Every finding on record at Lee Manor

Based on interview and record review, the facility failed to provide appropriate transfer for a resident who is Dependent for transfers requiring a mechanical lift transfer with 2 persons transfer assist due to being non-ambulatory. This deficiency affects one (R210) of three residents reviewed for accidents and incidents. This failure resulted in R210 to have a right lower leg laceration requiring 12 stiches. Findings include:R210 is a [AGE] year-old admitted on [DATE] to the facility with the following diagnosis in part but not limited to Alzheimer's disease with late onset, Vascular Dementia unspecified, unsteadiness on feet, other abnormalities of gait and mobility, weakness, presence of right artificial knee joint.Facility Reported Incident dated 6/27/26 documents at approximately 1:30PM, R210 sustained a laceration to the right lower extremity during transfer from wheelchair to bed. The transfer had been completed when the residents' right leg came in contact with the bed rail, resulting in a skin laceration with minimal bleeding. On 7/14/26 at 11:05 AM, R210 said that she doesn't recall exactly what happened on date of incident 6/27/26, said she recalled only one staff member transferring her, no mechanical lift used, said her right leg got injured. On 7/16/2026 at 10:25 AM, V2 (Director of Nursing), said that during certified nurse aide incident on incident date 6/27/26 investigation statement for R210, V26 (Certified Nurse Aide) said she transferred R210 using a gait belt and was the only staff transferring. V2 said that she expects her staff to follow transfer protocol, all mechanical lift transfers should be a 2-person assist. On 7/16/2026 at 10:30 AM, V25 (Restorative Nurse) said that R210 is dependent for transfers and uses mechanical lift, said that R210 requires a 2 person transfer for any mechanical lift transfer. V25 said she was sad to hear that R210 had a one-person assist transfer using a gait belt and sustained a skin laceration, said it was not an appropriate transfer. On 7/16/26 at 10:36 AM, V26 (Certified Nurse Aide) said she was taking care of R210 on date 6/27/26, said she transferred R210 from wheelchair to bed using a gait belt and was the only staff present in the room, said that she is aware that R210 is a mechanical lift transfer and all mechanical lift transfers require a 2 person assist. V26 said she used a gait belt for transfer, and R210 right leg was caught in the bed rail sustaining a skin laceration.Functional Abilities and Goals- admission assessment dated [DATE] indicates Mobility - Chair/bed-to chair transfer- Dependent. Restorative assessment dated [DATE] indicates Dependent for transfers- requiring 2-person staff assist. The Care Plan dated 10/24/25 has an ADL Self Care Performance Deficit evident by limited mobility, limited range of motion to Bilateral Upper Extremities and Bilateral Lower Extremities, decreased strength, non-ambulatory. Interventions in place include TRANSFER: Requires Mechanical lift (Sit to Stand Machine) for transfers with 2-persons assist.Facility Policy on Transfer Protocol/Limited Lift revised 6/2015.Statement of Policy:It is the policy of [NAME] Manor to attempt to protect both residents/patients and employees from injury in the course of transferring patients/residents. This policy is to ensure a safe working environment for staff providing care to residents. Resident transfer status will be revised via care plan time frame and on as needed basis.Resident transfer status will be tagged in the resident's room.Procedure:All residents/patients will be assigned a number or letter that identifies the kind of transfer that is appropriate for their individual needs according to the following. M- identified a patient/resident who requires a mechanical lift during transfer, all patient/residents requiring a mechanical lift automatically requires that two staff members will assist during a transfer. All patients/residents will be assessed within 72hours of admission and assigned the appropriate number or letter to indicate the kind of transfer that is appropriate, all patients/residents will be assigned a 2 immediately upon admission or readmission until an appropriate assessment has been accomplished. All patients/residents will be re-assessed on a quarterly basis or as needed subsequently to an injury or significant change in condition. The symbol identifying the type of transfer that is appropriate for each patient/resident will be posted above the patients/residents bed for accessible reference.No patient/resident is to be transferred without first verifying the symbol assigned to that patient/resident to know what type of transfer is required by that patient/resident on that day.

Based on observation, interview, and record review the facility failed to implement infection control practices affecting 1 of 5 (R152) residents reviewed for infection control in total sample of 35 Findings Include:On 7/14/2026 at 10:30 AM during incontinence care V14 (Certified Nursing Assistant) was wearing double gloves, removed one glove and continued the tasks. V14 observed with no hand hygiene performed throughout the whole incontinence care. V14 said hand hygiene should have been done after gloves were removed and before putting on a new one and double gloving should not be done. On transfer of R152 the indwelling catheter bag was placed on the floor. Bag remained on the floor during incontinence care.On 7/14/2026 at 10:46 AM V16 (Infection Control Manager) said double gloving is not an acceptable practice, hand hygiene should be done before, during, and after each task. Indwelling catheter bag should not be set on the floor. On 7/15/2026 at 8:54 AM V2 (Director of Nursing) said gloves are for single use, hand hygiene should be done before, during and after task, and catheter bag should not be set or left on the floor. This is important for infection control practices.R152 admitted on [DATE]. Diagnosis information includes (not a complete list) neuromuscular dysfunction of bladder, extended spectrum beta lactamase (ESBL) resistance, and presence of urogenital implants. Order summary report, 6/30/2023, read suprapubic urinary catheter. Care plan report, revision 7/4/2023, read R152 has potential to develop complications due to presence of indwelling catheter. Interventions include keep the drainage bag covered off the floorPolicy and Procedure1. Title: Handwashing/Hand Hygiene, no datePolicy Interpretation and Implementation2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub or alternatively, soap and water for following situations:a. Before and after direct contact with residentse. Before and after handling an invasive device (e,g, urinary catheters, IV access sites)m. After removing gloves10. Single-use disposable gloves should be used:b. When anticipating contact with blood or body fluids2. Title: Catheter Care, Urinary, revised September 2014Infection Control2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bagb. Be sure the catheter tubing and drainage bag are kept off the floor

Based on observation, interview, and record review, the facility failed to provide timely incontinence care to dependent residents. This applies to 4 of 4 residents (R1-R4) reviewed for incontinence care in a sample of 4.The findings include:1.R1 is a [AGE] year-old male with severely impaired cognition as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R1 is dependent on toileting hygiene.On 3/27/26 at 9:40 AM, R1 was observed in his bed, pointing to his soaked incontinent brief. Upon the writer's request, V4 (Certified Nursing Assistant / CNA) checked on R1 for incontinence and observed R1 with a brownish colored urine-soaked incontinent brief.On 3/27/26 at 9:40 AM, V4 stated that she started at 7:00 AM and didn't get a chance to change R1.A review of the R1's incontinent care plan document interventions, including clean peri-area with each incontinent episode.2.R2 is a [AGE] year-old male with severely impaired cognition as per the MDS dated [DATE]. The MDS also documents that R1 is dependent on toileting hygiene.On 3/27/26 at 10:10 AM, R2 was observed on his low bed with two incontinent briefs on and mattress linen wet. The inner brief was observed to be urine-soaked with a brownish discoloration.On 3/27/26 at 10:10 AM, V6 (CNA) stated, R2 is peeing a lot, and that's why I put him on two diapers. I am going to change him with only one diaper now.A review of R1's incontinent care plan document interventions, including assisting the resident by toileting frequently.3.R3 is an [AGE] year-old female with moderate cognitive impairment as per the MDS dated [DATE]. The MDS also documents that R1 is dependent on toileting hygiene.On 3/27/26 at 10:15 AM, R3 was observed in her bed with a brownish discolored, urine-soaked incontinent brief.On 3/27/26 at 10:15 AM, V7 (CNA) stated, R3 was changed around 7:00 AM by night CNA, and I am going to change her now.A review of the R3's incontinent care plan document interventions, including: Assist the resident by toileting frequently.4.R4 is a [AGE] year-old female with severely impaired cognition as per the MDS dated [DATE]. The MDS also documents that R1 is dependent on toileting hygiene.On 3/27/26 at 10:20 AM, R3 was observed in her bed with a urine-soaked brief with brownish discoloration even to the outside of the brief and mild wet padding.On 3/37/26 at 1022 AM, V8 (Hospice CNA) stated that she visits R4 twice per week and that she is going to change R4 now.A review of the R4's incontinent care plan document interventions, including incontinent care after every diaper change.On 3/27/26 at 1:45 PM, V2 (Director of Nursing / DON) stated, It's not acceptable to leave residents with urine-soaked, brownish-colored incontinent briefs. I will talk to my staff on putting two diapers on residents and to check on residents frequently.

Based on interviews and records reviewed the facility failed to complete a wound assessment and document treatment and findings of the assessment of one resident (R91) who developed a reddened area on her left and right buttock, and failed to ensure there were effective interventions to prevent further deterioration. This failure affected one of five of 5 (R91) reviewed for pressure ulcers in a sample of 36. This failure resulted in R91 developing an unstageable pressure ulcer that required debridement. The findings include: R9's diagnosis include but are not limited to Alzheimer's Disease, Parkinson's Disease, Diabetes, Retention of Urine, Vascular Dementia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. On 04/15/25 at 10:50 AM R91 in bed, sleeping on air mattress, on back. R91 did not verbally respond to the surveyor for interview. On 04/16/25 at 11:15AM R91 in bed, sleeping, did not wake when spoken to. On 4/16/25 11:17AM V16, LPN said R91 has a sacral wound, at stage IV and she is on hospice. V16 said R91 stays in bed. V16 said R91 was on antibiotic for her pressure ulcer but she just finished the treatment. On 4/17/25 at 8:25AM V17, CNA, said I turn R91 every 2 hours. R91 awake, eyes open, eating breakfast, looking out the window. No verbal response. At 8:38AM V17 said R91 is completely dependent on staff, she can't move. V17 said we have to turn her; she doesn't help or try to get up. During an interview, in Spanish, in the conference room with the surveyors on 4/17/25, V17 said he reported to wound care a red area, unopened, just red on her buttocks, about the size of a lime. (V17 made a gesture with his fingers in a circle shape and the surveyor asked if that was about the size of a lime and V17 said yes.) V17 said there was no documentation or anything I wrote to report this. V17 said it is just a verbal report to the nurse, right away. V17 said we kept applying the barrier ointment to her and turning her. V17 said it was between 3-7 days when I reported to the nurse before the hospice nurse saw the wound. V17 said I told V19 about it when I first saw it. On 04/17/25 at 09:25 AM V18, Wound Care Director, said R91 has a stage IV pressure ulcer. V18 stated it is the worst one (wound) in the building. V18 said R91's wound was unavoidable because of poor nutrition and her declining health. V18 said the wound has undermining. V18 said we were treating her with antibiotics. V18 said the wound treatment was already done today. V18 said R91's wound was facility acquired, seen initially on 1/21/25 as a stage 3. V18 said R91 had a history of pressure ulcers prior to this one. V18 said the first person to report R91's wound was the hospice nurse to V16 on 1/21/25. V18 said initially R91's wound was classified by the wound doctor as an end of life wound but we can only do for 4 weeks so we classified as IV. V18 said I coded R91's wound wrong initially as stage 3 on the MDS, but I should have classified it as a Deep Tissue Injury (DTI). On 4/17/25 at 11:38AM V19, Wound Nurse, said R91 had a history of wounds that had healed. V19 said the CNA, V17, reported redness to R91's left and right buttocks. V19 said when I saw the area it was red, but she had nothing in her sacrum. V19 said the redness was from pressure, it was superficial Stage 1 when I saw it. V19 said I did not document an assessment of the wound. V17 said I should have documented it. V17 said I went on vacation on 1/17/25 and I was back to work on 2/24/25. On 4/18/25 at 8:58AM V18 said when I spoke with the hospice nurse, she said R91 skin was clear on her hospice admission assessment on 1/16/25. Her skin was reported impaired on 1/21/25. V18 said we had a treatment for a dressing to be applied in January, but we didn't put it on the treatment record. On 4/18/25 at 11:02 AM V23, Wound Doctor, said the facility had a clerical error and the wound order was not on the treatment records. When a wound is found in an ideal world there would be a wound assessment so we can determine what kind of wound it is (like pressure) and to determine if there is improvement or decline by monitoring the wound. On 4/18/25 at 11:54am V1, Director of Nursing, said the purpose of the TAR is to record and document that wound care treatments are done. V1 said if the order is not on the TAR there is no way to show the treatment was done. V1 said I expect all orders to be on the physician order sheets and the TAR. Hospice General Note on 1/16/25 documents clear skin. Treatment Administration Record (TAR) January 2025 has order for Chamosyn that was initiated July 2024, no other treatment. Progress notes for R91 dated 1/21/25 6:29PM new pressure ulcer on sacral. Current treatment bordered foam. There are no notes or assessments documenting what V17 said she saw, the redness. V17 started vacation on 1/17, so the area was seen prior to 1/17/25. Progress notes for R91 dated 1/21/25 at 7:54PM wound care noted purplish color discoloration on sacral area. R91's Wound Assessment Details dated 1/21/25 notes stage 3 size 1.50 x 0.40 x 0.20 with light serous drainage. (picture is included on assessment) Notes section written by V18 states this is a deep tissue injury. Will close the assessment and have new assessment with proper staging. Treatment identified foamed silicone three times per week. R91's Wound Assessment Details dated 4/12/25 notes stage 4, slough 20%, heavy serosanguineous drainage, 4.8x 4.8x 1.1. undermining present at 12:00 16cm. Review of Treatment Administration Record January-February 2024. Treatment documented includes Chamosyn moisture barrier to left and right buttock initiated on 7/25/24 and discontinued 4/7/25. Apply sacral wound topically every day and evening for wound care moist to dry packing after sodium hypochlorite solution 2/20/25-4/7/25. On 2/19/25 a Silver alginate foam added to sacral wound. (no treatment initiated documented on 1/21/25) Wound Evaluation and Management Summary dated 1/30/25 documents debridement procedure on R91's sacrum. Wound Evaluation and Management Summary dated 2/6/25 Dressing silicone border apply three times per week for 16 days. Leptospermum honey apply 3 times per week for 30 days. (This treatment is not on the TAR for February) The facility presented Unavoidable Wound Documentation dated 1/24/25, 3 days after identified as stage 3. The facility Pressure Ulcer Policy dated 1/19/22 states the nurse shall describe, document/report the following: full assessment of pressure sore including location, stage, length, width, and depth. The facility Wound Care Policy dated October 2020. Verify there is a physician's order for this procedure.

