility free from odors, accumulations of dirt, dust and safety hazards. 2. Floors and horizonal surfaces are cleaned routinely. Finishes on floors provide an appropriate finish and disinfectants are used where required. 3. Walls and ceilings are maintained free from dirt or other matters. 4. Entrances, exits, walkways, driveways and other outside or entry areas are kept free from debris and dirt. 5. Beds, bedside tables, chairs overbed tables, nightstands and dressers should be cleaned with a germicidal and allowed to air dry. 6. Dry dusting is used on items such as pictures, plaques, mirrors, bulletin boards, tops of partitions, vents, tops of cabinets, coat racks and window/door frames. Damp dusting may be used as needed. (Photographic Evidence Obtained.) 2. On 6/11/2025 at 11:38 a.m., an interview was conducted with Staff O, Maintenance Assistant and a Maintenance Director from another facility. Staff O stated the Air Conditioner (A/C) unit #11 was not functioning properly and stated there was a bent blade in the A/C fan causing the issue. Staff O stated the issue had been going on since October 2024. The maintenance director from another facility stated they were contacting the A/C company to have the A/C fixed. An unidentified nursing staff member was witnessed standing in the south hallway close to the nurses' station down the hallway to the right, fanning her face with her hand and stated, I found a cool spot. During a tour on 6/11/2025 at 4:46 p.m. with the administrative team - Nursing Home Administrator (NHA), the director of Nursing (DON) and Staff O, Maintenance Assistant, Maintenance Director from another facility and Staff D, Licensed Practical Nurse/Unit manager (LPN/UM) of the east hallway. The NHA stated the A/C company was up on the roof today taking measurements to fix A/C unit #1 in the physical therapy gym) and A/C unit #19 (north nurses' station and hallway). The NHA stated A/C unit #11 was a new request. Staff O, Maintenance Assistant confirmed A/C unit #11 in the south hallway/activities room area had been an on-going problem since October 2024. On 6/12/2025 at 12:11 p.m., an interview was conducted with the administrative team. The NHA stated the A/C company took measurements yesterday, (6/11/2025) during the revisit survey to fix the A/C concerns identified previously. The NHA could not confirm a payment had been made to the A/C company for the original requests, but provided a new quote dated 6/11/2025 for repairs of A/C unit #11. The NHA stated she was unaware of the issues with A/C unit #11 until yesterday, but the maintenance assistant stated it had been an ongoing issue since October 2024. The facility did not have a policy on A/C units maintenance and repairs.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #2) of five residents sampled for falls received the supervision required to prevent three falls in 18 days and sustaining a fall on 9/26/20 that required surgery for [REDACTED]. Resident #2 fell six times from 7/4/20 to 9/26/20 requiring two transfers to the hospital. The facility failed to investigate the root cause of the falls for Resident #2 to ensure adequate interventions and supervision were in place. Findings Included: Review of Resident #2's hospital record revealed a History and Physical dated 9/27/20 with a chief complaint of fall at facility. The History of present illness was a [AGE] year old lady admitted to hospital secondary to trip and fall. Patient not able to provide much history, suspected significant dementia present. Patient is disoriented to place and person. Review of chart showed the patient was brought in after a fall with laceration to head complaining of right hip pain. Work up done seems non-syncopal x-rays revealed patient to have right femoral neck fracture. A CT of head was negative for acute finding .Patient has been seen by orthopedic surgeon and taken to the OR (operating room) for arthroplasty. Review of the accident and incident log documented Resident #2 sustained falls on: 9/26/20 at 7:19 p.m. in her room sustaining a laceration and [MEDICAL CONDITION] sent to the emergency room resulted in [MEDICAL CONDITION] and laceration. 9/12/20 at 5:11 p.m. in her room without injury. Intervention added, place resident in wheelchair for all meals. 9/9/20 at 3:30 p.m. in her room without injury. Intervention added, floor mats. 8/15/20 at 3:47 p.m. in the hallway of the South wing sustaining a Hematoma, sent to the emergency room . Intervention added, Broda chair. 8/8/20 at 8:30 a.m. in her room without injury. Intervention added, offer toileting after breakfast. 7/4/20 at 2:00 p.m. in her room sustaining laceration to the left eyebrow treated in house. No interventions documented. On 10/13/20 at 4:05 p.m., the Director of Rehab stated Resident #2 was on occupational therapy, physical therapy, and speech therapy (OT, PT and SP) until 9/25/20. The resident could ambulate but was not steady. She was ambulating up to 75 feet with minimum assistance using a rolling walker. She was transferring with contact guard assistance and stand by assist for bed mobility. Safety awareness was an issue due to cognitive deficits. She should never have been up in her room unsupervised. We have weekly meetings that go over resident recommendations with nursing staff. After she was diagnosed with [REDACTED]. On 9/25/20, Resident #2 improved from 75 to 90 feet which improved up to minimum assistance with the therapist providing up to 25% assistance for the resident's weight. Resident #2's cognitive deficit was very low. She was unable to understand and redirect. Review of the facility documents and fall investigations related to Resident #2 with the Assistant Director of Nursing (ADON) on 10/13/20 at 1:36 p.m. revealed Resident #2 fell on [DATE] at 7:19 p.m. after staff completed care and the resident's eyes were closed. The staff left the room and heard a thud. The ADON provided copies of the fall investigations, which did not describe any of the information the ADON was providing. The ADON said falls were discussed in the morning meeting as a team to look for trends, to see what is not working, and come up with a plan from there. It's the entire interdisciplinary (IDT) team at the morning meeting, which includes the ADON, Director of Nursing (DON), Nursing Home Administrator (NHA), Unit Managers, the therapy department, and the Case Manager. The ADON stated she did not have any documentation related to a root cause investigation for the six falls sustained by Resident #2. The ADON stated she does ask the staff if they saw the resident and gets a statement to see what happened. According to the ADON, she only got one witness statement for the 9/26/20 fall and had no other witness statements for Resident #2's five other falls. A review of the one statement the ADON had related to Resident #2's fall on 9/26/20 was from the CNA assigned to her care. The CNA reported that she had just cleaned, toileted, and placed the resident in bed, when she left the room to answer another resident's call light. She heard a resident holler that Resident #2 was in the hallway by the door with her head bleeding. The aide stated that Resident #2's mats were down by her bed and the bed was in the low position when she left the room at 1900 hours (7:00 p.m.). Review of the skilled documentation dated 9/26/20 at 6:37 a.m. for Resident #2 reflected: primary [DIAGNOSES REDACTED]. Speech clarity checked for unclear speech-slurred or mumbled words. Ability to understand others checked as sometimes understand-responds adequately to simple, direction communication only. Cognition documented as inattention and disorganized thinking. Urinary incontinence checked as always incontinent. Current toileting program or trial checked as NO. Musculoskeletal checked as not steady, only able to stabilize with staff assistance. Moving on and off toilet checked as not steady, only able to stabilize with staff assistance. Surface to surface assistance (transfer between bed and chair or wheelchair) checked as not steady, only able to stabilize with staff assistance. Currently receiving therapy for PT, OT and SLP/ST. Summary reflected resident ambulates on occasion with unsteady gait noted. The documentation included a summary of, Resident A & O (alert and oriented), no S/S (signs or symptoms) of distress, voices needs, ambulates on occasion with unsteady gait noted, fluids enc (encouraged), call light in reach, will continue to monitor. Review of the Situation Background Appearance Review and Notify (SBAR) communication form dated 9/26/20 at 7:00 p.m. reflected Resident #2 sustained a fall. Pain checked as not clinically applicable to the change in condition being reported. Recommendation to send to the emergency room for further evaluation. Review of the facility document dated 9/26/20 at 7:19 p.m. revealed a nursing description of, resident up walking in room and found lying on the floor by the door with head on floor with laceration to back of head. The resident description was noted as, Resident Unable to give description. Immediate actions taken were: Resident assessed, treatment applied to stop bleeding. Physician notified and order to send to the emergency room . Intervention: medication review. Injury type: laceration to back of head. Predisposing psychological factors checked as confused, gait imbalance, impaired memory, and fragile/sensitive skin. Review of the fall risk evaluation dated 9/26/20 at 7:19 p.m. reflected cognition checked as behavior not present and no evidence of acute change in mental status. History of falls was checked yes. Ambulation in relation to elimination status checked as non-ambulatory and requires staff assistance with elimination. Walking and turning around checked as not assessed. Fall risk score of 6. Determination reflected a score of 10 or above represents high risk. Initiate a fall risk care plan for high risk components regardless of resident not scoring a 10 or above. Review of the physician progress notes [REDACTED]. She has been observed sitting in her wheelchair at the nurses station. Diagnosis/plan: 7. Fall: Nursing to increase rounding. Patient to be up in wheelchair for all meals. 