Based on interviews and records reviewed the facility failed to follow their practice and provide 2 person assist with bed repositioning of a dependent resident. This failure affects one of three residents (R91) reviewed for falls. This failure resulted in R91 falling out of bed when staff turned her and sustained head injury requiring 1 staple to the back of her head. The findings include: R91 is nonverbal and diagnosis include but are not limited to Alzheimer's Disease, Parkinson's Disease, Diabetes, Retention of Urine, Vascular Dementia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. On 4/17/25 at 12:33PM V7, Assistant Director of Nursing, said on 4/5/25 around 6:00am R91 had a fall. V7 said I interviewed staff on Monday, including V20, CNA. V7 said V20 said when doing care and turning R91 she slid from the bed. V7 said R91 was on an air loss mattress. V7 said the nurse was called and there was blood. V7 said R91 was sent to the hospital for evaluation. V7 said R91 returned with 1 staple to the back of the head. V7 said it was a serious injury. V7 said R91 required 2 persons for repositioning, she should have been 2 person assist for repositioning in the bed. V7 said the root cause of R91's fall was the CNA was unable to properly turn the patient. V7 said V20 should have known to use 2 persons. V7 said in-service was done with V20 to ensure V20 uses the proper staff persons. On 4/17/25 at 1:39PM V21, Restorative Nurse, said repositioning in bed is always 2 person assist if the resident is dependent and also if they are 2 person transfer. V21 said I do the assessment quarterly. R91's incident report dated 4/5/25 CNA reported to nurse he was giving CNA care and as he turned R91 on R91 left side R91 slid off the bed. Laceration to the back of head. R91's Progress Notes dated 4/5/25 notes 2 staff persons from ambulance transported resident back to the facility. R91 noted with skin tear on left posterior cephalic, with one staple applied from the hospital. Attempts to reach V20, CNA, on 4/17/25 at 1:04PM and 1:25PM unsuccessful. R91's Restorative Evaluation dated 1/21/25 notes she is dependent with ADL. Assessment and Care plan do not identify 1 or 2 persons for assistance. R91's hospital record dated 4/5/25 notes a laceration repair to the back of her head and 1 staple used.