9. Altered Mental Status(AMS): She has returned to her baseline confusion. Nursing to monitor for increased AMS. During an interview with the ADON on 10/13/20 at 1:36 p.m., she stated Resident #2 sustained a fall in her room on 9/12/20 at 5:11 p.m. and was found on floor, lying on her left side next to the bed with her legs and arms out with her back to the bed and head lying on floor. Response appropriate and at baseline. Patient reported hitting her head. The floor mats were down according to the ADON's statement. The ADON was unable to provide documentation to show that the floor mats were down. Intervention put in place was up to wheelchair for all meals per the ADON as her dinner tray was on the bedside table. The ADON stated she was unsure of what happened and when the resident was last toileted or seen and could not provide documentation and stated the team included the intervention due to the dinner tray sitting at the bedside table. The ADON said the cause of the fall was unknown and unwitnessed. The ADON said, before the resident tested positive for COVID-19, the resident was always up with staff and up for meals. The ADON stated she was given activities and stated we had difficulty keeping six feet apart. The ADON stated, I feel the interventions are appropriate to try to keep her safe. It's not documented the last time she was seen, toileted or if the fall mats were down. The aides were outside the room. Review of the facility document dated 9/12/20 at 5:11 p.m. provided by the ADON reflected, aid retrieved this nurse to report pt was found in floor beside her bed. Nurse immediately assessed pt. Pt was observed to be on her left side, legs extended, with arms out, back to her head, with head lying on the floor. Pt responses appropriate and baseline, pt reports having hit her head, no immediate bruising noted or observed, no redness or swelling noted. Pt observed wearing appropriate footwear. Pt was continent at time of fall. dinner tray on bedside table. Nuero checks within normal limits and stated she cannot remember. There is some redness on her inner right arm, when asked what happened here she stated she thinks she hit the table when she fell . No reports of pain at this time. No apparent injuries noted. Range of motion in all four extremities. Pt assisted to her bed and then wheelchair to dining room with staff. Description: Pt stated she was trying to get up but cannot remember why. Pt denies pain. Pt states she did hit her head. Immediate action taken- Historical reports reviewed of patients previous falls, a trend is noted that she is most often falling between the times of 2:00 p.m. and 5:00 p.m. with outliers in the morning. It is probable from this trend that patient is falling during dining times and the most appropriate action at this time would be to have patient up in wheel chair in dining room for all dining times. Awaiting on call physician call back to see if psych eval or urinalysis is needed. Intervention: Resident up in wheelchair for all meals. Predisposing physiological factors checked as confused, gait imbalance, impaired memory, incontinent, and weakness/fainted. Predisposing situation factors checked as ambulating without assist. Review of the nursing progress notes dated 9/12/20 at 5:11 p.m. reflected aid retrieved this nurse to report pt was found in floor beside her bed. Nurse immediately assessed pt. Pt was observed to be on her left side with head lying on the floor. Review of the physician progress notes [REDACTED]. She was observed sitting in her wheelchair at the nurses station. General: mildly lethargic, cooperative and conversive in no acute distress. She is sitting upright in bed, appears comfortable. Diagnosis/plan: 7. Fall: nursing to increase rounding. Patient to be up in wheelchair for all meals. Review of the fall risk evaluation dated 9/12/20 at 9:29 p.m. reflected the resident cognition checked as behavior present, fluctuates. Resident checked as having falls. Ambulation in relation to elimination status checked as ambulatory and incontinent. Walking checked as activity did not occur. Moving on and off toilet checked as not steady, only able to stabilize with staff assistance. Fall risk score total of 13. Total score above 10 represents high risk. Review of the facility document dated 9/9/20 at 3:30 p.m. provided by the ADON reflected Resident found in the floor at 3:30 p.m. Resident can not recall how this happen. Immediate action taken- Assessed, FROM noted x 4 extremities, Intervention: floor mats. Mental status checked as alert with periods of forgetfulness, oriented to person. Predisposing physiological factors checked as gait imbalance and impaired memory. Review of the nursing progress notes dated 9/9/20 at 1:44 p.m. reflected the resident alert with confusion, currently in bed with head of bed up. All needs met by staff. Review of the nursing progress notes dated 9/9/20 at 6:05 p.m. reflected the resident status [REDACTED]. Low airloss mattress in place, bed in low position, call light in reach, all needs met by staff. Review of the skilled documentation dated 9/9/20 at 1:44 p.m. reflected the cognition was checked as inattention and disorganized thinking. Musculoskeletal was checked as moving from seated to standing, walking, turning around and facing the opposite direction checked as not steady, only able to stabilize with staff assistance. Review of the physician/practitioner progress notes dated 9/10/20 at 11:42 a.m. reflected resident seen for a fall. She was found sitting on the floor, she verbalized, I fell . She denies hitting her head or loss of consciousness. She has a minor skin tear on her right knee. She has been observed sitting in her wheelchair at the nurses station. General: mildly lethargic, cooperative and conversive in no acute distress. She is sitting upright in bed, appears comfortable. Diagnosis/plan 7. Fall: nursing to increase rounding. [MEDICATION NAME] 5 mg twice a day discontinued per family request. Review of the skilled documentation dated 9/12/20 at 6:52 p.m. reflected Cognition was checked as inattention and disorganized thinking. Always incontinent was checked for bowel and bladder. Musculoskeletal was checked as not steady, only able to stabilize with staff assistance. Moving on and off toilet as not steady, only able to stabilize with staff assistance. Surface to surface transfer was checked as not steady, only able to stabilize with staff assistance. Review of the fall risk evaluation dated 9/9/20 at 9:07 p.m. reflected the fall risk score of 14. During the interview with the ADON on 10/13/20 at 1:36 p.m. she stated Resident #2 fell on [DATE] at 3:47 p.m. The resident was found lying on her back with a Hematoma on the backside of her head. She was found in the hallway on the south wing. The fall was not observed. Increased confusion. Unable to follow verbal commands. Resident noted with increased agitation. Called 911 and sent to hospital. Intervention on return given a high back chair she could get around in. (no one in hall way at time of fall) with change of shifts at 3:00 p.m. The ADON stated all residents are assessed by therapy on return from the hospital after a fall. The ADON stated we will do a medication review but had not come to that point with Resident #2. We were looking at other interventions for her. The ADON stated that Resident #2 came back and noted to be declining and required more assistance. Review of the SBAR form dated 8/15/20 reflected the change of condition as a fall that seems different than usual. Mental status checked as increased confusion or disorientation and functional status evaluation checked as falls. Skin evaluation checked as other and described as Hematoma to the back of head. Pain checked as new to the back of the head. Neurological evaluation checked as altered level of consciousness described as increased confusion, disorientation. Recommendations to send to the hospital for evaluation. Review of the facility document provided by the ADON dated 8/15/20 at 3:47 p.m. reflected resident noted lying on the floor on her back with wheelchair near. Hematoma to backside of head noted upon assessment. Observed with increased confusion. Unable to follow verbal commands. Noted increased tremors. No new physical functional limitation noted. Resident with noted increased agitation and attempting to get up. Blood pressure 112/66, pulse 70, respirations 20, temperature 97.1, oxygen of 95%. Ice applied to back of head while awaiting emergency transport personnel. Description to send to hospital for evaluation due to symptoms. Intervention: high back chair. Injury type: Hematoma to the back of the head. Predisposing physiological factors checked as confused and impaired memory. Predisposing situation factors checked as using wheeled walker. Review of the nursing progress notes dated 8/15/20 at 12:40 p.m. reflected resident is alert with confusion and forgetfulness, all needs met and anticipated by staff. Continues on one person assistance from staff with ADL needs. Incontinent of bowel and bladder. No acute distress noted as per attending nurse. Lacks safety awareness, fall risk. Bed in low position. Continued to be prioritized by staff for fall prevention risk due to attempt to climb out of bed. No signs and symptoms of any distress noted. Review of the nursing progress notes dated 8/15/20 at 3:47 p.m. reflected resident noted lying on the floor on her back with wheelchair near, Hematoma to back side of head noted upon assessment. Observed with increased confusion. Unable to follow verbal commands. Noted increased tremors. No new physical functional limitation noted. Resident with noted increased agitation and attempting to get up. Ice applied to back of head while awaiting emergency transport personnel. Review of the physician progress notes [REDACTED]. She was found on the floor with increased confusion and a Hematoma on her head. She was sent to the emergency room evaluated and released. She is more alert today than her previous exam. No signs or symptoms of injury. She is sitting up in a bed today and is minimally conversive but cooperative. She has no complaint of pain. she is alert to self only which is her baseline. 6. Fall: Nursing to increase rounding. Review of the fall risk evaluation dated 8/15/20 at 3:47 p.m. reflected a fall risk of 11. Review of the skilled documentation dated 8/15/20 at 12:40 p.m. reflected the cognition checked as inattention and disorganized thinking. Musculoskeletal checked as moving from seated to standing, walking, turning around and facing the opposite direction checked as not steady, only able to stabilize with staff assistance. During an interview on 10/13/20 at 1:36 p.m. with the ADON she stated that the resident fell on [DATE] at 8:30 a.m. the ADON stated the resident was observed sitting on the bathroom floor with her Foley catheter hanging from her bed that she pulled out. No injury noted. Intervention - Staff to offer toileting after breakfast. Catheter left out. Review of the facility document dated 8/8/20 at 8:30 a.m. provided by the ADON reflected the resident was observed sitting on the bathroom with her Foley catheter hanging from her bed. The resident stated she had to use the restroom. Immediate action taken: staff checked her skin from head to toe and assisted her back to her bed washed her up and assisted her into her wheel chair. Intervention: offer toileting after breakfast. Predisposing physiological factors confused, impaired memory and incontinent. Review of the nursing progress report dated 8/8/20 at 5:25 p.m. resident received alert and oriented to person only she verbalizes some of her needs but requires constant redirection earlier during day shift. Resident was observed sitting on the bathroom floor with her Foley catheter hanging from the bed. Her doctor was notified and gave orders to leave her catheter out and monitor her output she has since urinated on the toilet twice. No noted retention at this time she exhibited no apparent injuries related to the fall. no [MEDICAL CONDITION], no bruising. She has been one to one with staff, her brother was notified of fall as was the ADON, resident us currently being assisted. Review of the skilled documentation dated 8/8/20 at 3:16 p.m. reflected Resident #2's cognition as altered level of consciousness. Summary reflected per attending nurse: resident is alert with confusion, all needs anticipated and met by staff. Review of the fall risk evaluation dated 8/8/20 at 8:30 a.m. reflected a fall score of 14. Review of the physician/practitioner progress notes dated 8/10/20 at 1:01 p.m. resident seen for a fall and lethargy. She was found on the floor of her bathroom with her Foley catheter discontinued. No visible trauma, patient was alert at the time. She was recently treated for [REDACTED]. She continues to be some mildly lethargic but has improved, is sitting upright in a chair today and is conversive. 