Based on interview and record review, the facility failed to identify, assess, and develop effective interventions to prevent residents from experiencing unplanned significant weight loss. This affected three of eight residents (R49, R109, and R145) reviewed for weight loss and weight loss prevention. This failure resulted in unplanned weight loss for R49 of 14% in six months, R109 8% in one month, and R145 10% in one month. Findings Include: A. R49 is a [AGE] year old with the following diagnosis: Alzheimer's disease, vascular dementia, hypertensive heart disease with heart failure, and dysphagia. A Nursing note dated 3/9/25 documents R49 refused to eat even though staff attempted to feed. There is no notification the physician was notified of poor appetite. A Nursing note dated 3/10/25 documents R49 is still having a poor appetite. R49 verbalized being hungry but is not eating food. R49 drank 1 cup (4 oz) of ensure for breakfast and lunch. The nurse practitioner was notified. A Nursing note dated 3/14/25 documents staff attempted to feed R49 but R49 refused. R49 verbalized being hungry but is not eating food. R49 drank 1 cup (4 oz) of ensure for breakfast and lunch. There is no notification the physician was notified of poor appetite. A Physician note dated 3/14/25 documents request to follow up by nursing for poor appetite. Plan to provide nutritional supplementation, nutrition consult, and monitor labs. A Nursing note dated 3/17/25 documents the nurse practitioner was made aware of R49 not eating and weight loss. R49 only appears to be gurgling fluids and not swallowing. Order received for labs to be completed tomorrow. A Nursing note dated 3/18/25 documents R49's sodium level was elevated so R49 was sent to the hospital for an evaluation. A Nursing note dated 3/26/25 documents R49 returned to the facility from the hospital. A Nursing note dated 3/27/25 documents R49 still has a poor appetite when staff attempted to feed. A Nursing note dated 3/28/25 documents the nurse practitioner was notified of R49's poor oral intake and no new orders were put in place. A Nursing note dated 3/30/25 documents R49 only had a couple spoons for breakfast and lunch. A Nursing note dated 3/31/25 documents R49 still has a poor appetite and had two sips of thickened ensure. A Nursing note dated 4/1/25 documents the nurse called pharmacy to follow up on the appetite stimulant, but it is not covered by insurance. The nurse practitioner was notified, and the medication was discontinued. A Physician note dated 4/1/25 documents R49 had a poor appetite and refusing meals since arrival. R49 is on nutritional supplementation but an appetite stimulant is not covered by insurance, so it was removed from the MAR. A Nursing note dated 4/2/25 documents R49 was sent to the hospital for pneumonia and heart failure. A Nursing note dated 4/10/25 documents R49 returned from the hospital on hospice. The Dietary/Nutrition note dated 1/19/25 documents the most recent recorded weight was documented as 116.9 pounds. R49 is pureed with super pudding with meals with a supplement of ensure 4 oz three times a day. R49 had an unintentional weight loss related to dysphagia and inadequate energy intake as exhibited by weight loss and documented poor intake. Weights show a 7.5% decrease in three months and an almost 12% decrease in six months. R49's appetite varies from 0-100%. There is an order for daily weights and to notify the physician of weight change per criteria. Appears that different weighing methods are used at times with significant differences between them. The Dietary/Nutrition note dated 2/26/25 documents the most recent recorded weight was 120.2 pounds. This still is considered a greater than 10% decrease within six months. R49's appetite is poor. R49 is only taking sips of ensure per progress notes. No new interventions were put in place to address the significant weight loss for six months. There is no documentation of a March dietary note. A Dietary/Nutrition note dated 4/17/25 documents the most recent recorded weight was 108.6 pounds. This is an unintended weight loss related to dysphagia and inadequate energy intake as exhibited by weight loss and documented poor intake. Weights show a greater than 5% decrease in one month. R49 is now on hospice and intake is very poor. Only taking bites of each meal. Super cereal and super pudding were offered but R49 does not take more than a few bites. Continue plan of care per hospice. R49's weights are documented as follows: 4/10/25 - 108.6 pounds, 3/27/25 - 113.2 pounds, 3/17/25 - 107.4 pounds, 3/15/25 - 126 pounds, 3/7/25 - 127 pounds, 2/20/25 - 120.2 pounds, 2/15/25 - 128.1 pounds, and 1/14/25 - 116.9 pounds. On 4/17/25 at 11:32AM, V5 (Dietitian) stated V5 comes to the facility two or three times a month or as needed when contacted by staff. V5 reported V4 oversees residents on tube feeds or with weight loss concerns. V5 stated R49 was last seen in February. V5 reported R49 is on daily weights for heart failure. V5 stated in February R49 had a 7.5% weight loss from the previous visit due to multiple hospitalization s and diuretic use. V5 reported R49 had a poor appetite for about two months and was only taking sips of the nutritional shake. V5 stated R49 had super puddings twice a day and ensure twice a day in place as interventions but no other interventions were added at that time because R49 was not eating. V5 denied being notified of R49 weight loss for the month of March so R49 was not seen during March. V5 reported if R49 continued to have a poor appetite then staff should have notified V5 to put in other interventions. V5 stated V5 was last in the building assessing residents on 4/8/25. V5 reported additional supplements will be added for R49 on V5's next visit. On 4/18/25 9:12AM, V7 (ADON) stated we asked that one or two CNAs go around the first week of the month to get resident weights. V7 reported one weighing scale per floor is used to ensure accuracy. V7 stated the weights are entered in an excel sheet and sent via email. V7 reported if there is a significant weight loss then V22 will let V7 know and a reweigh will be conducted and if it is still a significant weight loss then V22 will contact V5. V7 stated weekly weights and calorie counts are put in for residents with noted weight loss. V7 reported the nurse will document the calorie count in PCC. V7 stated the physician is notified of the recommendations of the dietitian. V7 reported if here is an issue with weight the dietitian is contacted. V7 stated the weight meetings are performed quarterly and residents are discussed for who is having weight loss. V7 reported V7 goes over the weights for the residents. V7 stated if a resident is losing weight, then weekly and daily weights will be completed if they have medical conditions. V7 stated residents should also be weighed upon readmission to see if there is a significant change in weight. V7 stated more than 5 pounds of weight loss is a significant weight loss. V7 reported it will trigger in the system. It will show in PCC once the weight is entered the system will generate a remark about the weight loss. V7 reported the dietitian will recommend supplements and will be placed in PCC and communicated to the nurses. V7 stated V7 is responsible for talking to the physician about other recommendations besides supplements. V7 reported interventions will also be documented in the care plan and family will be involved to see if they have any suggestions. V7 stated the same case with R49. V7 reported R49 had a poor appetite for about two months. V7 stated R49 would say R49 would want to eat but then not consume any food. V7 reported R49's poor appetite was addressed by V22. V7 stated R49 also had worsening CHF and began having frequent hospitalization s. The Physician Order Summary documents R49 receives a pureed no added salt diet with nectar thick liquids. R49 needs feeding assistance for all meals. A calorie count with all meals for three days was ordered on 2/24/25. The facility did not provide any documentation of a completed calorie count during this investigation. Weekly weights were ordered on 4/10/25 for four weeks. The Medication Administration Record dated 03/2025 documents an appetite stimulant was ordered on 3/31/25 but was not administered due to the medication not being available. An order dated 12/3/24 documents staff need to monitor oral intake and notify if R49 has a poor appetite or decreased oral intake. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status could not be completed because R49 cannot/is rarely understood. Section K of MDS documents R49 had a loss of 5% or more in the last month or 10% or more in the last six months and is not on a physician-prescribed weight loss regimen. Within the last seven days, total calories received are 25% or less than what R49 should be consuming. The Dietary Profile dated 11/10/24 documents R49 has a body mass index of 18.4%. R49 has supplements of ensure 4 or three times a day, super cereal at breakfast and super pudding at breakfast, lunch, and dinner. Appetite is fair but R49 appears underweight. Goal is to improve oral intake to 75% with gradual weight gain desire. The Dietary Profile dated 4/5/25 documents R49 is still taking the same supplements. R49 is documented as having a good appetite. Plan to reassess upon readmission. R49 was sent to the hospital on 4/2/25. The POC Amount Eaten charting dated 01/2025 documents R49's appetite differs from 0-100% eaten with the majority being 51-75%. The POC Amount Eaten charting dated 02/2025 documents R49's appetite varies from 0-75% with the majority being 26-50%. The POC Amount Eaten charting dated 03/2025 documents R49's appetite varies from 0-50% eaten with the majority being 0-25%. The Care Plan revised on 4/11/25 documents R49 has a diagnosis of congestive heart failure. An intervention dated 10/06/23 documents monitor for signs of malnutrition and encourage adequate nutrition. The Care Plan revised on 2/4/25 documents R49 is at increased nutrition risk related to recent significant weight gain, receiving a mechanically altered diet, and currently on diuretic therapy. Interventions created on 2/6/20 document provide and serve ensure 8oz as ordered and monitor intake and record each meal. There are no other interventions documented on the care plan that were added to address R49's significant weight loss or poor appetite. B. R109 is a [AGE] year old with the following diagnosis: Alzheimer's disease, vascular dementia, and diastolic heart failure. A Physician note dated 3/11/25 documents R109's adult failure to thrive is stable. R109 has had an improved appetite per documentation. There is no documentation the physician was notified of the weight loss in March. A Physician note dated 3/18/25 documents R109's adult failure to thrive is stable. Recommendation to add spices and soy sauce to improve taste. A Dietary/Nutrition dated 1/19/25 documents the most recent weight was 127.6 pounds. R109 has had an unintentional weight loss related to variable intake. R109 has had a greater than 5% increase in one month. There is no dietary note for February or March. A Dietary/Nutrition note dated 4/17/25 documents the most recent weight was 116.9 pounds. This is an unintentional weight loss. R109 has variable intake. Super pudding at dinner was added on 4/6/25. An appetite stimulant was also added to promote increased appetite. COVID outbreak on the floor in February which may have contributed to weight loss. April weight was requested. R109's weights are documented as follows: no weight for April, 3/11/25- 116.9 pounds, no weight for February, 1/13/25- 127.6 pounds, 12/11/25- 121 pounds, no weight for November, 10/29/24- 122 pounds, and 10/22/24- 124 pounds. On 4/17/25 at 11:32AM, V5 reported R109 is ordered weekly weights due to heart failure. V5 reported V5 recommended a calorie count in November be completed to see how much R109 was eating. V5 denied ever looking at the calorie count or following up to see if the calorie count was completed. When asked why V5 never followed up with the completion of the calorie count, V5 said, I don't know. I guess I'm stupid. V5 stated V5 was not notified of the weight loss in December but should have been so new interventions could have been put in place. V5 reported R109 was last seen in 01/2025 due to having a significant weight loss from 127 pounds to 116 pounds. V5 stated R109 has not been seen in April yet due to no April weigh being recorded. V5 stated weights should be taken at least monthly or weekly/daily depending on the physician order. V5 reported V5 only recommends supplements, and the physician is responsible for managing medications and adding appetite stimulants. V5 denied needing to make recommendations for the appetite stimulants because the nursing staff should be talking with the physician if they want to get that ordered. V5 confirmed weight loss for R49, R109, and R145 was unintentional. On 4/18/25 at 9:12AM, V7 reported R109 was sent to the hospital and had significant weight loss when R109 returned. V7 stated the food preferences are being address. V7 reported R109 has also had a poor appetite. V7 reported the PCP will start any medications to increase appetite. V7 stated during the COIVD outbreak some February weights weren't done, and the platform scale couldn't be used. V7 stated the facility does have other scales that could have been used at that time. The Physician Order Summary documents R109 is ordered a general mechanical soft diet that needs assistance feeding each meal. A calorie count with all meals for three days was ordered on 2/24/25. The facility did not provide any documentation of a completed calorie count during this investigation. An order on 10/25/24 documents ensure plus twice a day. An order on 4/6/25 documents super pudding to be given at lunch and dinner. An order for weekly weights to be performed was ordered on 10/26/24. The Medication Administration Record dated 03/2025 documents the appetite stimulant was started on 3/18/25. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score could not be completed because R49 cannot/is rarely understood. Section K of MDS documents R49 had a loss of 5% or more in the last month or 10% of more in the last six months and is not on a physician-prescribed weight loss regimen. The Dietary Profile dated 4/6/25 documents the most recent weight as 116.9 pounds. R109 is on ensure plus twice a day and recommendations including super pudding with lunch and dinner. R109's appetite is documented as good. Will continue to monitor intake, labs, and skin with a weight goal for tolerance of current diet with gradual weight gain. The POC Amount Eaten charting dated 03/2025 documents R109's appetite differs from 0-100% eaten with the majority being 26-50%. The POC Amount Eaten charting dated 04/2025 documents R109's appetite varies from 0-100% with the majority being 50-75%. The Care Plan revised 10/10/24 documents R109 is at increased risk for nutrition related to mechanically altered diet with recent significant weight loss. An intervention was created on 10/1/19 to provide supplements as ordered and monitor intake and record each meal. No new interventions were documented after this date. There is a revision dated 4/9/25 but no new interventions are noted. C. R145 is a [AGE] year old with the following diagnosis: malignant neuroendocrine tumors, encounter for gastrostomy, and dysphagia. A Nursing note dated 1/12/25 documents R145 was sent to the hospital for elevated white blood cell count. R145 was not in any acute distress. R145 was admitted with pneumonia. A Nursing note dated 1/28/25 documents R145 readmitted to the facility. A Physician note dated 1/28/25 documents R145 was recently treated at the hospital for infection. R145 also had unintentional weight loss, dysphagia, and regurgitation of undigested food. The Dietary/Nutrition note dated 12/20/24 documents the most recent documented weight as 191.6 pounds. R145 appetite varies from 51-100%. There has been a greater than 10% loss over the past six months. R145 is on a nutritional shake for added calories. No other interventions were added at this visit. The Dietary/Nutrition note dated 1/29/25 documents the weight still as 191.6 pounds. R145 has had an unintentional weight loss due to dysphagia. R145 went to the hospital on 1/12/25 and returned with a G tube. Plan is to continue feedings as ordered. The Dietary/Nutrition note dated 2/17/25 documents the most recent weight as 167.6 pounds. R145 has had an unintentional weight loss due to dysphagia and is now on G tube feeds. This has been a weight loss of greater than 10% in six months. Feedings were increased due to weight loss. The Physician Order Summary documents a dietary supplement for increased calories was added on 4/3/25. An order for tube feeds at 75 mL an hour for 21 hours was placed on 4/3/25. R145's weights are documented as the following: there is no weight documented for April, 3/10/25 - 170.8 pounds, 2/14/25- 167.6 pounds, there is no weight documented for January, 12/17/24- 191.6 pounds, 12/11/24- 183.9 pounds, 12/3/24- 191.6 pounds. On 4/17/25 at 11:32AM, V5 stated V5 started seeing R145 in 2021 but weight loss did not occur until 2024. V5 stated R145 went to the hospital in 01/2025 but V5 was not notified on any weight loss before R145 left. V5 stated R145 was taking supplements of a nutritional shake before going to the hospital. On 4/18/25 at 9:12AM, V7 stated R145 was sent out and R145 has cancer so R145 had a significant weight loss. V7 reported the dietitian would know what interventions were in place for R145. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 15 (no cognitive impairment). Section K documents a weight loss of 5% or more in the last month or 10% or more in last six months that is not a physician prescribed weight loss regimen. The Dietary Profile dated 1/28/25 documents R145 is nothing by mouth and receives tube feedings. Awaiting readmission weight to complete assessment. The Hospital Records dated 1/12/25 document R145 was admitted to the hospital for an elevated white blood cell count. R145 reported a major unintentional weight loss, dysphagia, and regurgitating undigested food. R145 weight upon admission was 172 pounds. The Care Plan revised on 4/5/25 documents R145 requires tube feeding related to dysphagia and swallowing problems. An intervention documented on 2/24/25 documents the dietitian will evaluate quarterly and as needed to monitor caloric intake and estimate needs. There is no other documentation in the care plan addressing R145's weight loss or nutritional risk with interventions. On 4/18/25 at 10:01AM, V22 (Nutrition Support Coordinator) stated V22 responsibilities are entering the weights into the system that are received from the nursing staff. V22 reported if the weights aren't accurate then a new weight is requested. V22 stated V22 also completes the Dietary Profiles, and the facility completes them to show their weight, how their eating is doing and to provide a baseline. V22 reported the facility has had an in-service because the daily and weekly weights are done. We do a quarterly meeting with all the disciplines and weight loss of all residents are discussed. V22 stated the last quarterly meeting was in April and those meeting minutes kept in the binder. V22 reported if the weight loss is still significant then when the dietitian comes in and the report is printed V5 will see who a significant weight loss is and make sure to see those residents. V22 stated V5 comes in a couple times a week. We will discuss weight loss interventions together to see if we can come up with something. V22 reported the recommendations are given to staff verbally and then given to the doctor to see what can be ordered. V22 stated if a resident continues to have weight loss, then we just document what the interventions are in place and continue to monitor. V22 stated all residents who have significant weight loss should be seen by the dietitian. V22 also reported that V22 audits the weight loss report at the end of the month to make sure everyone is taken care of. On 4/18/25 at 1:22PM, V23 (Associate Medical Director) stated the expectation is to implement interventions when weight loss is first noted. V23 reported the weight loss meetings should be conducted to go over the current interventions. V23 stated the dietitian should be involved and see the residents who are losing weight. V23 reported the dietitian is responsible for finding supplements to help with weight loss. V23 stated residents should be weighed monthly but if they are losing weight it needs to be more often to monitor the weight loss and if any other interventions need to be put in place. V23 stated appetite stimulants, calorie counts, and medication reviews can also be added as interventions for weight loss. The policy titled, Monthly, Weekly, & Daily Weights, dated 12/12/18 documents, Statement of Policy: It is policy of [NAME] Manor Rehabilitation and Nursing Facility that all residents will be weighed monthly per State and federal Regulations unless otherwise indicated. Monthly Significant Weight Loss: All residents will be weighed starting the first day of the month. The weights will be obtained by the CNA and nursing staff. Upon completion of the re-weights, the nutrition support manager will record all of the weights into PCC. The nutrition support manager will generate the weight and vitals expectations report, which will reflect a 5% weight change for one month; 7.5% weight change for three months; and 10% weight change for six months. The weight and vital exception report will be given to the registered dietitian monthly for review. The registered dietitian will follow up on any significant weight changes on a monthly basis. Weekly and Daily Significant Weight Loss/Changes: Weekly and daily weight will be obtained by the CNA nursing staff. Nursing will enter weekly and daily weights into PCC. Upon entering weekly and daily weights into PCC, nursing will compare the weight to be entered to the previous weight obtained, if there is significant weight change, nursing at that time will determine if the weight is correct, or if reweight is necessary at that time. Nursing will also contact nutrition support manager to report any significant weight changes. Nursing will also contact the physician related to any significant weight changes and follow any physician orders related to significant weight changes at that time. The policy titled, Nutrition Assessment In-Depth, dated 2021 documents, .The dietitian exercises clinical judgement to determine the best nutrition approach(s) by recommending interventions appropriate to the individual. The policy titled, Interventions for Weight Loss, dated 2021 documents, Policy: Interventions are provided to address a decline in a client's appetite and food intake, a significant weight loss or insidious weight loss trend. Procedure: Nutrition interventions can be initiated by a member of the healthcare team prior to assessment of the client's nutrition status by the dietitian .Pharmacists can help the staff identify medications that alter taste or cause dry mouth, lethargy, nausea, or confusion. Physicians and nurse practitioners help identify causes of anorexia and weight loss.

Based on interview and record review, the facility failed follow the Physician Notification in Change of Condition Policy by not notifying MD (Doctor of Medicine) about medications administered late. This failure affected one resident (R157) of eight residents reviewed for notification. Findings include: On 4-15-25 at 11:03 AM, surveyor observed V3 (Registered Nurse) preparing medication for administration. V3 replied R157's medications were due at 9:00 AM. On 4/17/25 at 09:39 AM, V2 (Registered Nurse) said there is a 1-hour window before and after the scheduled time. The nurse is supposed to write a note on the delay in administration of medication. Depending on the medication you would let the MD know about late administration. On 4/17/25 at 10:08 AM, V1 (Director of Nursing) said there is 1 hour window before and after the scheduled time for administration. For Doxycycline the MD should be notified because it's an antibiotic and the schedule can be re-adjusted. Eliquis and Amlodipine are once a day hence it does not need MD notification. The nurse should make a note explaining why the medication was administered late. V3 did not document any notes explaining late administration or MD notification. V3 is on vacation (after 4-16-25) however facility is trying to reach V3 for interview. On 4/17/25 at 11:06 AM, V3 (Registered Nurse) said R157 medications were due at 9:00 AM. V3 was not available for interview after 4-15-25. Facility made several attempts to contact V3 for interview. Surveyor reviewed R157's Medication Administration record and noted medications administered at 10:58 AM. Surveyor reviewed Nursing Progress Notes and did not see any physician notification notes re: late medications.