6. Fall: Nursing to increase rounding. During an interview with the ADON on 10/13/20 at 1:36 p.m. the ADON stated the resident fell on [DATE] in her room and was found lying on her back between the footrest of the roommate's bed and the door of the bathroom. The resident stated she was trying to use the bathroom, a laceration noted to her left eyebrow with scant bleeding and swelling. ROM decreased on left hip with resident complaint of pain with rotation. She stated she was trying to use the bathroom and tripped on the roommates wheel chair by the bathroom. Intervention was to switch from B bed to A bed. Her eye was steri stripped. The X-ray was completed on 7/4/20 no fracture or dislocation noted. Review of the facility document dated 7/4/20 at 2:10 p.m. provided by the ADON reflected, Resident observed on her back on the floor between the footrest of room mates bed and the door of the bedroom. Resident stated that she was trying to use the bathroom. Resident was assessed for injuries and laceration noted to left eye brow with scant bleeding and mild swelling. Range of motion decreased on left hip. Resident complaint of pain on internal and external rotation of left hip. No other injuries noted. Steri strip applied to laceration on left eyebrow as well as ice pack. Intervention: steri strip applied to laceration on left eyebrow. Called placed to physician to request orders. Interventions to switch beds from B to A. Predisposing environmental factors revealed confused. other information included room mates tipper extensions on wheelchair while trying to use rest room. Review of the fall risk evaluation dated 7/4/20 at 2:10 p.m. reflected the resident with a fall score of 5. During an interview on 10/13/20 at 5:06 p.m. with Staff member A, RN she stated that Resident #2 was impulsive and lacked safety awareness. If she was put in bed she would get up. She was getting better in the beginning then she came back from the hospital at one point more confused. Staff A stated that when she was assigned to Resident #2, she would put her at the nurses station. When Resident #2 first arrived, she was able to walk and was an elopement risk. During an interview with on 10/13/20 at 5:13 p.m. with Staff member B, South West unit manager, she stated the resident was confused and alert. She came back from the hospital with wounds and was confused. She had a low air loss mattress and prior to COVID-19 she was alert and mobile. We never put her on one to one for the falls. The CNA would document on Activities of Daily Living (ADL's). During an interview with Staff member C, CNA, on 10/13/20 at 5:10 p.m. she stated, before COVID-19 the resident was not impulsive but would get up and try to walk. During an interview with Staff member D, RN, on 10/13/20 at 5:11 p.m. she stated she had the resident on the 200 unit and she would walk all the time. The resident would get confused. There was a fall and it was documented. We document in the chart and assess the resident, we start neuro checks, complete the incident report for who, what, when where and why. The nurse on shift will document on the incident report and we complete witness statements and assessments that go to the DON. During an interview with Staff member E, LPN on 10/13/20 at 5:21 p.m. he stated the resident was at risk for falls and confused. She was a fall risk and required close supervision with one to one at times and it was care planned. Review of the physical therapy discharge summary signed on 9/28/20 at 10:38 a.m. reflected summary since eval and patient response: patient was showing good progress prior to hospitalization due to fall. Pt was attempting to transfer and ambulate unassisted due to cognitive deficits. Review of Resident #2's care plan reflected a focus area related to an actual fall, initiated on 3/30/20, revised on 3/30/20. The goal was to resume actual activities without further incident through the review date with a target date of 11/11/20. Interventions initiated on 3/30/20 were to continue on the at-risk plan and dump wheelchair. Interventions initiated on 7/4/20 included switching sides of the room from the B bed to the A bed. Interventions initiated on 8/15/20 included broda chair. Interventions initiated on 9/9/20 included floor mats. Interventions initiated on 9/14/20 included up out of bed during meals. Interventions initiated on 9/26/20 included medication review. Continued review of the care plans revealed: Focus area related to impaired cognitive and communication function/dementia or impaired thought processes related to impaired decision making, [DIAGNOSES REDACTED]. Intervention to cue, reorient and supervise as needed initiated on 3/30/20. Focus area initiated on 3/27/20 to require assistance with activity of daily living (ADL) functions related to cognitive impairment. 6/25/20 resident required supervision/limited assist, 8/5/20 declined in function after hospitalization , revised on 8/5/20. Goal to safely ambulate 100 feet with four wheeled walker and supervision by next review initiated on 8/5/20, target date of 11/11/20. Goal to safely perform ADL's with supervision by next review initiated on 8/5/20, target date of 11/11/20. Interventions included ambulation -supervision with ambulation due to wandering. 8/5/20 therapy treating for increased assistance initiated on 3/30/20 and revised on 8/5/20. transfers: one assist with transfers initiated on 3/27/20, mobility: walks/wheels only with physical assistance initiated on 3/27/20. Review of the interdisciplinary [MEDICAL CONDITION] review meeting dated 9/24/20 attended by the DON, unit managers, social services, pharmacist or pharmacist recommendations review reflected the source of the information came from the patient chart, nursing staff and social services. Continue medications at current doses, staff to monitor behaviors. No side effects noted at this time. Tapering medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the residents function, well being, safety, and or quality of life. Review of the physiatrist report dated 9/18/20 reflected the resident seen via telemedicine with a plan: deconditioning- she is contact guard for bed mobility, minimum assist for transfers, ambulating 30 feet with rolling walker and moderate assistance, assist for toileting. During an interview with the Director of Nursing (DON) on 10/13/20 at 5:44 p.m., he stated the nurse starts the report for a fall. Then we discuss the fall the next morning. The interdisciplinary team (IDT) team is involved. We look at the falls and included the nurse practitioner that's here and we come up with interventions and the nurse documents for 3 days after the fall. Resident #2 was not cognitively intact and always looking for her husband who brought her in here to us. You could not get her to relax, and she was put on one to one about six months ago. After she was sick with COVID-19 she would not get out of bed and they were adjusting her medications. She used to run around the building and when she came back she would just lay in the bed. After adjusting her medications she was getting more active. We could not stop her from falling and were not aware that she had a fall with a fracture when she left us on 9/26/20. She went out for a [MEDICAL CONDITION]. Had we known she had a fracture from her fall we would have reported the fracture. The DON stated that we would typically have a fall packet that can be found on the unit. The ADON would have the documentation in a packet. At that time the ADON was asked if she had any fall packets related to the six falls sustained by Resident #2, and she stated that she does not have any packet related to falls with witness statements for this resident. The DON confirmed that he did not have any fall packets with fall investigations. The DON re-stated that the facility was not notified of the fracture but was aware of the resident going to another facility. The DON stated the facility liaison sends updates for people that went to the hospital. The DON stated that he did not have anyway of keeping Resident #2 off the floor. He said the resident was headstrong and she will just keep falling regardless of where she was located. Review of the facility's policy titled, accidents and incidents - investigating and reporting policy revised July 2017, 2 pages reflected: all accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator. 1. The nurse supervisor/charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. the following data as applicable shall be included on the report of incident/accident form: c. the circumstances surrounding the accident or incident; e. The name of witness and their accounts of the accident or incident; l. follow-up information. 7. Incident/accident reports will be reviewed by the Safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the policy for, How to conduct an investigation revised on 5/1/11, 4 pages reflected: The facility has designed and implemented processes which strive to enable the facilities to come to resolution after thoroughly investigating all accidents, incidents, losses, thefts, etc. The person designated by the facility to be the investigator will remain objective and maintain neutrality during an investigation. Procedure: 2. The information should include who, what, when, where, how and why. 8. Document a brief, concise, objective description, in the medical record of what was actually observed. 10. Determine what' occurred, what is the chronological order of action leading up to the alleged incident, what information does other relevant staff members, roommate, family members have of the incident or factor leading up to the incident. 16. Conclude how the incident occurred. 17. Conclude if/how the incident could have been avoided.

Based on interview and resident record review, the facility failed to update and revise a care plan for bed mobility, safety, and toileting/use of a bedpan when one resident (#1) out of eleven sampled residents was readmitted to the facility after hospitalization for an amputation of her remaining leg. The [AGE] year old resident sustained [REDACTED]. The resident died on [DATE] of complications that were related to a [MEDICAL CONDITION], which resulted in findings of on-going immediate jeopardy. 1. A review of the clinical record for Resident #1 revealed that she was a [AGE] year old female originally admitted to the facility in 2009, per the facesheet, with a past medical history that included diabetes, end stage [MEDICAL CONDITIONS], and [MEDICAL CONDITION] ([DIAGNOSES REDACTED]. The most recent History and Physical as dictated by the resident ' s physician and, dated [DATE], revealed that she had a surgical history that included bilateral amputation of both of her legs. Further review revealed that she was discharged from the facility to an acute care hospital on [DATE] for a change in mental status. An entry recorded in the nurses ' notes, dated [DATE] at 5:30 p.m., revealed that she was readmitted on [DATE] and had undergone an above-the-knee amputation of her right leg. She was described as alert but confused, and required "extensive assistance for activities of daily living, bed mobility and incontinence care. " 2. A "Nursing Comprehensive Admission Data " flow sheet was completed on [DATE] at 5:30 p.m. A right above-the-knee amputation, as well as left above-the-knee amputation and diabetes were listed as the admitting diagnoses. A review of the Fall/Fall Risk care plan revealed that it was last updated with the date of [DATE]. An entry under " interventions " stated " P.T. (physical therapy) referred related to wheelchair positioning and resident slid from chair on [DATE]. " There was no documentation of the most recent right above the knee amputation. Under " problems" on the care plan there was an entry, dated [DATE], that had "Left [MEDICAL CONDITION]" listed as a fall risk and " wound to left [MEDICAL CONDITION] and right heel" for cognitive and/or sensory factors as a fall risk. There were no goals or appropriate interventions listed now that the resident had no legs at all. In fact, the care plan still made reference to the resident ' s right heel, which she no longer had. One intervention was listed as "appropriate footwear." 