Based on observation, interview and record review, the facility failed to coordinate an appointment with the audiologist to remove hardened ear wax from a resident's bilateral ear canals causing an increase in hearing loss for one out of one (R73) resident reviewed for hearing loss in a total sample of 36. Findings Include: R73 is a [AGE] year old with the following diagnosis: Alzheimer's disease, Parkinson's disease, vascular dementia, and paraplegia. The Audiology Progress note dated 12/18/24 documents R73 had a very hard time communicating because R73 could not hear what was being said even while wearing headphones with amplified microphone. R73 reports having poor hearing, but recently, it seems to have gotten worse. Wax was noted in both ears and removal was attempted. In the right ear, about half of the wax was successfully removed. In the left ear, the wax was too hard for any amount to be removed at the time of the appointment. The hearing aid was cleaned and working well. After half of the ear wax was removed from the left ear, R73 told the physician R73 could hear again out of the hearing aid. R73 was happy about this. The deep hardened waxed in both ears is currently making the hearing worse than what it is. Plan to use wax softening drops. Ear wax removal was scheduled for the next visit to attempt to remove more wax once it has been softened by the eardrops. On 04/15/25 at 10:45AM, the surveyor introduced self to R73, and R73 requested the surveyor write down what was being said due to not being able to hear. R73 stated R73 is hard of hearing and has a hearing aide for the left ear. R73 put on glasses to read what the surveyor wrote but told the surveyor the glasses were old and the wrong prescription so R73 could not see or hear what the surveyor was attempting to communicate. On 4/17/25 at 10:50AM, the surveyor tried to speak to R73 but R73 interrupted the surveyor stating R73 could not hear in either ear. The left hearing aide was in place. The surveyor again tried to write down the conversation but R73 told the surveyor that R73 could not see what was written on the paper. On 4/17/25 at 10:57AM, V4 (CNA) stated the nurse puts R73's hearing aides in every morning. V4 reported the hearing aides don't help R73 hear any better and R73 still is hard of hearing with the hearing aide in place. V4 stated staff write out conversations on a piece of paper or type out messages on their phones to communicate with R73. V4 reported staff will also get close to R73's and speak directly into R73's ear. V4 stated R73 can verbalize needs but it is hard for R73 to understand staff. V4 denied being aware of R73's audiology appointments and denied being aware of any excessive amounts of ear wax. On 4/17/25 at 11:02AM, V10 (Nurse) stated R73 wears the hearing aide in the left ear. V10 denied R73 had a hard ear wax build up in the ears and denied knowing about a build up of wax in the past. V10 denied knowing how often the audiologist comes to see residents. V10 stated R73 is hard of hearing and staff communicates with R73 by getting close to R73 and speaking loudly as well as using a thumbs up or thumbs down. V10 reported when a resident has a wax build up, the audiologist will order ear drops to soften the ear wax and then remove the ear wax. V10 denied being aware of how soon the doctor comes after the drops are administered. At 1:33PM, V11 (Infection Prevention Nurse) stated the facility was in COVID outbreak status from 1/4/25 through 3/13/25 when the facility received the last positive. V11 reported the facility does not allow outside physicians to the floor where the outbreak is located. V11 confirmed that outbreak status ends two weeks after the last positive which would have been 3/27/25. At V12 (Former Social Services) stated R73's sister called and wanted an update on the hearing aides. V12 reported some wax was removed the last appointment and still had some wax in the ears that was contributing to the hearing loss. V12 stated R73 got the wax softening ear drops but then the facility was under lock down for COVID for at least two months so the audiologist was not able to see R73. V12 reported V12 didn't call the audiologist to come to the facility after the lockdown was completed. V12 stated the last time the audiologist was in the facility was 03/05/25 but didn't see R73 on that visit. V12 stated the audiologist only sees 10 people per visit and if R73 was seen the last time then R73 will be moved to the end of the list. V12 stated 95% of R73's hearing loss is gone and R73 complained to the facility she couldn't hear any longer sometime before December. V12 reported staff communicates with R73 by writing information down for R73 to read or cupping their hand and yelling into R73's ear. V12 stated V12 last worked in the facility on 4/14/25 and R73 still did not have the wax removed to improve hearing. V12 denied reading the audiology note that R73 should have been assessed by the audiologist on the next visit to the facility. A Nursing note dated 1/16/25 documents R73 tested positive for Covid. The Covid Surveillance Line List documents the facility first went into outbreak status on 1/4/25 and had the last positive test on 3/13/25. Two weeks after the last positive was 3/27/25. A Social Service note dated 4/7/25 documents social services received a call from R73's family member. The family member wanted an update on the hearing aids. The family was informed that the facility was under isolation precautions due to Covid approximately two months. Social services explained that R73 had hardened ear wax that still needed to be removed per December 2024 audiology progress note. The Medication Administration Record (MAR) dated 12/2024 documents R73 received the wax softening drops to both ears two times a day for five days from 12/19/24 through 12/23/24. The Care Plan dated 12/27/24 documents R73 has a problem with receptive communication, is only sometimes able to understand communication from others and has highly impaired hearing abilities. Although an audiologist has prescribed hearing assistive devices, the hearing aids do not help R73 any better with them. R73 is now deaf in both ears. Social services communicates with R73 in writing. An intervention includes refer to ear, nose, and throat doctor to clear wax out of the ears and reevaluate hearing as directed by the physician. The Minimum Data Set (MDS) dated [DATE] documents R73 has highly impaired ability to hear. R73 does use a hearing aid. R73's ability to understand others is documented as usually understands but misses some parts of the message during conversation. Section C of the MDS documents a Brief Interview for Mental Status score as six (severe cognitive impairment). The policy titled, Hearing Impaired Resident, Care of, that is undated documents, Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, all the residents, and visitors. Policy Interpretation and Implementation .2. Staff will assist the resident or representative with locating available resources, scheduling appointments and arrange transportation to obtain needed services.

Based on observations, interviews, and records reviewed the facility failed to accurately assess the number of side rails appropriate for one of one resident's (R137) use of side rails in a sample of 36. The findings include: On 04/15/25 at 11:28 AM R137's bed observed with bolsters, 1/4 side rails upper and lowers in bed and floor matts in the room. 04/15/25 03:16 PM V24, CNA, said R137 is dependent on us, can feed self, she can turn with help, she is confused. V24 said R137 can't get out of bed, her legs restrict her movement. V24 said R137 can't turn without assist from me. 04/15/25 11:28AM quarter rails observed on bed. Top and bottom. 04/16/25 10:33 AM R137 getting turned by V25 and 2nd CNA, IV in left hand, no heel boots, ace bandages on bilateral legs, right knee lidocaine patch. Staff rolled her, R137 not able to turn or grab rail. At the end of care V25 lowered the bed and placed floor matts. V25 raised the lower rails and left the room, the upper rails were left in the up position during care. The 2nd CNA left the room after assisting to reposition R137. On 4/17/25 at 1:39PM V21, Restorative Nurse, said I am not aware R137 has 4 rails on her bed. The family wants us to use that bed. 4/17/24 2:04PM V21, Restorative Nurse, said R137 is supposed to use upper rails, not the lower part. V21 said I don't have an assessment for the bolsters. V21 said the family wants the bed with the bolsters. V21 said I should have an assessment for the bolsters. V21 said the rail and bolster assessments are done quarterly. On 4/18/25 at 8:31AM V7, Assistant Director of Nursing, said on R91's care plan I see intervention to lower the side rails, but it does not say how many to use. V7 said there is nothing in the care plan about the bolsters for R91. Facility presented a document with the delivery date 91's bed was delivered to the facility for use on 5/15/24. Device Observation, Education, Consent form dated 3/4/25 identifies 1/4 side rail to be used as an enabler (no number or pleural use of the word rail). Cognition is confused, impaired decision making, short attention span, short term memory deficit, and diminished comprehension of condition. Unable to recover balance. Mobility is impaired, non ambulatory. Range of motion deficits to all extremities. No behavioral risk. This device is being used for resident's independence and psychological well being as an enabler. Care plan updated. R91's care plan does not include use of bolster or for 1/4 rails.

Based on observation and interview, the facility failed to post Nurse Staffing Data in a prominent area available for residents and visitors. This failure has the capacity to affect all residents. Findings include: On 4-17-25 at 12:50 PM, surveyor toured the 1st floor and was unable to find Nurse Staffing Data verified with V1 (Director of Nursing), V8 (Administrator), and V9 (Receptionist). On 4-17-25 at 1:05 PM, V9 (Receptionist) said she has not seen the Nurse Staffing Data this morning and currently V1 is working on the Nurse Staffing Data at this time. On 4-17-25 at 1:08 PM, V1 (Director of Nursing) said the scheduler is responsible for posting the Nurse Staffing Data and said the scheduler is on vacation at this time. V1 said the Nurse Staffing Data is posted at the Receptionist's Desk and at the 1st floor Nursing Station. V1 said the Nurse Staffing Data explains the staff-to-resident ratios. On 4-17-25 at 1:32 PM, V8 (Administrator) said Nurse Staffing Data shows family and visitors the staff working hours and explains the ratios of staff to residents. The scheduler is responsible for the nurse staffing data is currently on Family Medical Leave of Absence. The Nurse Staffing Data is to be posted at the front desk and Nurse Staffing Data wasn't posted earlier this morning.