3. On [DATE] at approximately 12:00 p.m., an interview with the Assistant Director of Nursing (ADON), who is also the risk manager that had conducted the review of the fall, confirmed that the resident was readmitted to the facility on [DATE] as a bilateral [MEDICAL CONDITION]. She also confirmed that the care plan had not been updated or revised to reflect the resident's new assessment, reflecting that she was a new bilateral [MEDICAL CONDITION], and the additional and updated interventions that would be appropriate. She stated that the recent above the knee amputation of the right remaining leg had caused a shift in her center of gravity, and this had caused a change in her ability to maintain balance without using her side rails in her effort to move in the bed, as well as maintaining balance by sitting in her wheelchair. She stated that occupational therapy had been ordered for the resident on [DATE] by the physician and she had been evaluated and initially treated on [DATE]. She stated that the entry on the care plan of " P.T. " was actually meant to state "O.T." and the resident had been receiving occupational therapy as ordered. 4. An entry in the nurse ' s notes concerning the fall, written by Employee C, dated [DATE] at 12:45 p.m., revealed that Resident #1 was in bed and on a bed pan. The side rails were noted to be up on both sides. When the certified nursing assistant (CNA) entered the room, he saw the resident on the floor. The resident "was unable to explain to explain what happened." The physician was notified, as well as a family member. Tylenol was administered. The next entry, dated 3:00 p.m., indicated that the resident continued to complain of pain, and a telephone order had been received by the physician for the resident to be transported to a local hospital emergency department. She was "picked up" at 3:10 p.m. Further documentation as a late entry in the nurses ' notes written by the unit manager and timed 12:55 p.m. on [DATE], revealed the physician was notified when the resident was found on the floor by the CNA. The nurses ' notes, again, stated that the "resident did not know what had happened." The same entry continued, " resident rolled to side to assess back area and no noted immediate injury. No swelling on back or back of head. Vital signs done 97.4, 80, 22, ,[DATE]. Resident yelling she wanted [MEDICATION NAME]. Orders received for [MEDICATION NAME] 50 mg by mouth every six hours as needed for pain." The last entry in the nurses ' notes was dated [DATE] at 7:15 p.m. and stated that the resident was admitted to the hospital with [REDACTED]. 5. During an interview on [DATE] at approximately 3:00 p.m., Employee #F confirmed that he was the certified nurse assistant caring for the resident on [DATE]. He stated that, when he entered room [ROOM NUMBER] on [DATE] at approximately 12:00 p.m., he saw the resident fall to the floor from underneath the privacy curtain. He stated that she was screaming and asking for [MEDICATION NAME] and to sit up. He stated that he asked a visitor who was at the door way to get additional help as he stayed with the resident. He confirmed that one of the side rails was on the floor with the resident. He also stated that he thought the side rail was loose earlier that day, but "not loose enough to call maintenance. I kind of noticed them, that something might be wrong." He confirmed that the resident required two people to assist with toileting and bed mobility, and would hold on to the side rails when turned. 6. A review of Resident #1 ' s clinical record revealed a physician's order, dated [DATE], for an occupational therapy evaluation for wheelchair positioning related to bilateral knee amputations. Further review revealed an "Initial Treatment Plan for Rehabilitation" for occupational therapy that was dated [DATE], and had a treatment [DIAGNOSES REDACTED]." A review of the occupational therapy progress notes revealed that Resident #1 was evaluated on [DATE] and then received therapy on [DATE], [DATE], [DATE], and [DATE]. On the evaluation the resident was noted to require maximum assistance for bed mobility. The interventions on the four therapy sessions did not encompass any exercises designed to target bed mobility or balance exercises for the altered center of gravity since the right above-the-knee amputation. The interventions listed included: custom wheelchair fittings, trunk strengthening at table top, and [MEDICAL CONDITION] management for right arm to increase ability to perform self- feeding. 7. On [DATE] at 10:50 a.m. a conference call was conducted with the Director of Rehabilitation, the Occupational Therapist, and the Certified Occupational Therapy Assistant. The Director of Rehabilitation confirmed that an order was written on [DATE] for wheelchair positioning, and a clarification order written on [DATE] for "skilled OT services three times a week for four weeks to include therapeutic exercises, neuromuscular re-education and positioning. When asked how the facility ensures communication between therapy and nursing staff to ensure a multi-disciplinary approach, she stated that after an occupational therapist does the initial evaluation to include the resident's functional assessment, goals, and plan, the information is verbally given to the charge nurse and the unit manager for a multidisciplinary approach, and a copy of the evaluation and treatment/progress notes are placed in the resident's chart. The rehabilitation director clarified that the "Initial Treatment Plan for Rehabilitation" is not a care plan in the sense of how the facility "usually refers to a care plan," or a nursing care plan. The information that is received from the therapist may be added to the nursing care plan. The Occupational Therapy Certified Assistant (COTA) stated that the focus of occupational therapy for Resident #1 was wheelchair mobility. She stated that the resident had been able to self -propel in a wheelchair prior to the most recent hospitalization and at the time of the evaluation was no longer able to do so. She stated that the resident had required total assistance for bed mobility before her hospitalization of [DATE]-[DATE] that resulted in the right above-the-knee amputation, and continued to require total assistance when she was readmitted on [DATE]; since this was not considered a change, it was not a focus for occupational therapy. She also stated that she was working with the resident to reclaim independent self -feeding skills again, as the resident was also able to do prior to the hospitalization . The COTA confirmed that the resident was seen according to the progress notes on [DATE], [DATE], [DATE] and [DATE], and stated that the progress was "minimal." The COTA further stated that it is not unusual for a resident to be able to self- propel in a wheelchair and have no ability to move in bed without assistance. She explained this to be because different "muscle groups and planes" are utilized while in bed versus while in a wheelchair. Further clinical record review revealed no documentation of communication between occupational therapy and nursing staff regarding Resident #1 ' s functional status and treatment plan. 8. The Individualized Care Plan for Fall/Fall Risk was dated [DATE] and listed the Fall Risk Factors to include "Left below-the-knee amputation" as a medical factor, but did not include the recent right below-the-knee amputation or that the resident was a new bilateral [MEDICAL CONDITION] when she was readmitted to the facility on [DATE]. There were no entries documenting the occupational therapy evaluation, dated [DATE], and the new goals and interventions. The latest entries indicated that there was a review date of [DATE] with a new review date of [DATE] and the only new entry listed under interventions was dated [DATE] and stated, "P.T. referral related to wheelchair sitting due to no Resident original wheelchair and slid from chair ,[DATE]." There were no physician's orders for physical therapy; the only therapy that the resident was receiving was occupational therapy with the initiation date of [DATE]. 9. On [DATE], a conference call was held with the facility's Certified Resident Assessment Instrument Coordinator. She confirmed that the resident had a fourteen day comprehensive assessment, dated [DATE], for the readmission that occurred on [DATE]. She stated that the resident had "No falls" indicated on the Fall History section of the assessment. She stated that the Functional Status assessment included a bed mobility score of ,[DATE] that indicated Resident #1 required two people to assist her, which included being pulled up to the head of the bed, and her ability to grasp hand rails. Her toileting score of ,[DATE] indicated that Resident #1 did not use anything but the bed pan and required two people to assist her with toileting. The Bowel and Bladder assessment indicated that the resident was always incontinent of bladder, and was frequently incontinent of bowel. The Nursing Comprehensive Admission Data tool, dated [DATE] at 5:30 p.m., indicated that the resident required "limited assistance" which is defined as "one person" for bed mobility and toileting. For prior level of functioning, the resident was described as "assist with activities of daily living." The admitting [DIAGNOSES REDACTED]." A review of the Activities of Daily Living Care Plan that was updated on [DATE] revealed that the resident was listed as "total care with toileting" and this included "bowel incontinence and bladder incontinence." The "Individualized Care Plan for Fall/Fall Risk ([DATE]) provided an intervention of " provide bedpan when she agrees to use it, " but, was silent as to assistance needed on the bedpan. The [DATE] revised "Care Plan Record" for "Alteration in ADLs/Total Self Care Deficit" included an intervention for assist resident with toileting/toileting program as indicated/as able when she is asking to use the bedpan." A review of the Activities of Daily Living Functional/Restorative Assessment and Progress tool, dated [DATE], revealed that the resident was dependent with all transfers and required a Hoyer lift, she used a bed pan for toileting, but was also incontinent of bowel and bladder, she received active and passive range of motion, occupational therapy, and positioning/support equipment, and used the side rails at night only. A Fall Risk Assessment, dated [DATE], revealed that the resident was at high risk for falls. The Side Rail Data Collection and Assessment tool, dated [DATE], revealed that the resident used the side rails to position herself in bed and was not able to position herself with another device other than the side rail, and listed the resident as requesting a side rail with an explanation given, "enabler for positioning." The assessment/plan for side rails listed pain and generalized weakness as medical symptoms that the use of a side rail would treat. It stated that Resident#1 had half rails initiated on both sides of the bed. 10. The care plan was not revised when Resident #1 was readmitted to the facility after undergoing a right above-the-knee amputation that resulted in her loss of both legs. There was no evidence of communication to ensure a multi-disciplinary approach between occupational therapy and nursing staff that would include new goals and interventions, and identify new problems together such as appropriate and safe assistive devices that the resident would require for bed mobility. There were interventions listed such as "appropriate footwear" that remained on the care plan, as well as wound care to her right heel. Resident #1 had requested the use of side rails on her bed to use as an enabler, and was provided with side rails that were not secured to the bed and caused her to fall from the bed, fracture her hip, and then ultimately die from related complications.

Based on observation, staff interview and resident record review, it was determined that the facility failed to provide an environment free from hazards, supervision to prevent falls and assistive devices to avoid serious physical harm for one (Resident #1) out of eleven residents reviewed. The investigation revealed that Resident #1, who had undergone amputation of both legs, fell from her bed to the floor along with a side rail that became separated from the bed. She sustained a fractured hip and died 12 days later of complications due to the fall and her fragile physical condition. This resulted in findings of immediate jeopardy which are on-going. Relevant findings include: 1. A record review of resident #1, a [AGE] year old female that underwent her first amputation of the left leg in 2009 and then the right leg in [DATE], according to the most recent History and Physical as dictated by the resident ' s physician and dated [DATE]. Nurses' notes, dated [DATE], portrayed that she sustained a fall in room # 231-A from her bed to the floor on [DATE] at approximately 12:00 p.m. The resident's medical [DIAGNOSES REDACTED]. 2. A review of the fall sustained by Resident #1 on [DATE], and conducted by the facility ' s Risk Manager, revealed that the resident had been placed on a bed pan at approximately 11:45 a.m. by Employee J, who gave the resident a call bell, pulled the privacy curtain, and left the room. At approximately 12:00 p.m., Employee F, who was identified as the Certified Nurse Assistant (CNA) that was assigned to the resident on [DATE], entered Resident #1 ' s room and saw her fall to the floor from the bed from under the privacy curtain. Employee G noted that the side rail was on the floor with the resident at the time of the fall. 3. During an interview on [DATE] at approximately 3:00 p.m., Employee F confirmed that when he entered room #231-A on [DATE] at approximately 12:00 p.m., he saw Resident #1 fall to the floor from underneath the privacy curtain. He stated that she was screaming and asking for morphine and to sit up. He stated that he asked a visitor who was at the door way to get additional help as he stayed with the resident. He also confirmed that one of two of the bed ' s side rails was also on the floor beside the resident. Employee F revealed during the same interview that he had noticed the bed rail was loose earlier that day, but he stated, "not enough though to call maintenance." He confirmed that when a bed rail is noted to be loose, the facility ' s policy is to notify the maintenance department, who will tighten the bed rail. He also confirmed that the resident required maximum assistance in bed and used the side rails to hold on to when she was turned. 4. On [DATE], at approximately 5:45 p.m., an interview was conducted with Employee I who stated that he has been working in the facility approximately one year. He stated that during that year, he has noted about 3 " add- on " side rails that have come off of a bed that a resident occupied. He stated that last week, one of these clip-on side rails came off of a bed while he was present. The employee did not report the loose rails to administration. He could not recall the room. He stated that he put it back on and tightened the knob again. He stated that he could not recall any falls due to missing side rails or side rails that have come off of the bed frame. 5. On [DATE] at approximately 2:00 p.m. during an interview, the maintenance director confirmed that he is responsible for fixing faulty or loose side rails. He also stated that he was present on the unit when Resident #1 fell from her bed to the floor on [DATE]. He stated that he heard screaming coming from room 231-A and he went to provide assistance to the nursing staff. He additionally confirmed that he saw the entire side rail lying on the floor with the resident when he entered the room. He stated that he then inspected the side rail. He stated that it did not appear to be broken, and he reattached the side rail that had fallen to the floor back to Resident #1 ' s bed at that time. He further stated that the side rail was a "clip system" metal rail that was not permanently secured to the bed frame. He stated that this type of a side rail has a "vise grip" knob that is used to tighten the clip to the bed frame. He confirmed that there are several beds in the facility with this type of clip-on side rail. He stated that he has been asked to fix this type of side rail before when it has become loose, and this usually requires tightening by using the vise grip knob. 6. During an interview with the Director of Nursing on [DATE] at approximately 2:05 p.m., it was revealed that the bed that Resident #1 fell from on [DATE], was now located in room #222-A and was empty. The bed and attached side rails in room #222-A were observed with the DON present. The side rails were observed to be attached to the frame of the bed with a clip that could be tightened or loosened by an attached knob. The knob was tight, but the side rails could be moved approximately an inch back and forth when shaken. The Director of Nursing confirmed that Resident #1 had undergone amputations of both of her legs. She stated that Resident #1 had an additional air mattress placed on top of her existing mattress which extended to the side rails. She confirmed that the compressibility of an air mattress to the side that a resident moves may have caused the resident to lean against the rail. She also confirmed that this resident, as having lost both of her legs, and the second one just a few weeks before, would be expected to require assistance with bed mobility and this could include the use of side rails. 7. On [DATE] at approximately 2:15 p.m. a repeat observation was made of the bed in room 222-A. The Unit Manager confirmed at that time that the bed was the same bed that was present in room 222-A on [DATE] which was the bed implicated in the fall that resident #1 sustained on [DATE]. Two surveyors and the Director of Housekeeping were present. The surveyors tested the vise grip knob on the right side rail. The knob was fully tightened; however, the side rail was very loose and wobbly. By pressing against the side rail, in simulation of a body leaning again the rail with moderate to strong pressure, the right side rail gave way completely and fell off the bed. The clips did not hold the side rail to the bed frame. The Director of Housekeeping confirmed that even though the knob was tight, the side rail was able to come off of the bed when moderate pressure was placed against the rail. The Director of Housekeeping also confirmed that the vise grip knob loosened when the rails were shaken. 8. An interview with the Administrator on [DATE] at approximately 10:15 a.m., revealed that every bed was inspected in the facility and there are currently 33 beds out of 150 that have this type of "add-on" side rail that were implicated in Resident #1 ' s fall on [DATE]. She identified the manufacturer and model number of the side rail, and produced a photocopy of the side rail that was taken from a supply catalogue. The side rail implicated in Resident #1 ' s fall matched the picture in the supply catalog. She also identified the bed ' s manufacturer and model number. The bed was not manufactured by the company that manufactured the bed rails. 9. A telephone call to the manufacturer of the side rails placed on [DATE] at approximately 12:00 p.m. revealed that there have been no re-calls or reports of any problems associated with this type of side rail. An additional call for clarification regarding specifically what type of bed is indicated or contraindicated for this type of side rail, was made on [DATE] from 4:05 p.m.- 4:15 p.m. The surveyor spoke with a technical representative who stated that this type of side rail is only indicated for certain beds manufactured and supplied by the same company. He further stated that these side rails are not indicated for this company ' s long term care beds. A subsequent call was made to the company on [DATE] at approximately 4:40 p.m. to see if long term care beds from another manufacturer would be compatible with this type of side rail. The technical representative stated that their long term care beds do not fit with this type of side rail, as the "channel that the spring deck is hooked up to does not hold the side rail properly; it would not hold down properly." He stated, " These rails go with the beds which we sell except for the long term care beds. These side rails are only for ' our ' specific beds " He called back on [DATE] at approximately 11:00 a.m. and said that he spoke with the Procurement Officer to confirm if this type of side rail could be safely used for another manufacturer ' s long term care bed. He stated that the Procurement Officer said that he does not recommend using this type of side rail with any other manufacturer ' s beds. 10. An Interview was conducted on [DATE] at 2:15 p.m with Employee C, who stated that she was the nurse that was assigned to Resident #1 on [DATE]. She stated, "I was in a room two doors away when I came outside and they were saying they needed help in 231-the resident was on the floor. She was saying over and over that she needed something for pain. She was asking for morphine. We used a drawsheet-there was a group of us--to transfer her from the floor to the bed. When she was back in bed I gave her two Tylenol. She was yelling, but she always yelled. It was part of her normal behavior. But she keep yelling and so I called the doctor and said the Tylenol is not working and he said to give her Ultram which I took out of the EDK kit. Twenty five minutes later she was still not comfortable and so we sent her out." 11. On [DATE] at approximately 2:25 p.m., an interview with the Unit Manager confirmed that the resident fell as described above, and that she was on duty at the time. She stated that she immediately assisted with assessing the resident and saw that she did receive the Tylenol immediately after the fall, as well as the Ultram approximately one hour later. She stated that when the resident continued to complain of pain, the physician was notified a third time and the resident was transported by ambulance to the hospital at approximately 3:00 p.m. She confirmed that the resident was crying out and yelling in pain from the time of the fall to the time that she was transported to the hospital, approximately three hours later. She stated that she did not notice any obvious injuries. She stated that, since the resident was an amputee, there was no way to assess the possibility of a broken hip by looking at the positioning of the leg. She confirmed that an X-ray would have confirmed whether or not the resident had sustained a fracture. She also confirmed unrelieved pain is a symptom of a fracture that requires immediate attention. 12. On [DATE] at approximately 3:00 p.m., an interview was conducted with Employee H, a nurse who was assigned to the resident for the 3:00 p.m. to 11:00 p.m. shift on [DATE]. She stated that, when she came on duty, she heard the resident screaming. She stated that the resident frequently called out, but, "this was a different kind of calling out. This was a scream that she was in pain. I knew something was wrong immediately. I knew she had to go to the hospital, and I told them that." 13. On [DATE] at approximately 12:00 p.m., an interview was conducted with the Assistant Director of Nursing (ADON), who was also the risk manager who conducted the investigation. She confirmed that the resident ' s recent above- the- knee amputation of her right leg had caused a shift in her center of gravity, and this caused a shift in her ability to maintain balance without using her side rails in her effort to move in the bed. She stated that, on [DATE], the resident was placed on a bed pan by her nursing assistant and the nursing assistant left the room to allow her privacy. A second CNA came into the room and saw the resident land on the floor from her bed under the curtain. She stated the resident was distraught and asking for pain medication. She stated that the physician was notified. No mention was made of the side rail that came off of the bed in the narrative description of the investigation, but during the interview, the ADON confirmed that the side rail had come off of the bed at the time the resident fell . She stated the bed was at standard height (not a low bed). The distance between the surface of the bed to the surface of the floor was approximately two and a half feet. The ADON also confirmed that the care plan had not been updated to include that the resident had the second leg amputated after her readmission to the facility on [DATE]. She stated that the resident was receiving occupational therapy which began on [DATE]. 