Based on interview and record review, the facility failed to follow their Community Privileges and Notice of Resident Rights and Responsibilities policies by not obtaining a doctor's order or consent from the durable Power of Attorney (POA) prior to allowing a resident to leave on pass with a family member. This affected one of three residents (R1) reviewed for pass privilege policy and procedure. Findings Include: R1 was admitted on with the diagnosis of Dementia with Lewy Bodies, Traumatic Brain Injury and Cognitive Communication Deficit. R1's Brief Interview for Mental Status, dated 8/19/24, documents a score of ninety-nine, which indicates the resident was unable to complete the interview with short (recall after five minutes) and long term memory problems. R1's Community survival /risk, dated 8/10/2024, documents: Resident (R1) is new to the facility with Lewy Body and alert times one. It is recommended and agreed upon with her surrogate (V19) that resident is not capable physically or cognitively able to go into the community independently. It is recommended she may go with (V19) (ONLY) with primary care physician (PCP) order. She (V19) is aware that when leaving the property she will need to sign her off the unit and sign her back in on the floor when she returns. Nursing note, dated 10/14/24, documents: R1 accompanied by V19 went out on pass. On 11/12/24 at 2:55PM, V20 (R1's POA) said the facility called and asked when was she going to bring R1 back to the facility. V20 said she had never been to the facility to visit R1 because she lives out of the state. V20 was unable to report who called from the facility. V20 said she never gave permission for anyone to take R1 out on pass. V20 said she feared for R1's safety, and called the police to do a [NAME] being check, because the facility did not know who took R1 out on pass. On 11/13/24 at 11:21AM, V4 ( Social Service Director )said, In order for a resident to go out on pass, they must have a doctor order, completed community assessment and be safe to go out. It is the same protocol for Dementia resident, but the Power of Attorney (POA) must be notified as well. On 11/13/24 at 12:30PM, V1 (Administrator) said R1 was admitted to the facility by V19 (surrogate decision maker). V1 said, We found out about (V20, R1's POA) on 9/7/24. (V20) sent a copy of the POA paperwork with (V20's) name on it on 9/9/24. (V20) was responsible for (R1). On 11/14/24 at 10:13AM, V10 (Social Service) said she was not aware of V20 until a week after R1's admission. V10 said, In order for a resident to go out on pass, the resident must have a doctor order. (R1) did not have a doctor's order to go out on pass. (V20) was not called either time when (R1) went out on pass with (V19). (V19) did not have (V20's) authorization to take (R1) out on pass. (R1) was not verbal upon admission, and would stare at staff when spoken to. Towards the end of (R1's) stay, (R1) could answer yes or no to basic care needs questions. V10 said she was informed V20 should have been the contact person for R1. R1's physician order sheet did not document an order to go out on pass. Out on pass sign out sheet, dated 10/14/24 and 10/22/24, documents: V19 signed out R1 destination outside. Police report, dated 10/21/24, documents: V20 stated V19 took R1 from the nursing home without V20's permission. V20 stated she is R1's POA. The facility called V20 asking when she was going to bring R1 back to the facility. V20 stated she did not have R1 because V20 lives out of state. V20 asked the employee who took R1, and they stated V19. V20 told the police V19 was not allowed to have access to R1. Durable Power of Attorney, notarized on 7/10/16, documents: appoint (V20) to be my true and lawful agent for (R1) and on my behalf to perform all such acts as my agent in his/her absolute discretion may deem advisable, as fully as I could do if personally present. This Power of Attorney is durable and shall not be affected my subsequent disability or incapacity. Expect as otherwise stated in this Power of Attorney, my Agent is given the fullest powers to act on my half. To authorize my admission to a medical, nursing, residential, or similar facility and to enter into agreement for my care. To make or do any of the following (use this space to list any additional powers you want your agent to have): to rectify situation that affect my physical and/or mental health. This power of attorney shall not expire by reason of lapse of time. This Power of Attorney shall be revoked by my giving my agent written notification on the revocation. Community Privileges policy, dated 9/2005, documents: Out on pass order will be obtained. Notice of resident rights and responsibilities policy no date documents: Should a resident be adjudicated incompetent or identified as lacking decision making capacity, the resident's representative (sponsor) shall act in behalf of the resident.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during medication administration by failure to disinfect medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency affects all four (R65, R82, R124 and R150) residents in the sample of 35 reviewed for infection control during Medication Administration. Findings include: On 3/19/2024 at 10:54AM, V12, RN (Registered Nurse), said she will take vital signs of R150 before giving his medications. V12 placed the BP cuff to R150's left arm and pulse oximeter on left index finger. V12 obtained BP 129/81mmhg (millimeter of mercury) and Oxygen (O2) saturation of 97%. V12 did not disinfect medical equipment (BP cuff and oximeter) used with R150 and prepared his medications. On 3/19/24 at 11:10AM, V12, RN, said that she will take vital signs of R124 before giving her medications. Without disinfecting the medical equipment used from another resident, V12 placed the BP cuff on R124's right arm and placed the pulse oximeter on right index finger. V12 obtained BP 128/76mmhg and O2 saturation of 95%. V12 did not disinfect medical equipment used with R124 and prepared her medications. On 3/19/24 at 11:34AM, R65 requested V12, RN, to take her vital signs. V12 took the same medical equipment, without disinfecting it. V12 placed the BP cuff to R65's left arm and pulse oximeter on left index finger. V12 obtained BP112/66mmhg and O2 saturation of 99%. V12, RN, did not disinfect the medical equipment after using it. On 3/19/24 at 11:38AM, V12, RN, said she will take R82's vital signs before giving her medications. V12 took the same medical equipment, without disinfecting it. V12 placed BP cuff around right arm and pulse oximeter on right index finger. V12 obtained BP 125/83mmhg and O2 saturation of 96%. V12 did not disinfect the medical equipment with R82 and prepared her medications. On 3/19/24 at 12:05PM, V12 said she should disinfect the BP cuff and pulse oximeter after each resident. V12 said she just forgot to disinfect it. On 3/19/24 at 12:35PM, V6, Infection Control Coordinator, said medical equipment such as BP cuff and pulse oximeter should be disinfected after each resident use. V6 added, It is a must to clean it, to prevent spread of infection. Facility's policy on Cleaning and Disinfection of Resident-Care Items and Equipment indicates: Policy statement: Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) bloodborne Pathogens Standard. Policy Interpretation and Implementation: 1. The following categories are used to distinguish the level of sterilization/disinfection necessary for items used in resident care: c. non-critical resident care items are those that come in contact with intact skin, but not mucous membranes include blood pressure cuffs 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 7. Intermediate and low-level disinfections for non-critical items include: a. Ethyl or isopropyl alcohol b. Sodium hydrochloride (5.25-6.15% diluted 1:500 or per manufacturer's instructions c. Phenolic germicidal detergents d. Iodophor germicidal detergents and e. Quaternary ammonium germicidal detergents (low level disinfection

Based on the interview and record review, the facility failed to prevent resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 hitting R1 in the face. The findings include: R1 is a [AGE] year-old male with cognition intact as per the Minimum Data Set (MDS), dated [DATE]. R2 is a [AGE] year-old male with moderate cognitive impairment per MDS, dated [DATE]. Record review on reportable documented a physical abuse between R1 and R2 on 8/5/23. On 9/9/23 at 10:30 AM, R1 stated, A long time ago, one guy hit me. He is not a good guy, and he is on the first floor now. My roommate tried to go through the door while I was on his way (R1 and R2 were in wheelchairs). He told me to move, and I said go ahead. Then he hit me in the face. It hurt me so .so. I didn't have any bleeding/swelling. On 9/9/23 at 10:40 AM, V3 (R1's Registered Nurse/RN) stated, I was giving medications to (resident room) when I heard (R1) screaming. (R1) came to the nurse's station, and I met him in front of the nurse's station. (R1) said his roommate (R2) hurt him. When I assessed (R1), there was no injury, bleeding, or swelling. On 9/9/23 at 10:40, V3 added, Both (R1) and (R2) were roommates. On 8/5/23, (R1) said something bad, and (R2) hit him in the face. The police questioned (R2), and he admitted that he hit (R1). (R2) stated he would hit him again if (R1) said bad words. On 9/9/23 at 12:35 PM, V5 (Certified Nursing Assistant/CNA) stated, On 8/5/23, when I heard (R1) screaming at around 9:00 AM, I was in the nurse's station entering data (how much each resident ate, transfer assist/locomotion, etc.) on to my tablet. I saw (R2) punching (R1). I asked him what you are doing and separated them. (R1) was blocking (R2's) way to exit his room. (R2) punched only once, and there was no injury or bleeding. Both residents were wheelchair users. On 9/9/23 at 11:00 AM, R2 was observed in his wheelchair in his room and stated, I don't know why they moved me to the fourth floor from the second floor. My old roommate (R1) called me something st .d, and I hit him in his face. He wasn't bleeding or in pain. Record review on the nursing progress note, dated 8/5/23 at 8:45 AM, documented verbal abuse between R1 and R2, before R2 hit R1's face. The progress note documented no swelling, bleeding, or loose tooth for R1. On 9/9/23 at 10:55 AM, V2 (Assistant Director of Nursing/ADON) stated, The nurse on duty (V3) saw the allegation between (R1) and (R2). She separated them, and we interviewed both residents. (R1) was using a mechanical wheelchair, and it was hard for him to move when (R2) asked him. (R2) was trying to exit his room. (R2) hit (R1) as (R1) was being mean to (R2). It was a one-way hit. The residents shouldn't be hit by another resident. On 9/9/23 at 2:30 PM, V1 (Administrator) stated, We make sure residents are compatible in cognition to share rooms. (R1) and (R2) were roommates for quite a while, and were good for quite some period. (R2) didn't have any history of physical abuse to any other resident. Residents shouldn't hit another resident. The facility presented the Abuse Prevention Program (revised on 2/24/2017) policy statement document: It is the facility's policy to establish protocols to avoid abuse and neglect of any kind to its residents/patients and properly report and investigate allegations presented.

Based on observation, interview, and record review, the facility failed ensure comprehensive, personalized activity care plans were completed for vulnerable residents. This failure applied to two (R13 and R118) of 35 residents reviewed for activities. Findings include: 1. On 04/24/23 from 10:46 AM - 11:10 AM, R13 was in the dining area during activities, sitting in her wheelchair at a table alone, with a puzzle [NAME] sitting on the table in front of her. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her during this time. Observed music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R13 was in the dining area during activities sitting in her wheelchair at a table alone with a puzzle [NAME] sitting on the table in front of her, while several other residents were participating in activities with staff directly across from R13. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her in activities during this time. Observed music playing from the television in the dining area during activities. R13's current care plan, initiated 03/24/2023, documents she is dependent on staff for all activities of daily living, she is unable to express herself and unable to get to and from activities room, husband comes twice daily to visit and assist her to eat, she will continue in the dining area and will listen to music and accept hand massage as needed; interventions also include invite and escort resident to all group activities. R13's care plan does not include information about her interests or personalized interventions based on her past interests or hobbies. R13's Admission Activities Assessment, dated 06/23/2022, documents she was born in Italy, is of Catholic religion, is not interested in puzzles or music, an interview for daily and activity preferences can be conducted, prefers large or small groups, she was formerly a business owner; she was new to the facility and needs a lot of encouragement and assistance due to dementia; she has a private caregiver; activities aides will provide pop and friendly visits daily for socialization; goals include attending/participating in activities of choice (3 times weekly) by next review date; R13's past hobbies and interests were not included in the assessment. R13's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details and notes she is dependent of staff to participate in activities due to dementia. R13's Quarterly Activities Progress note, dated 10/28/2022, documents her last goal included attending and participating in activities of choice (3 times weekly) by next review date; That goal was given when she first came into the building and does not match her capabilities in general; She isn't able to participate in group due cognitive decline and needs total assist in all activities of daily living; she will remain in the dining area and will listen to music and observe while holding props for texture; her husband is also very much involve and if weather is nice he takes her for a stroll outside; her new goal includes being included in the large group and observing group while listening to music when not outside with her husband through next review date. R13's Activities Progress note, dated 3/24/2023, documents her last goal was to be included in the large group while listening to the music when not outside with her husband throughout next review date; she remains in the dining area and listens to music and activity assistant provides hand massage at least once a week; her husband visits twice daily in the morning for breakfast and in the evening for dinner and he spends quality time with her; her husband usually talks to her or feeds her goodies that he brings for her; she is unable to express herself verbally; her new goal includes listening to the music on a daily basis while also getting a gentle hand massage throughout next review date. 2. On 04/24/23 at 10:50 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, with no activity materials for several minutes, while multiple other residents were provided coloring materials and bead mazes. R118 answered yes when the surveyor asked him if he wanted to color. When asked if R118 was offered coloring materials, V17 (Activities Director) stated she will offer them to him now. R118 accepted V17's offer to color. R118 colored with no issue with V17's assistance. Music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, not being engaged by activities staff, and without any activity materials, while several other residents were participating in activities with staff directly across from R118. Observed no staff attempt to engage R118 in activities during this time. Observed music playing from the television in the dining area during activities. R118's current care plan, initiated 01/27/2023, documents he is no longer able to watch and, we don't know if he is even listening to anything that goes around him. R118 is in the dining area around others, he only watches people but is unable to do anything at this point he will only accept hand massage and activities staff will play music for him; interventions also include play music for R118 on a daily basis; provide hand massage once a week or as tolerated. R118's current care plan does not include information about his interests or personalized interventions based on his past interests or hobbies. R118's Admission Activities Assessment, dated 09/17/2019, documents he has some ability to participate in activities; his recreational interests include newspaper sports edition, dogs, spring gardening, sports, watching action/comedy movies, fresh air, always liked to stay active, and votes; his favorite summer activities included planning summer vacation with family, his favorite fall activities included preparing to decorate for Halloween, his favorite winter activities included getting ready for the holidays; he needs encouragement, prefers a small group; during activities he does prefer to spend time observing, and participates in activities of his interest; A lot of encouragement is needed in order to receive participation from resident. R118's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details; and notes his advanced dementia limits his ability to independently choose activities and he requires total assistance to wheel to and from activities. R118's Quarterly Activities Progress note, dated 10/28/2022, documents his last goal included watching television, listening to music and accepting daily news in room through next review date; he is unable to participate in any group activity due to cognitive deficit and physical capability; he is also unable to speak and can't verbalize needs and wants, therefore staff will keep him dry and comfortable every shift; he will continue to listen to music and will hold props for sensory stimuli; his daughters visit resident often and they always bring goodies and clothes for him; his new goal includes watching television, listening to music and accepting daily news in his room through next review date. R118's Quarterly Activities Progress note, dated 4/25/2023, documents his last goal included continuing to bring him to the dining area on a daily basis and activities staff will continue to play music while providing hand massage once a week; R118 is in the dining area for the most part and is unable to participate in the active games and is also unable to follow directions; for the most part we play music for him and provide a hand massage once a week as well as coffee and cookies and assistance with feeding him the cookie; daughter visits monthly and they bring food and favorite drink for him; we will continue with goal and approach. On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/RN) stated from her observation, R13 has not been engaging even with V26 (Family Member) who visits twice daily, and does not have that much interaction. V25 stated there have been some sporadic episodes where R13 talks or interacts a little, but are very rare. V25 stated V17 (Activities Director) would be responsible for preparing the activities care plan. V17 stated R13 is not interactive. V17 stated she did not review R13's records from when she was located on another floor when completing her activities assessment, but she could speak with V26 to create a more personalized care plan for her. V17 stated she has asked V26 about R13's prior interest, and he informed that she never really participated in activities, and her main interests are family and family reunions and family oriented activities. V17 stated R13's and R118's activities care plans should be more personalized. V17 stated she is in the middle of training activities staff and has begun initiating a small group for residents like R13 and R118 who have lower functioning residents. The facility's Care Plans, Comprehensive Person Centered Policy reviewed 04/25/23 states: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will: facilitate resident and/or representative involvement; include an assessment of the resident's strengths and needs; and incorporate the resident's personal and cultural preferences in developing the goals of care. The comprehensive, person-centered care plan will: include measurable objectives; describe the services that are to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well-being; The facility's Activity Programs Policy states: Activity programs are designed to meet the interests of and support the mental and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes independent individual activities and assisted individual activities. (Activities) are considered any endeavor, other than routine Activities of Daily Living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Individualized activities are provided that: reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.

Based on observation, interview, and record review, the facility failed to ensure personalized activities were provided for vulnerable residents based on their interests, preferences and needs. This failure applied to two (R13 and R118) of 35 residents reviewed for activities. Findings include: 1. On 04/24/23 from 10:46 AM - 11:10 AM, R13 was in the dining area during activities, sitting in her wheelchair at a table alone, with a puzzle [NAME] sitting on the table in front of her. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her during this time. Observed music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R13 was in the dining area during activities, sitting in her wheelchair at a table alone with a puzzle [NAME] sitting on the table in front of her while several other residents were participating in activities with staff directly across from R13. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her in activities during this time. Observed music playing from the television in the dining area during activities. R13's current care plan, initiated 03/24/2023,, documents she is dependent on staff for all activities of daily living, she is unable to express herself and unable to get to and from activities room, husband comes twice daily to visit and assist her to eat, she will continue in the dining area and will listen to music and accept hand massage as needed; interventions also include invite and escort resident to all group activities. R13's care plan does not include information about her interests or personalized interventions based on her past interests or hobbies. R13's Admission Activities Assessment, dated 06/23/2022, documents she was born in Italy, is of Catholic religion, is not interested in puzzles or music, an interview for daily and activity preferences can be conducted, prefers large or small groups, she was formerly a business owner; she was new to the facility and needs a lot of encouragement and assistance due to dementia; she has a private caregiver; activities aides will provide pop and friendly visits daily for socialization; goals include attending/participating in activities of choice (3 times weekly) by next review date; R13's past hobbies and interests were not included in the assessment. R13's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details and notes she is dependent of staff to participate in activities due to dementia. R13's Quarterly Activities Progress note, dated 10/28/2022, documents her last goal included attending and participating in activities of choice (3 times weekly) by next review date; That goal was given when she first came into the building and does not match her capabilities in general; She isn't able to participate in group due cognitive decline and needs total assist in all activities of daily living; she will remain in the dining area and will listen to music and observe while holding props for texture; her husband is also very much involve and if weather is nice he takes her for a stroll outside; her new goal includes being included in the large group and observing group while listening to music when not outside with her husband through next review date. R13's Activities Progress note, dated 3/24/2023, documents her last goal was to be included in the large group while listening to the music when not outside with her husband throughout next review date; she remains in the dining area and listens to music and activity assistant provides hand massage at least once a week; her husband visits twice daily in the morning for breakfast and in the evening for dinner and he spends quality time with her; her husband usually talks to her or feeds her goodies that he brings for her; she is unable to express herself verbally; her new goal includes listening to the music on a daily basis while also getting a gentle hand massage throughout next review date. 2. On 04/24/23 at 10:50 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, with no activity materials for several minutes, while multiple other residents were provided coloring materials and bead mazes. R118 answered yes when the surveyor asked him if he wanted to color. When asked if R118 was offered coloring materials, V17 (Activities Director) stated she will offer them to him now. R118 accepted V17's offer to color. R118 colored with no issue with V17's assistance. Observed music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, not being engaged by activities staff and without any activity materials while several other residents were participating in activities with staff directly across from R118. No staff attempted to engage R118 in activities during this time. Observed music playing from the television in the dining area during activities. R118's current care plan, initiated 01/27/2023, documents he is no longer able to watch and, we don't know if he is even listening to anything that goes around him. R118 is in the dining area around others, he only watches people but is unable to do anything at this point he will only accept hand massage and activities staff will play music for him; interventions also include play music for R118 on a daily basis; provide hand massage once a week or as tolerated. R118's current care plan does not include information about his interests or personalized interventions based on his past interests or hobbies. R118's Admission Activities Assessment, dated 09/17/2019, documents he has some ability to participate in activities; his recreational interests include newspaper sports edition, dogs, spring gardening, sports, watching action/comedy movies, fresh air, always liked to stay active, and votes; his favorite summer activities included planning summer vacation with family, his favorite fall activities included preparing to decorate for Halloween, his favorite winter activities included getting ready for the holidays; he needs encouragement, prefers a small group; during activities he does prefer to spend time observing, and participates in activities of his interest; A lot of encouragement is needed in order to receive participation from resident. R118's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details; and notes his advanced dementia limits his ability to independently choose activities and he requires total assistance to wheel to and from activities. R118's Quarterly Activities Progress note, dated 10/28/2022, documents his last goal included watching television, listening to music and accepting daily news in room through next review date; he is unable to participate in any group activity due to cognitive deficit and physical capability; he is also unable to speak and can't verbalize needs and wants, therefore staff will keep him dry and comfortable every shift; he will continue to listen to music and will hold props for sensory stimuli; his daughters visit resident often and they always bring goodies and clothes for him; his new goal includes watching television, listening to music and accepting daily news in his room through next review date. R118's Quarterly Activities Progress note, dated 4/25/2023, documents his last goal included continuing to bring him to the dining area on a daily basis and activities staff will continue to play music while providing hand massage once a week; R118 is in the dining area for the most part and is unable to participate in the active games and is also unable to follow directions; for the most part we play music for him and provide a hand massage once a week as well as coffee and cookies and assistance with feeding him the cookie; daughter visits monthly and they bring food and favorite drink for him; we will continue with goal and approach. On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/RN) stated from her observation R13 has not been engaging even with V26 (Family Member), who visits twice daily and does not have that much interaction. V25 stated there have been some sporadic episodes where R13 talks or interacts a little, but are very rare. V25 stated V17 (Activities Director) would be responsible for preparing the activities care plan. V17 stated R13 is not interactive. V17 stated she did not review R13's records from when she was located on another floor when completing her activities assessment, but she could speak with V26 to create a more personalized care plan for her. V17 stated she has asked V26 about R13's prior interest, and he informed that she never really participated in activities and her main interests are family and family reunions and family oriented activities. V17 stated R13's and R118's activities care plans should be more personalized. V17 stated she is in the middle of training activities staff and has begun initiating a small group for residents like R13 and R118 who have lower functioning residents. The facility's Care Plans, Comprehensive Person Centered Policy reviewed 04/25/23 states: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will: facilitate resident and/or representative involvement; include an assessment of the resident's strengths and needs; and incorporate the resident's personal and cultural preferences in developing the goals of care. The comprehensive, person-centered care plan will: include measurable objectives; describe the services that are to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well-being; The facility's Activity Programs Policy states: Activity programs are designed to meet the interests of and support the mental and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes independent individual activities and assisted individual activities. (Activities) are considered any endeavor, other than routine Activities of Daily Living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Individualized activities are provided that: reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.

Based on observation, interview, and record review, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months for monitoring of side effects while using antipsychotic medication for a resident who was exhibiting signs of sudden, irregular facial movements. This failure applied to one (R18) of five residents reviewed for unnecessary medications in sample of 35. Findings include: R18 is a [AGE] year-old female, with a Diagnoses History includes Alzheimer's, Recurrent Major Depressive Disorder (11/7/2016), Vascular Dementia, Unspecified Psychosis (as of 02/26/2010), Anxiety Disorder (12/27/2007), and Epilepsy who was admitted to the facility 12/01/2005. R18's current physician orders documents an active order effective 02/03/2021 for one 1mg Abilify (Antipsychotic) tablet to be given by mouth once daily related to unspecified Psychosis. R18's April 2023 Medication Administration Record documents she received Abilify daily as ordered from April 1 - 25th. R18's Pharmacist Clinical Review & Recommendations from January - April 2023 does not document any irregularities. R18's AIMS (Abnormal Involuntary Movement Scale), dated 09/16/2021, documents she exhibited minimal facial or oral movements including facial expressions and lip/mouth movements, and mild tongue movements with a final score of 5. R18's AIMS (Abnormal Involuntary Movement Scale), dated 12/07/22, documents she has not exhibited any signs of abnormal facial movements with a final score of 0. There were no other AIMS assessments located in R18's medical records from 09/16/2021 - 04/24/2023, and none provided by the facility during the survey from that time period. On 04/25/25 at 10:40 AM, R18 was smacking her lips, opening and closing her mouth, and thrusting her tongue repetitively. R18's dentures were moving in and out of her mouth. R18's Psychiatric Progress Note Report, dated 04/11/2023, documents she was personally examined by the Nurse Practitioner, was examined and reviewed for side effects and a brief neurological exam was completed to rule out Tardive dyskinesia (a condition where your face, body or both make sudden, irregular movements which you cannot control) with no abnormal movements noted; will titrate or make adjustments to dose of medications based on current symptom progression; no side effects noted, counseling provided on potential side effects, nursing staff advised to call with adverse side effects. On 04/25/23 from 11:46 AM - 12:00 PM, V2 (Director of Nursing) stated she noticed R18 has Tardive Dyskinesia (Abnormal Involuntary Movements) such as her movements with her eyes and sometimes involuntary facial movements. V2 stated R18 has been at the facility for approximately [AGE] years. V2 stated R18 is on psychotropic medication. V2 stated R18 has exhibited the facial movements for approximately more than a year. V2 stated AIMS assessments are conducted every six months, and when there are any changes. On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/Registered Nurse) stated she is aware of R18's symptoms of Tardive Dyskinesia (TD), and has performed an AIMS assessment on her and observed her to have those symptoms as well. V25 stated she believes she observed R18 with these symptoms during the AIMS she conducted in September 2021. V25 stated she is not sure why an AIMS assessment was not conducted every six months for R18, but there were some challenges for completing assessments during COVID. V25 stated R18's signs and symptoms of TD are minimal, and may be on and off, and perhaps may have been unnoticeable during her December AIMS assessment. V25 stated there have been some dose reductions in R18's psychotropic medications from 2018 - current. V25 stated in July of 2018, R18 was taking Abilify at 5mg once daily, then in September of 2018 it was reduced to 2.5mg daily, in November of 2019 the Ability was lowered to 2mg once daily, then in February of 2021 the Abilify was reduced to 1mg daily. V25 stated R18's TD symptoms could potentially have not been present during the time of her December 2022 AIMS due to her dose reductions, but she cannot be certain of that. V25 stated she believes R18's TD symptoms have persisted since identified, and she has been on antipsychotics for a long time. V25 stated the AIMS assessments should be conducted every six months to ensure there is no worsening of R18's TD. The facility's Psychotropic Medication Policy and Procedure revised 07/29/2019 states: It is the policy of the facility that physicians/medical providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. AIMS (Abnormal Involuntary Movement Scale) will be performed on any resident on an antipsychotic on initiation of medication and every 6 months; significant change will be reported to the physician.