14. Further review of the clinical record revealed a physician's order [REDACTED]. " An occupational therapy " Initial Treatment Plan for Rehabilitation, " dated [DATE], had a treatment [DIAGNOSES REDACTED]." She was last seen for occupational therapy the day before the fall on [DATE]. On [DATE] at 10:50 a.m., a conference call was conducted with the Director of Rehabilitation, the Occupational Therapist and the Certified Occupational Therapy Assistant. The Director of Rehabilitation confirmed that an order was written for occupational therapy on [DATE]. She stated that upon receiving an order for [REDACTED]. She did not have an explanation why the initial evaluation was not done until [DATE], but did call back approximately one hour later to say the resident refused the first two initial evaluation attempts, stating that she was too tired. She stated that after an occupational therapist does the initial evaluation to include the resident ' s functional goals and the plan, the information is verbally given to the charge nurse and the unit manager for a multidisciplinary approach. She also stated that a copy of the evaluation and plan is placed in the resident ' s chart. The rehabilitation director stated that the " Initial Treatment Plan for Rehabilitation " is not a care plan in the sense of how the facility usually refers to a care plan, or a nursing care plan. This information may be added to the nursing care plan. The Certified Occupational Therapy Assistant (COTA) stated that the focus of occupational therapy for Resident #1 was wheelchair mobility and included improved postural alignment and sitting tolerance up to 4 hours within ,[DATE] weeks. She stated that the resident had required total assistance for bed mobility before her hospitalization of [DATE]-[DATE] that resulted in the right above-the-knee amputation, and continued to require total assistance when she was readmitted on [DATE]. Since this was not considered a change, it was not a focus for occupational therapy. She further stated that the resident had been able to self-propel using a wheelchair prior to the hospitalization , and due to poor trunk control and bilateral upper extremity weakness, could no longer self-propel in a wheelchair. She also stated that she was working with the resident to reclaim independent self- feeding skills as the resident was able to do prior to the hospitalization . The Certified Occupational Therapy Assistant confirmed that the resident was seen according to the progress notes on [DATE], [DATE], [DATE] and [DATE]. She stated that she had worked with the resident only four times, and the progress was minimal. She stated that it is not unusual for a resident to be able to self- propel in a wheel chair and still have no bed mobility, and require maximum assistance. She stated that this is because the resident is " operating on different planes and different muscle groups. " 15. Further clinical record review revealed no documentation of communication between occupational therapy and nursing staff regarding Resident #1 ' s functional status and treatment plan. The Individualized Care Plan for Fall/Fall Risk was dated [DATE] and listed the Fall Risk Factors to include "Left below-the-knee amputation " as a medical factor, but did not include the recent right below-the-knee amputation or that the resident was a new bilateral amputee when she was readmitted to the facility on [DATE]. The latest entries indicated that there was a review date of [DATE] with a new review date of [DATE] and the only new entry listed under interventions was dated [DATE] and stated, "P.T. referral related to wheelchair sitting due to no Resident original wheelchair and slid from chair ,[DATE]." There were no physician's order [REDACTED]. 16. On [DATE] a conference call was held with the Certified Resident Assessment Instrument Coordinator. She confirmed that the resident had a fourteen day comprehensive assessment dated [DATE] for the readmission that occurred on [DATE]. She stated that the resident had "No falls" indicated on the Fall History section of the assessment. She stated that the Functional Status assessment included a bed mobility score of ,[DATE] that indicated Resident #1 required two people to assist her, which included being pulled up to the head of the bed, and her ability to grasp hand rails. Her toileting score of ,[DATE] indicated that Resident #1 did not use anything but the bed pan and required two people to assist her with toileting. The Bowel and Bladder assessment indicated that the resident was always incontinent of bladder, and was frequently incontinent of bowel. The Nursing Comprehensive Admission Data tool, dated [DATE] at 5:30 p.m., indicated that the resident required "limited assistance" which is defined as "one person" for bed mobility and toileting. For prior level of functioning, the resident was described as "assist with activities of daily living." The admitting [DIAGNOSES REDACTED]. " A review of the Activities of Daily Living Care Plan that was updated on [DATE] revealed that the resident was listed as "total care with toileting" and this included " bowel incontinence and bladder incontinence." A review of the Activities of Daily Living Functional/Restorative Assessment and Progress tool, dated [DATE], revealed that the resident was dependent with all transfers and required a Hoyer lift. She used a bed pan for toileting, but was also incontinent of bowel and bladder. She received active and passive range of motion, occupational therapy, and positioning/support equipment, and used the side rails at night only. A Fall Risk Assessment, dated [DATE], revealed that the resident was at high risk for falls. The Side Rail Data Collection and Assessment tool, dated [DATE], revealed that the resident used the side rails to position herself in bed and was not able to position herself with another device other than the side rail, and listed the resident as requesting a side rail with an explanation given, "enabler for positioning." The assessment and plan for side rails listed pain and generalized weakness as medical symptoms for the use of side rails. It stated that Resident #1 had half rails initiated on both sides of the bed. 17. Further record review of the hospital record ' s discharge summary, dictated by the attending physician for Resident #1, revealed that she was diagnosed with [REDACTED]. A description of her hospital course included that an attempt was initially made to perform hip surgery to control the resident ' s complaints of severe pain, but the surgery had to be stopped when she developed very low blood pressure and had to be placed on a ventilator for life support. She then was taken back to the operating room and the " left hip fracture was removed without replacement. " Despite all treatment, after surgery she developed multi-system failure and ventilator dependency. Due to the progressive low blood pressure and her pre-existing co-morbidities, her family eventually made the decision for her to be taken off of the ventilator and placed on comfort measures only and then transferred to an in-patient Hospice center. The discharge date on the discharge summary was [DATE]. 18. During an interview with the resident ' s son on [DATE] at approximately 10:00 a.m., it was revealed that the resident died on [DATE] at a Hospice center. He stated that before the fall, the resident had been " ..doing better." After she had that other leg off, we all thought that she would be doing better now and in less pain. But they called me that day and told me that she fell out of bed. Then they called me again a few hours later and said they sent her to the hospital. When I talked to her in the hospital later, she said that the side rail gave way and she fell ." The son stated that she had problems with her blood pressure after the surgery and never recovered. He stated that the death certificate said that she died from complications due to a fall. 19. On [DATE] at approximately 10:30 a.m. the resident ' s physician confirmed that Resident #1 had sustained a fall with a subsequent fracture. The physician stated, "The nursing home called me and said that she had fallen. She had just had her leg amputated a few weeks before that. I asked them if she needed x-rays. They said no. They said she just needed pain medicine. When they called me back to ask for stronger pain medicine, I told them that she needed to be transferred to the hospital. " The physician confirmed that the resident experienced a physical decline during the surgery and did not recover. She stated that she was on vacation when the resident died . A copy of the death certificate was obtained for Resident #1 in which it was revealed that the resident died on [DATE] and the cause of death was "complications of hip fracture."

Based on resident record review, facility record review, policy review, staff interviews and observations, it was determined that the facility failed to maintain essential resident care equipment in safe operating condition for one (#1) out of eleven sampled residents. The investigation revealed that Resident #1, a [AGE] year old female who had undergone amputations of both legs, fell from her bed to the floor along with a side rail that separated from her bed. She sustained a [MEDICAL CONDITION] and died 12 days later of complications due to the fall and her fragile physical condition. This resulted in findings of immediate jeopardy which are on-going. Relevant findings include: 1. A clinical record review of the nurses ' notes for resident #1, dated 2/1/12, revealed that she sustained a fall from her bed to the floor on 2/1/12 at approximately 12:00 p.m. The most recent History and Physical as dictated by the resident ' s physician and dated 2/1/12, revealed that she had a surgical history that included bilateral amputation of both of her legs. The resident ' s medical [DIAGNOSES REDACTED]. 2. A review was conducted by the facility ' s Risk Manager on 2/1/12 which included a summary of events. Resident #1 had been placed on a bedpan by a Certified Nurse Assistant (CNA), Employee J. The privacy curtain was pulled around her and she was given a call bell. Employee J then left the room and approximately 15 minutes later, another CNA, Employee F, entered the room and saw the resident fall to the floor beneath the curtain. Further review of the investigation revealed that Employee F witnessed the resident fall to the floor under the curtain, and also gave a written statement that one of two of the bed ' s side rails was also found on the floor with the resident. An additional statement was also included that was written by the environmental services/maintenance director that stated, " On 2/1/12, called to resident ' s room to inspect side rail that had come off bed with resident fall. Side rail is not screw in type of rail. The bed and its rail are of the type where rail clips onto bed frame and unclips for removal. Side rail inspected and no damage seen reattached to bed without difficulty and reattached as it normally does. Rail appears to have dis-attached due to resident weight and leaning on rail. " 3. A review of the maintenance log revealed that there were three beds in the facility that had been serviced for loose or faulty side rails for January and February of 2012. Resident #1 ' s room was not included in the rooms that had been serviced. 4. On 2/20/12 at approximately 2:00 p.m. during an interview, the maintenance director confirmed that Resident #1 ' s side rails were not listed in the maintenance log as being one of the sets of rails that had been recently inspected. He also confirmed that he is responsible for fixing faulty or loose side rails. He could not confirm the type of side rails that were recorded in the maintenance log. He also stated that he was present on the unit when Resident #1 fell from her bed to the floor on 2/1/12. He stated that he heard screaming coming from room 231 and he went to provide assistance to the nursing staff. He additionally confirmed that he saw the entire side rail lying on the floor with the resident when he entered the room. He stated that he then inspected the side rail. He stated that it did not appear to be broken, and he reattached the side rail that had fallen to the floor back to Resident #1 ' s bed at that time. He further stated that the side rail is a " clip system " metal rail that is not permanently secured to the bed frame. He stated that this type of side rail has a " vise grip " knob that is used to tighten the clip to the bed frame. He confirmed that there are several beds in the facility with this type of clip-on side rail. He stated that he has been asked to fix this type of side rail before when it has become loose, and this usually requires tightening by using the vise grip knob. 5. On 2/23/12, at approximately 5:45 p.m., an interview was conducted with Employee I who stated that he has been working in the facility approximately one year. He stated that during that year, he has noted about 3 " add- on " side rails that have come off of a bed that a resident occupied. He stated that last week, one of these clip-on side rails came off of a bed while he was present. The employee did not report the loose rails to administration. He could not recall the room. He stated that he put it back on and tightened the knob again. He stated that he could not recall any falls due to missing side rails or side rails that have come off of the bed frame. 6. During an interview with the Director of Nursing (DON) on 2/20/12 at approximately 2:05 p.m., it was revealed that the bed that was implicated in Resident #1 ' s fall, was located in room #222-A and was empty and available for another resident. The bed and attached side rails in room #222-A were observed with the DON and the maintenance director present. The bed was a regular hospital bed with a metal frame and springs, and a wooden head board and foot board. The side rails were observed to be attached to the frame of the bed with a clip that could be tightened or loosened by an attached knob. The vise grip knob was tight, but the side rails could be moved approximately an inch back and forth when shaken. On 2/23/12 at approximately 2:15 p.m., a repeat observation was made of the bed in room 222-A with two surveyors and the director of housekeeping present. The Unit Manager confirmed, at that time, that the bed was the same bed that was present in room 222-A on 2/20/12 which was the bed implicated in the fall that resident #1 sustained on 2/1/12. The surveyors tested the knob on the right side rail. The knob was tight, but the side rail was loose and wobbly. By pressing outward on the inside of the side rail, in simulation of a body leaning again the rail, with moderate to strong pressure, the right side rail gave way completely and fell off the bed. The clips did not hold the side rail to the bed frame. The Director of Housekeeping confirmed that even though the knob was tight, the side rail fell off the bed under moderate pressure. The Director of Housekeeping also confirmed that the vise grip knob loosened when the rails were shaken. 7. An interview with the Administrator on 2/24/12 at approximately 10:50 a.m. revealed the facility currently has 33 beds out of 150 that have this type of " add-on " or " clip-on " side rail that were implicated in Resident #1 ' s fall on 2/1/12. The administrator stated that there have been no prior incidents or falls to her knowledge that were related to this type of side rail before, or since Resident #1 ' s fall on 2/1/12. She stated that she was unaware that there was a problem with this type of side rail. She further stated that this type of rail was manufactured and purchased from a supply company that she identified, and she produced a photocopy from a supply catalog. The side rail implicated in Resident #1 ' s fall was matched to the supply catalog and identified. She provided the name of the bed, but stated that she was unaware when and where the beds were purchased; they were in the facility when she was hired. 8. A telephone call to the supply company was placed on 2/24/12 at approximately 12:00 p.m. and revealed that there have been no re-calls of this type of side rail. An additional call for clarification regarding specifically what type of bed is indicated or contraindicated for this type of side rail was made on 3/1/12 from 4:05 p.m. to 4:15 p.m. The surveyor spoke with a technical representative who stated that this type of side rail is only indicated for certain beds manufactured and supplied by this company and not for their long term care beds. The type and model number of the bed that Resident #1 fell from was given, and the representative stated that this bed was not manufactured by their company. A subsequent call was made to the company on 3/1/12 at approximately 4:40 p.m. to see if long term care beds from another manufacturer would be compatible with this type of side rail. He explained that the long term care beds do not fit with this type of side rail, as the " channel that the spring deck is hooked up to does not hold the side rail properly; it would not hold down properly. " He stated, " These rails go with the beds which we sell. They are to be used for ' our ' specific beds. " He called back on 3/2/12 at approximately 11:00 a.m. and said that he spoke with the Procurement Officer who stated that he does not recommend using this type of side rail with any other manufacturer ' s beds. 9. A Fall Risk assessment dated [DATE] revealed that Resident #1 was at high risk for falls. The Side Rail Data Collection and Assessment tool, dated 1/18/12, revealed that the resident used the side rails to position herself in bed, was not able to position herself with another device other than the side rail, and listed the resident as requesting a side rail with an explanation given, " enabler for positioning. " The assessment/plan for side rails listed pain and generalized weakness as medical symptoms indicating the use of side rails. It stated that Resident #1 had half rails initiated on both sides of the bed. Further record review revealed that the resident required extensive (two person) assistance with bed mobility according to the Nursing Comprehensive Admission Data tool, dated 1/17/12. 10. Further review of the clinical record for Resident #1 revealed an order, dated 1/19/12, for an occupational therapy (OT) evaluation for " wheelchair positioning related to bilateral above-the-knee amputation. " The evaluation was completed on 1/25/12 with revised orders of, " OT Clarification Order: Skilled OT services three times a week for four weeks to include ther-ex (therapeutic exercise), NMR (neuromuscular re-education) and positioning. " A review of the occupational therapy Initial Treatment Plan for Rehabilitation, dated 1/25/12, stated that the resident had a functional goal that included demonstrating improved postural alignment and sitting tolerance. This included a review of her bed mobility revealed that she was unable to move from sitting to supine or supine to sitting in bed, and required maximum assistance with bed mobility including rolling and scooting in bed. 11. Review of the clinical record revealed that there was no indication or documentation of any communication between the nursing staff and occupational therapy regarding resident #1 to update the nursing care plan for " Fall/Fall Risk " or for " Alteration in Activities of Daily Living: Total Dependence Upon Staff Members for Activities of Daily Living/Requires Total Care " related to bed mobility needs or the use of assistive devices such as side rails. There was an entry on Fall/Fall Risk that was dated " 10/24 " that stated " provide bed pan when she agrees to use it, " and on " Alteration in Activities of Daily Living " dated 10/24/11 that stated " total care with toileting on occasion will ask for bedpan " and " bowel incontinence and bladder incontinence. " The last MDS assessment, dated 1/29/12, indicated the resident was " always " incontinent of bladder, and " frequently " incontinent of bowel. 12. An entry in the nurse ' s notes written by Employee C, dated 2/1/12 at 12:45 p.m., revealed that that Resident #1 was " in bed and on the bed pan with side rails up x 2. " When the certified nursing assistant (CNA) entered the room, he saw the resident on the floor. The resident " was unable to explain to explain what happened. " During an interview on 2/20/12 at approximately 3:00 p.m. Employee F confirmed that he was the certified nurse assistant on 2/1/12 that was assigned to Resident #1. He stated that when he entered room #231 on 2/1/12 at approximately 12:00 p.m., he saw her fall to the floor from underneath the privacy curtain. He stated that she was screaming and asking for [MEDICATION NAME] and to sit up. He stated that he asked a visitor who was at the door way to get additional help as he stayed with the resident. He confirmed that one of the side rails was on the floor with the resident. He also stated that he thought the side rail was loose earlier that day, but " not loose enough to call maintenance. I kind of noticed them, that something might be wrong. " He confirmed that the resident required two people to assist with toileting and bed mobility, and would hold on to the side rails when turned. 13. During an interview with the Resident #1 ' s son on 2/23/12 at approximately 10:00 a.m., it was revealed that the resident died on [DATE] at a Hospice center. He stated that before the fall, the resident had been " ...doing better. After she had that other leg off, we all thought that she would be doing better now and in less pain. But they called me that day and told me that she fell out of bed. Then they called me again a few hours later and said they sent her to the hospital. When I talked to her in the hospital later, she said that the side rail gave way and she fell . " The son stated that she had problems with her blood pressure after the surgery, and never recovered. He stated that the death certificate said that she died from complications due to a fall. 14. A copy of the death certificate was obtained for Resident #1 in which it was revealed that the resident died on [DATE] and the cause of death was " complications of [MEDICAL CONDITION]. " 15. Thirty-two additional beds with these add-on side rails were available for resident use, placing residents at increased risk for fall and injury for the next twenty-four days. In addition, the same side rail that was implicated in Resident #1 ' s fall was placed back on her bed immediately after the fall by the maintenance director, thereby, putting her at risk for another fall until she was transported to the emergency room three hours later. This side rail remained on the bed for twenty four days after the accident, potentially putting any other resident at risk that was assigned to this bed.

1. Based on resident record review, policy review, staff interviews and observations, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively to maintain the highest practicable physical well-being for one (#1) out of eleven residents reviewed, through fall prevention, updating the care plan to reflect the resident ' s change in condition and ensuring that resident care equipment was maintained in safe operating condition. Resident #1, a vulnerable [AGE] year old, was determined to be at a high risk for falls, and had previously undergone amputation of both of her legs. The facility ' s documentation revealed that Resident #1 fell from her bed, along with a side rail that became separated from the bed. Although the facility knew that the side rail implicated in Resident #1 ' s fall on [DATE] had detached from the bed and fallen with the resident, it was replaced back on to the resident ' s bed immediately after the fall. The facility review that was completed did identify this type of side rail as being potentially hazardous. No investigation was conducted concerning the safety of continuing to use this type of side rail for other residents. No in-servicing or staff education was done with employees regarding side rails and assessing safety, as well as reporting problems. The administrator stated that 33 residents had this type of " add-on " side rail on their beds, which had continued to be in use since Resident #1 ' s fall on [DATE], potentially putting these residents at risk for harm. The facility procured and utilized side rails that were not compatible, poorly fit and, therefore, unsafe with the beds on to which they were placed. The circumstances regarding the side rail in Resident 1 ' s fall were not investigated thoroughly, and the resident was put at risk again for three hours until she was transported to the hospital. An additional thirty-three residents that had this same type of side rail were at risk for falls for the next twenty three days. The resident was transported to the hospital three hours later, diagnosed with [REDACTED]. This resulted in findings of immediate jeopardy which are on-going. Relevant findings include: 1. Although the facility knew that the side rail implicated in Resident #1 ' s fall on [DATE] had detached from the bed and fallen with the resident, it was replaced back on to the resident ' s bed immediately after the fall. The investigation that was completed did identify this type of side rail as being potentially hazardous. No investigation was conducted concerning the safety of continuing to use this type of side rail for other residents. No in-servicing or staff education was done with employees regarding side rails and assessing safety, as well as reporting problems. The administrator stated that 33 residents had this type of " add-on " side rail on their beds, which had continued to be in use since Resident #1 ' s fall on [DATE], potentially putting these residents at risk for harm. The facility procured and utilized side rails that were not compatible, poorly fit and, therefore, unsafe with the beds on to which they were placed. The implications of the side rail in Resident 1 ' s fall were incompletely investigated, and the resident was put at risk again for three hours until she was transported to the hospital. An additional thirty-three residents that had this same type of side rail were at risk for falls for the next twenty three days. 2. A Review of the POS Essential Job Duties and Responsibilities: Influences administrative, operation, and human resources policies and decisions, and ensures compliance with quality standards ...and resident rights and responsibilities. " Further review revealed, " Ensures the provision of quality of services through the design and implementation of facility wide quality assurance and program evaluation plans. " 3. A clinical record review for Resident #1 revealed an undated face sheet that she was a [AGE] year old female that was originally admitted to the facility on [DATE], and her most recent readmission occurred on [DATE]. A review of the resident ' s History and Physical, dictated by her physician and dated [DATE], revealed that the resident had a past surgical history of bilateral amputations of her legs. Her medical [DIAGNOSES REDACTED]. Further clinical record review for Resident #1 revealed an entry in the nurse ' s notes dated [DATE] at 12:45 p.m., that stated Resident #1 fell from her bed, approximately two and a half feet, to the floor. A subsequent entry on the same date, timed 3:00 p.m., revealed that Resident #1 was transported to a local hospital for unrelieved pain. The last entry on the same date was timed 7:15p.m., and revealed that Resident #1 was admitted to the hospital with [REDACTED]. 