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5%. There were 25 opportunities with two errors resulting in an 8% medication error rate observed. This failure applied to two (R83 and R177) of two residents reviewed during the medication administration task. Findings include: 1. On 04/23/23 at 10:12 AM during medication pass observation, V16 (Registered Nurse, RN) was observed preparing R83's Diclofenac gel. R83's MAR (Medication Administration Record) recorded: Diclofenac Sodium External Gel 1% apply to neck area topically four times a day for pain on the neck area apply 2 grams (gms) 4 times a day. V16 squeezed the Diclofenac gel onto her finger and applied to R83's neck area. R83 stated, A little bit more. V16 squeezed more of the Diclofenac gel and spread it again onto her (R83) neck. V16 was asked regarding dose as ordered. V16 replied, I squeezed like a bunch on my finger, its already 2 gms. I should have used the dosing card but I cannot find it. According to Diclofenac Sodium topical Gel, 1% Instructions for Use: Important: Use the dosing card that is inside the Diclofenac Sodium topical gel carton to correctly measure each dose. The dosing card is re-usable. Do not throw the dosing card away. 2. On 04/23/23 at 10:30 AM, V16 was preparing R177's Polyethylene Glycol . R177's MAR documented: Polyethylene Glycol Powder (Polyethylene Glycol 1450) give 17 grams (g) by mouth one time a day. V16 poured the Polyethylene Glycol using the cap, filled the cap at the second line, which was below the top line. V16 verbalized, I used the cap and filled it until this line, not the top line. The back of the Polyethylene Glycol bottle stated in part: Directions in the back of the bottle: Adults and children [AGE] years of age and older: Fill to the top of the bottle cap which will provide the correct dose (17g). On 04/25/23 at 11:59 AM, V2 (Director of Nursing) was interviewed regarding medication administration. V2 replied, Staff needs to follow the 7R's during medication administration - right patient, right dose, right time, right route, right frequency, right medication/drug and right documentation. Nurses must follow the manufacturer's guidelines or specific instructions for medication administration. Facility's policy titled, Administering Medications, revised date April 2019 documented in part but not limited to the following: Policy heading Medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review, the facility failed to transcribe and follow physician orders for wound treatment of a surgical wound for 5 days, and failed to notify the resident representative of the treatment plan to leave sutures in place beyond the usual time frame, for 1 of 1 resident (R2) reviewed for physician orders and notification. Findings include: On 3/31/23 at 10:44AM, V18 (R2's family) said the facility left R2 sutures in longer than they were supposed to, and the sutures were supposed to only stay in for 10 days. V18 said R2 got sutures on 2/14/23 after sustaining a laceration to the right leg when she was being transferred to bed. R2's face sheet shows R2 has diagnosis of pain in left shoulder, pain left knee, atherosclerotic heart disease, heredity and idiopathic neuropathy, obesity, bilateral artificial knee, urinary tract infection, other abnormalities of gait and mobility, other reduced mobility, abnormal posture, history of falling. R2's face sheet denotes R2 has a power of attorney for care. R2 MDS (Minimum Data Set), dated 1/4/23, denotes, in-part, R2's BIMs score of 11 (mild cognitive impairment). On 4/4/23 at 10:27AM, V11 (wound treatment nurse) said R2 sustained a laceration to the right leg during a wheelchair to bed transfer. V11 said R2 saw the wound doctor on 3/1/23, and the wound treatments to the right leg was changed on 3/1/23. V11 said the orders were not initiated until 3/6/23. V11 said the orders were changed to Bactroban and calcium alginate. V11 said Bactroban is an antimicrobial that treats and prevents infections, and calcium alginate is used as an absorbent with there is exudate from the wound. V11 said physician orders should be implemented immediately when ordered. V11 said initiating the wound treatment on 3/6/23, five days after the physician order, was not appropriate when following physician orders. V11 (wound treatment nurse) said the plan was to keep R2's sutures in place longer than usual. V11 said the physician removed several sutures from R2's right leg wound, and the plan was to keep the 3 sutures in place so that the wound would not fail (open). V11 said she did not discuss this with the family, she only informed the family that the wound was stable. V11 said a care plan was not developed for the sutures, there was a plan of care for the right leg wound. Review of R2's wound care assessment and progress note, dated 3/1/23, denotes, in-part, exam, reviewed patients' chart, discussed prognosis and tx (treatment) options with nursing staff and patient, removed all non-productive sutures today, leaving distal 3 present for removal next week. Dressed RLE (right lower extremity) wound with Bactroban, adaptic, calcium alginate and foam island, continue 3x/wk (week) after 0.9% NS( normal saline) and cover with tubi grip and derma saver. Dressed LLE (left lower extremity) wound with Bactroban and foam island, continue 3x/week after 0.9% NS (normal saline) wash and cover with tubi-grip and derma saver. R2's physician order sheet, dated 3/3/23 with start date of 3/6/23, denotes, in-part; apply to RLE (right lower extremity) laceration topically every day shift every Monday, Wednesday, Friday for wound care after 0.9NS (normal saline) cleanse and cover with adaptic, calcium alginate and bordered foam. cover with tubi-grip and derma saver to RLE (right lower extremity). On 4/4/23 at 2:24 PM, V17 (Director of Nursing) said the nurse should follow physician orders when they are received. V17 said it is her expectation that the nurse transcribe and carry out orders before their shift ends. V17 said it is her expectation that a STAT (emergency) order is carried out immediately. On 4/4/23 at 2:35 PM, V20 (wound physician) said he expects the facility to follow any orders that he gives for treatment. V20 said he ordered the calcium alginate because R2 had small drainage to the right leg wound.V20 said the calcium alginate was not vital to treatment, it was for absorption. V20 said he saw R2 on 3/1/23, and R2 did not have any signs of infection to the right leg wound, no redness, no swelling. V20 said he removed the non-vital sutures on 3/1/23, and the plan was to leave the sutures in for a longer period so that the wound did not open up. V20 said R2 had poor circulation, and that would affect wound healing. Facility policy titled Change in a resident's condition or status, denotes in-part our facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the residents medical/mental condition and/or status. Facility policy titled wound care denotes in-part the purpose of this is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician order for procedures. Assemble the equipment and supplies as needed. Dressing material as indicated; antiseptic as ordered.

Based on interview and record review, the facility to follow the Transfer Protocol by not ensuring a safe transfer from wheelchair to bed, which resulted in 1 resident sustaining a skin tear to right leg which required 9 sutures. This failure affected 1 resident of 3 reviewed for transfers (safety). Findings include: Initial Reportable, dated 2-14-23, documents: on 2-13-23 at around 8:40 AM, Certified Nursing Assistant/CNA reported to the nurse on duty that the resident was bleeding from the right leg. Nurse noted a skin tear to her right leg due to transfer. Nurse on duty performed first aid and applied pressure to the site, covered with dressing, bleeding stopped. Called attending physician, received orders to send patient to local hospital for further treatment. Responsible party (POA) daughter was notified. at 2:00 AM, resident came back from ER with dressing to the right lower leg with sutures. Resident is alert and verbally responsive, not in any form of distress. Final Reportable, dated 2-20-23, documents: Conclusion: Interviews from staff that worked on the day of the incident were collected. CNA recalled that the resident put the call light on around 8:35 PM. When the CNA entered the room, the resident asked to be put to bed from wheelchair because she is tired. According to the CNA assigned, he positioned himself adjacent to the bed, removed footrests from wheelchair, and properly transferred the resident from the wheelchair to the bed. As soon as the resident sat on the bed, resident mentioned that the right leg is hurting, When the CNA checked the leg, he noticed a skin tear with bleeding. CNA applied pressure to stop the bleeding, he called the nurse to assess the patient immediately. Nurse performed first aid and pressure dressing immediately, and bleeding has stopped. Nurse called MD and ordered to send to ER via 911. POA informed of the transfer to the hospital. Resident had sutures to the right leg per hospital report. Based on staff interviews, the team determined that R1's skin tear was unavoidable. The cause of the skin tear is due to the bed and patient's fragile skin. The resident's leg was touching the side of the bed during the transfer. Even though the resident is alert enough, (R1) at times can have poor safety awareness. There was enough lighting in the room and environment is clutter-free. Hospital Record, dated 2-13-23, documents: HPI (History of Present Illness): Patient is an [AGE] year-old female who presents to the ED (Emergency Department) with the skin tear on her right leg. Patient states that she is being transfer from a wheelchair to the bed when her right leg was caught. Laceration details: Location: Leg, Leg Location: R lower leg, Length (cm): 9, Treatment: Area cleansed with: Saline, Repair Method: Sutures, Suture Size: 4-0, Number of sutures: 9, Clinical Impression: ED Diagnosis: 1. Fall against object, 2. Laceration of right lower extremity, initial encounter. On 3-1-23 at 11:11 AM, V2 (Director of Nursing/DON) said R1 is alert, oriented , and able to make her needs known; however, she has periods of forgetfulness and has mood swings. R1 will refuse or be uncooperative. V2 was not on duty during R1's accident on 2-13-23 at 8:05 PM. V2 was informed of R1's incident the following morning during morning report. This was immediately reported to the state by V2 when she was informed. V2 said R1 sustained cuts to her right lower leg, which could have been from the wheelchair or from the bed. R1's old bed was removed and replaced with a newer bed with rounded edges. R1 was given skin protectors for bilateral lower legs to provide protection, and staff was in-serviced on proper transfers. On 3-1-23 at 10:42 AM, V4 (Certified Nursing Assistant/CNA) said he transferred R1 from chair to bed. R1 was in the wheelchair wearing a gait belt. V4 removed the wheelchair foot rests, bed was in low position, and bed side rails were down. V4 did stand and pivot transfer. During the transfer, R1 screamed about her leg. V4 put R1 in bed and noted bleeding to R1's left leg. V4 is not sure if the leg was cut from the wheelchair edge or bed side rail. V4 immediately notified the agency nurse. Agency nurse assessed and treated the bleeding immediately. V4 makes sure the legs are not coming into contact with the wheelchair or bed side rails. R1 has a new bed in place. On 3-1-23 at 11:28 AM, V3 (Wound Nurse) said R1 has venous insufficiency (chronic) and diabetes. V3 said R1 has paper thin skin and fibrotic skin. The nature the injury could be due to the edge of the wheelchair, or the edge of the bed. Facility provided a new bed with wounded edges, and facility ensures R1 will use bilateral skin protectors for protection of lowers legs. Transfer Protocol/ Limited Lift Policy, revised June 2021, documents: Statement Policy: It is the policy of [NAME] Manor to attempt to protect both residents/patients and employees from injury in the course of transferring patients/residents.