4. An interview was conducted with the Director of Quality/ Risk Manager on [DATE] at 12:50 p.m. regarding Resident #1 ' s fall on [DATE]. She stated that she had initiated a review immediately after the occurrence on [DATE], and had been in consultation with the Administrator and Director of Nursing. She stated, " We could not have done anything to have anticipated her falling from the bed like that ...there was no way that we could ever have predicted that this could have happened, and we were not at fault. " A facility summary referenced, " This occurrence was not foreseeable and based on resident history, not preventable. " She did confirm that the side rail had come off of the bed during Resident #1 ' s fall. She stated that the type of side rail that was attached to Resident #1 ' s bed was not meant to have pressure placed against it, such as it could not sustain a resident leaning against it. She stated the Maintenance Director had inspected the side rail after the fall. A written statement included with the investigation from the Maintenance Director stated, " On [DATE] called to resident ' s room to inspect side rail that had come off bed with resident fall. Side rail is not screw in type of rail. This bed and its rail are of the type where rail clips onto bed frame and unclips for removal. Side rail inspected and no damage seen reattached to bed without difficulty and reattached as it normally does. Rail appears to have dis-attached due to resident weight and leaning on rail. " The Director of Quality/Risk Manager confirmed that when the maintenance director did not find the side rail damaged, it was reattached to the bed that Resident #1 remained in for the next three hours until she was transferred out to a local hospital. She stated that no further reviews, quality assurance or in-services were done regarding ensuring the safe use of side rails. However, she stated that an in-service was given following the fall on ,[DATE]-2/ 2012 regarding " Fall Risks Associated with Bed Pan Use, " and the focus was, " Do not leave resident alone on bedpan stand at the door or remain in the room to hear when assistance is needed. " A review of the sign- in list revealed 47 of 107 direct care staff attended this in-service. After [DATE], this in-service was not offered again. She confirmed that the resident still could have fallen if she was leaning against the side rail even if an employee was at the doorway. 5. On [DATE] at approximately 3:00 p.m. an interview was conducted with Employee F. He confirmed that he was the certified nursing assistant (CNA) that was assigned to Resident #1 on [DATE] at the time of the fall. He confirmed that he saw her fall to the floor under the privacy curtain when he entered the room to assist the roommate to the bathroom. He confirmed that the bed rail had separated from the bed and was lying on the floor with the resident. He stated that the resident was screaming in pain and wanted to sit up. He stated that he stayed with her and asked for a visitor who was standing in the doorway to get help from the other staff members. He confirmed that the resident was lifted back to bed approximately 5 minutes later by using a sheet positioned underneath her and ,[DATE] other staff persons. He stated that he recalled earlier that day that this side rail was loose. He stated, " But not enough to call maintenance. " He stated, " I kind of noticed them ... that something was wrong. " He confirmed that when a bed rail is observed to be loose, the facility ' s policy is for the staff member to notify the maintenance department. He stated that he had seen Resident #1 hold on to the side rails to assist her with mobility while she was receiving care. 6. On [DATE] at approximately 2:00 p.m. an interview was conducted with the Maintenance Director, who confirmed that he is responsible for fixing faulty or loose side rails. He stated reports of faulty side rails are routinely considered a priority, as they have resident safety implications. He also stated that he was present on the unit when Resident #1 fell from her bed to the floor on [DATE]. He stated that when he heard screaming coming from Resident #1 ' s room, he went to provide assistance to the nursing staff. He stated that he saw the side rail lying on the floor in the resident ' s room close to Resident #1. He stated that he inspected the side rail, and when it did not appear to be broken, he reattached the side rail that had fallen to the floor back to Resident #1 ' s bed, which she remained in until her transfer to the hospital three hours later. He further stated that the side rail is a " clip system " or " add-on " metal rail that is not permanently secured to the bed frame. He stated that this type of a side rail has a " vise grip " knob that is used to tighten the clip to the bed frame. He confirmed that there are several beds in the facility with this type of clip-on side rail. He stated that he has been asked to fix this type of side rail before when it has become loose, and this usually requires tightening by using the vise grip knob. He stated that this type of side rail was not intended for a resident that would be leaning against it. 7. On [DATE] at approximately 2:05 p.m., The Director of Nursing (DON) confirmed that Resident #1 had undergone amputations of both of her legs, and the second one just a few weeks prior to [DATE]. She stated that Resident #1 was also obese and had very limited bed mobility. The DON further stated that Resident #1 had an additional air mattress placed on top of her existing mattress, which extended to the side rails. She confirmed that the compressibility of an air mattress to the side that a resident may move could have caused the resident to lean against the rail. She also confirmed that this resident, as having lost both of her legs, and the second one just a few weeks before, would be expected to require assistance with bed mobility and this could include the use of side rails. The DON stated that the bed that Resident #1 used, including the side rails, was now located in room [ROOM NUMBER]-A, and was vacant, awaiting an admission. 8. On [DATE] at approximately 2:05 p.m., the bed and attached side rails in room [ROOM NUMBER]-A were observed with the DON and Maintenance Director present. The bed was a regular bed with a metal frame and spring, a wooden head board and foot board. The side rails were observed to be attached to the frame of the bed with a clip that could be tightened or loosened by an attached knob. The knob was noted to be tight, but the side rails could be moved approximately an inch back and forth when shaken. On [DATE] at approximately 2:15 p.m. a repeat observation was made of the bed in room [ROOM NUMBER]-A with two surveyors and the Director of Housekeeping present. The Unit Manager confirmed the bed and attached side rails had not been moved since the first inspection on [DATE]. The surveyors tested the vise grip knob on the right side rail. The knob was tight, but the side rail was loose and wobbly. One surveyor pressed outward on the right side rail, in simulation of a body leaning against the rail, with moderate to strong pressure, and the side rail fell off the bed to the floor. The clip did not hold the side rail to the bed frame. The Director of Housekeeping confirmed that even though the knob was tight, the side rail was able to come off of the bed when moderate pressure was applied. 9. An interview with the Administrator on [DATE] at approximately 10:15 a.m. revealed that every bed in the facility was inspected and there are currently 33 beds out of 150 that have this type of " add-on " or " clip-on " side rail that was implicated in Resident #1 ' s fall on [DATE]. The administrator stated that there have been no prior incidents or falls to her knowledge that were related to this type of side rail before, or since Resident #1 ' s fall on [DATE]. She stated that she was unaware that there was a problem with this type of side rail, despite acknowledgement that the side rail had come off of Resident #1 ' s bed at the time of her fall. She identified the manufacturer and model number of the side rail, and produced a photocopy of the side rail that was taken from a supply catalogue. The side rail implicated in Resident #1 ' s fall was matched to the supply catalog and identified. She identified the bed ' s manufacturer and model number, but stated that these beds were purchased prior to her hire date and she could not determine the supplier. A telephone call to the manufacturer of the side rails placed on [DATE] at approximately 12:00 p.m. revealed that there have been no re-calls or reports of any problems associated with this type of side rail. An additional call for clarification regarding specifically what type of bed is indicated or contraindicated for this type of side rail, was made on [DATE] from 4:05 p.m. to 4:15 p.m. The surveyor spoke with a technical representative who stated that this type of side rail is only indicated for certain beds manufactured and supplied by the same company that manufactures the side rails. He stated that the bed that was implicated in Resident #1 ' s fall was made by a different manufacturer, as he could not identify the model number of the bed that was provided by the Administrator. He stated that, additionally, this type of side rail is not indicated for the long term care beds that are manufactured by the same company. A subsequent call was made to the company on [DATE] at approximately 4:40 p.m. to see if long term care beds from another manufacturer would be compatible with this type of side rail. The technical representative confirmed that their long term care beds do not fit with this type of side rail, as the " channel that the spring deck is hooked up to does not hold the side rail properly; it would not hold down properly. " He stated, " These rails go with the beds which we sell, except for the long term care beds. These side rails are only for ' our ' specific beds. " He called back on [DATE] at approximately 11:00 a.m. and said that he spoke with the Procurement Officer to confirm if this type of side rail could be safely used for another manufacturer ' s long term care bed. He stated that the Procurement Officer said that he does not recommend using this type of side rail with any other manufacturer ' s beds. 10. A review of Resident #1 ' s clinical record revealed a Fall Risk Assessment, dated [DATE], which indicated her to be at high risk for falls. The Side Rail Data Collection and Assessment tool, dated [DATE], revealed that the resident used the side rails to position herself in bed and was not able to position herself with another device other than the side rail. It also stated that Resident #1 requested the side rail, with an explanation given, " enabler for positioning. " The assessment/plan for side rails listed pain and generalized weakness as medical symptoms that the use of a side rail would treat. It stated that Resident#1 had half rails initiated on both sides of the bed. 11. On [DATE] at approximately 5:45 p.m. an interview was conducted with Employee I who stated that he has been working in the facility approximately a year. He stated that within that year, approximately three different " add- on " side rails have come off of a bed that a resident occupied while in his care. He stated that last week one came off of a bed while he was present. He could not recall the room. He stated that he put it back on and tightened the knob again, as he had done previously. He stated that he cannot recall any falls due to missing, defective, or poorly attached side rails. He stated that he did not report the loose side rails to Administration. 12. During an interview with the Resident #1 ' s son on [DATE] at approximately 10:00 a.m., he said that Resident #1 died on [DATE] at a Hospice center. He said that the family had made the decision to take her off of life support after she did not do well after the surgery to remove the broken bone from her hip on [DATE]. He stated that before the fall, the resident had been " ...doing better. After she had that other leg off, we all thought that she would be doing better now and in less pain. But they called me that day and told me that she fell out of bed. Then they called me again a few hours later and said they sent her to the hospital. When I talked to her (Resident #1) in the hospital later, she said that the side rail gave way and she fell . " The son stated that she had problems with her blood pressure after the surgery, and never fully recovered. He stated that the death certificate said that she died from complications due to a fall. 13. Resident #1 had requested a side rail to use as an enabler, which she required since she was unable to move without assistance in her bed. She was also on an air mattress, which further compromised her bed mobility by air shifts when she moved. She was provided with " add- on " side rails that were not permanently attached to her bed, and not intended by the manufacturer to be used in conjunction with a bed from another manufacturer. The same side rail was observed coming unattached from the bed with moderate pressure applied by a surveyor. On [DATE], she fell from the bed, along with the side rail. After three hours, she was transported to the hospital and diagnosed with [REDACTED]. She died twelve days later. The death certificate stated that death was due to complications of a fracture.