Based on interview and record review, the facility failed to keep a resident free from being physically abused by another resident. This failure applied to two (R1 and R2) of three residents reviewed for incidents and abuse. Findings include: R1 is a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include: Alzheimer's disease with early onset , dementia in other diseases classified elsewhere, moderate, with other behavioral disturbances, anxiety disorder, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, mild cognitive impairment of uncertain or unknown etiology, homicidal ideations, delusional disorders, irritability and anger, violent behavior, and cognitive communication deficit. R1's MDS (Minimum Data Set), dated 10/13/22, documents a BIMS (Brief Interview of Mental Status) score of 6/15 (indicating severe cognitive impairment). R2 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include: Type 2 diabetes, heart failure, chronic gout, age-related physical debility, hallucinations, major depressive disorder, and need for assistance with personal care. R2's MDS, dated [DATE], documents a BIMS (Brief Interview of Mental Status) score of 14/15 (indicating intact cognition). Facility reported incident between R1 and R2 on 01/05/23, which documented (R1) hit (R2) in the face .(R2) had minimal bleeding of nose and refused to go to the hospital despite being asked three times, therefore doctor ordered X-ray exam of the nasal bones. Per X-ray final report, there was no fracture, dislocation or bony destructive lesion noted. Paranasal air cells demonstrate no specific abnormalities. Prior to the altercation, (R1) had begun to display behaviors of increased wandering in the long hallway and randomly staring sternly at people within his vicinity of view which caused others to be uneasy and frightful and noted to be agitated towards staff when being politely redirected on 01/04/23, therefore attending psychiatrist and Psych NP (Nurse Practitioner) was made aware and orders were to send (R1) out involuntary petition to (local hospital psych unit) for further evaluation. This hospital acknowledged that they will have a bed the next day 01/05/23. Nursing staff continued to closely monitor (R1) and redirect him as needed .Statement of CNA (Certified Nursing Assistant) (V6) noted, when he saw (R1) walking quietly and slowly toward (R2), he immediately hit (R2) in the face unexpectedly. Staff immediately intervened .Nurse stated that (R1) was walking around the dining room when he was told by (R2) to move away from the TV. (R1) became agitated and hit (R2) on the face reported by (CNA, V6). (V6) separated the residents. Nurse immediately went to the dining room and observed (R2) covering her nose. Pressure was applied and bleeding was controlled. Called POA and MD, to send (R1) out via 911. Surveyor review of R1's medical record includes the following documentation, indicating an increase in R1's behaviors: Social Service Progress Note, dated 1/4/23 14:25, It was brought to the attention of the IDT (Interdisciplinary Team) from other family members on the 2nd floor that (R1) randomly stares directly at random residents and may stand to close not respecting usual customary boundaries of space and may randomly walking into rooms in the unit. Progress Note, dated 1/4/23 17:00, Resident was being monitored 1:1 by CNA while waiting to be sent out to behavioral facility, observed resident pacing along the hallway back and forth, going inside resident rooms and touching staff. Writer redirected resident and guided to stay on his room, but preferred to stay at the dinning (sic) area with the CNA. Progress Note, dated 1/4/23 18:10, Observed resident at the dinning (sic) room with CNA being monitored 1:1 by CNA. Progress Note, dated 1/4/23 18:13, Writer received call from (POA), resident responsible party, wanted to speak to the resident, informed (R1) and talked to her, staff stayed by the nurse station while supervising (R1). Progress Note, dated 1/4/23 21:47, Received call from behavioral facility that resident will be admitted in the morning due to bed availability, writer and staff continued monitoring resident for safety. Progress Note, dated 1/4/23 22:49, writer observed resident on his room resting, staff continued providing 1:1 supervision. Progress Note, dated 1/5/23 07:05, at 7.05 Night nurse gave report to this writer that resident hit long hall resident on the nose in the dining room before 7am and she called D.O.N (Director of Nursing) and paged MD. Progress Note, dated 1/5/23 07:15, Night nurse called 911,and 911 team here to pick up, report given to (hospital) ER (emergency room ) staff by night nurse. On 1/21/23 at 4:20PM, V6, CNA, stated, I didn't hear what (R1) said because I was far. I just saw that he walked up to (R2) and bumped her. He wasn't trying to fight or anything. He just went away. I was like I don't know, maybe two or three tables away from him. No, he was not on 1:1. He is very quiet, and he just walks around. He is not normally aggressive; he is very quiet normally .I think (V7, CNA - morning shift) was also there (in the dining room). On 1/20/23 at 12:17PM, V7, CNA, stated on 01/05/23 she arrived to work early, around 6:30AM for her 7AM shift, and so she was in the dining room. She was on the other end of dining room from TV, and had her back to R1 and R2. There was no time to intervene. (R1) is not normally aggressive and was not on any special monitoring or supervision that she was aware of. On 01/20/23 at 2:00PM, V4, MDS Coordinator/Weekend Supervisor, stated, (R1) was on 1:1 supervision after the incident that happened with (R2). I got report from the morning when I came in for 3-11 shift (on 01/04/23) and we continued 1:1 supervision. I assigned one CNA to him. When we have 1:1 I assigned, one CNA to that resident only; if the resident is in the room, the CNA should have a chair by the door and constantly checking what they are doing inside the room; all staff are also made aware for safety of everyone. 1:1 should be walking together, or the CNA could be opposite table sitting in the dining room unless there are other people around; then they should be within 6 feet apart so we can prevent right away from anything happening. Prior to the incident with (R2), I'm not sure if he was on any 1:1. He was already on 1:1 on the 4th - the CNA should be with him in the dining room, on his side. I didn't create a behavior monitoring sheet for him that night because I thought he was going to the hospital. I don't know if they made one on that shift. We do have behavior monitoring sheets that should be filled out. On 01/20/23 at 2:36PM, V5, Social Worker, stated, We are trying to find the most appropriate placement that can meet his (R1) needs. We've been faxing facilities and they aren't accepting him, and we have no idea why they say they can't accept him .Many of the long-term care facilities won't take him because he's young and he has aggressive behaviors. Psych facilities are just not getting back to us. V5 was asked why R1 was not sent to the hospital when it was noted that his behaviors were escalating on the day prior to the incident (01/04/23), and V5 stated, They did an involuntary petition because of him being dangerous. I think that (Social Service Director) was working on trying to get a direct admit for him .Psychotherapy was asked to come see him, and she came to see him yesterday and (Psychiatrist NP) comes in on Wednesdays so they can tweak the medicine, etc. and work with his PCP .(we're) asking (Psych NP) for more frequent visits and asking (psychotherapist) for more frequent visits. We're really trying to find a more appropriate place for him. On 1/21/23 at 2:28PM, V2, DON, stated abuse risk assessments are done upon admission and quarterly. Abuse assessment for R1, with effective date 11/15/22, score is 2, which is indicative of moderate likelihood of previous mistreatment and potential future symptoms related to mistreatment. Additional abuse assessment, dated 01/11/23, scored R1 at a 5, which requires addressing symptoms in resident care plan. Surveyor asked facility to provide any additional abuse assessments and V5 (Social Worker) confirmed these were the only ones available. Care plans for R1 include the following: Created on 03/21/21 The resident is/has potential to be physically aggressive. Interventions last updated 3/21/21, include: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; Assess and address for contributing sensory deficits; COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated.; Monitor/document/report PRN any s/sx of resident posing danger to self and others.; When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Created on 3/21/21 (revised on 10/13/22) Resident has hx of an episode of physical aggression along with agitation- R1 was sent out to ER for safely and other's safety. Resident had physical aggression towards staff member, by putting his hands around her neck while alone in the room. Interventions include: Refer to psych group for medication evaluation and treatment; Resident will be immediately redirected as needed when any inappropriate behavior occurs; Staff will be careful not to put roommate to avoid escalation of his agitation as much as possible. Last updated intervention dated 10/12/22 is to refer R1 to be seen by psychologist. Created on: 10/6/22 R1 demonstrates movement behavior. R1 have (sic) trouble understanding the immediate environment. Symptoms include: Roaming and wandering in and out of rooms. Interventions last updated 10/6/22, include: If R1 goes into another peer's room, redirect .Walk in the same direction as R1. Do not initially try to force: R1 to change direction .Make rounds/room checks per facility protocol to minimize chance of unauthorize leave. Created on: 12/07/22 Potential Risk for Abuse/Neglect Interventions last updated 12/07/22 include: Observe the resident for signs of fear and insecurity during the delivery of care. Take steps to calm the resident and help them feel safe. Review assessment for potential risk factors. Abuse assessment for R2, with effective date 1/19/23, score is 2, which is indicative of moderate likelihood of previous mistreatment and potential future symptoms related to mistreatment. Surveyor asked facility to provide any additional abuse assessments, and V5 (Social Worker) confirmed this is the only one available for R2. Care plans for R2 include the following: Created on 01/17/23 R2 is noted to engage in verbal behavioral symptoms that include screaming at facility personnel, using derogatory language, calling persons fat and needing to go on a diet, declining to take physician prescribed scheduled medications, declining to consume meals, and engaging in isolative behaviors . Interventions dated 01/17/23 include: Use short, direct sentences to help me accomplish the goal. Sometimes there's nothing you can say or do to get me to take my medications and reapproaching me in 15 minutes (or so), will work well to give me another try . Created on 01/20/23 Potential Risk for Abuse/Neglect Interventions created and initiated on 01/20/23 include: Assure the resident that they are in a safe environment with caring professionals. Offer reassurance, reminders, cues, reiteration to reasons for cares in efforts to enhance trust with environment and the caregivers that are present to assist; Review assessment for potential risk factors . Facility policy titled, Abuse Prevention Program, (Revised February 24, 2017) includes: Policy This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by . - Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property - Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; - Identifying occurrences and patterns of potential mistreatment; - Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; . The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals . Definitions The following definitions are based on federal and state laws, regulations and interpretive guidelines. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means . - Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .

Based on observation, interview, and record review, the facility failed to follow their wound care protocols to prevent the development and worsening of pressure ulcers; and failed to consistently implement interventions, monitoring, and bed-linen management care to prevent further worsening and/or development of new and existing pressure ulcers for 5 (R72, R111, R153, R167, and R148) of 12 residents reviewed for pressure sores in the sample. These failures resulted in all 5 residents sustaining avoidable stage 3 pressure ulcers, stage 4 pressure ulcers, unstageable pressure ulcers and worsening pressure ulcers. Findings include: On 3/21/21 at 11:50 AM, survey team requested a wound report from V2 , Director of Nursing/DON who provided a list of current residents with [NAME] (In-House Acquired) pressure ulcers which showed: 1.) R72-Wound identified on January 15, 2022- Stage 3 Sacrum. Present on Admission. (Deteriorating). 2.) R148-Wound identified on Feb. 9, 2022- Unstageable Left lateral malleolus ([NAME]-In House Acquired) + Unstageable Right lateral malleolus ([NAME]-In House Acquired). 3.) R153-Wound identified on Nov. 10, 2021-Unstageable lateral left Foot pressure ulcer. ([NAME]-In House Acquired) + Wound identified on Jan. 20, 2022-Stage 3 Pressure ulcer on Sacrum. 4.) R111-Wound identified on Oct. 11, 2021- Stage 4 Left Gluteus. ([NAME]-In House Acquired). 5.) R167-Wound identified on Jan. 2, 2022- Stage 3 Coccyx. In House Acquired. ([NAME]-In House Acquired). 1. R72 is a [AGE] year old resident admitted to facility on 1/14/22 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Records show on 2/15/22 at 2:03 PM, V35(physician) wrote in part: Skin: No visible lesion or rash .Increased risk for pressure injuries. Continue daily skin assessment, frequent repositioning, offloading heels when in bed, and moisture barrier. Wound care services to follow as indicated. There was no mention of a deteriorating stage 3 pressure ulcer to the sacrum or any mention as to how and when the sacrum pressure ulcer was first discovered and/or status of the wound. On 3/22/22 at 10:30 AM, wound care observations were conducted by V8 (Wound nurse #2) and V12 (Certified Nursing Assistant-CNA). R72 was observed in bed on a blue air mattress lying atop several bunched up linens that appeared dingy and gray. There were 2 other sheets folded several times layered under R72's buttocks and R72 was wearing an incontinence brief. Surveyor asked V12 about the linens on the bed R72 was laying on. V12 stated, Yes they look dirty, but that's how we got them from laundry. I didn't change them this morning because when I got it, there weren't any clean sheets yet. I was going to change her after breakfast. V8 (Wound nurse #2) stated, I don't change the sheets, the CNA's do that but they should not put so many on the bed and it shouldn't be folded up like that under her (referring to R72). V8 continued with the treatment: (R72) has a stage 3 to her sacrum area and it's mostly on one side on the middle of her sacrum and it measures about 0.3 centimeters by 0.1 centimeters by 0.1 centimeters and it's still open so it's still a stage 3. It got bad but it's stable now. Surveyor asked V8 and V12 about a blue sign observed hanging to the left of R72's bed that read Reposition for meals. V12 said, I didn't even notice that. V8 stated, They are supposed to reposition her in bed. Surveyor asked how often this was done, V12 and V8 looked at each other and V8 stated, They should do it at least every two hours. V12 stated, I try but we have a lot of people to do. Surveyor asked when she repositioned R72, V12 stated, I got her up this morning but she was in the dining room until they told me to put her back to bed. 2. R148 was admitted to facility on 11/8/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Braden skin breakdown risk assessment, dated 11/8/21, showed R148 to be at a moderate risk for skin breakdown. A MDS (Minimum Data Set) assessment, dated 11/18/21, showed no pressure ulcers upon admission but at-risk for skin breakdown. There were no skin preventative measures marked to be in place such as turning and repositioning or pressure reducing devices for bed or chair, hydration or nutrition, or any other interventions for potential skin breakdown listed in this assessment. Records show on 2/3/22, V37, Nurse Practitioner, wrote in progress note: Skin: no rash, no ulcers, no [CONDITION(S)]. A facility wound report provided to survey team on 3/21/22 showed on February 9, 2022, R148 had an unstageable left lateral malleolus in-house-acquired pressure sore, and a second unstageable right lateral malleolus that was also in-house-acquired. Records show no hospitalization s since admission to the facility on [DATE]. Review of records showed no nursing record regarding R148's unstageable left lateral malleolus pressure ulcer discovered on 2/9/22, six days after the nurse practitioner wrote her entry of Skin: no rash, no ulcers, no [CONDITION(S)]. On 2/22/2022, V38 (MDS Coordinator) created a care plan for (R148) which reads, (R148) has unstageable ulcer on left lateral malleolus and right lateral malleolus- receiving treatment and followed by wound care. On 3/22/22 at 10:45 AM, wound treatment observations conducted with V7 (Wound nurse #1), V8 (Wound nurse #2) and V11 (Certified Nursing Assistant-CNA) showed R148 in bed lying atop gray and dingy linens that appeared moist with perspiration, and with strong odor of urine. The sheets were crumpled up and slid down from under R148's back. Under the residents buttocks were 2 flat sheets that were folded over several times, and appeared to create an absorbent affect on the resident, but instead were crumpled up under the resident. V11(CNA) stated, These sheets always come up from under her and I always have to slide them back up from her. Those sheets are like that (gray), they come up from laundry like that. I will change them after she eats lunch. Surveyor asked why there were no clean linens provided for R148 in the morning, V11 stated, When I got in this morning (7 AM) there were no clean linens yet from the laundry so I waited till after lunch. V7 (Wound nurse #1) continued with the wound treatment and showed surveyor R148's wounds. V7 stated, She has an unstageable pressure sore on the right malleolus. I don't remember when she got it but it is facility-acquired in-house. I clean it with normal saline and then place Santyl and [MEDICATION(S)] ointment, and then cover it with bandage, and then we put her socks on it and heal protectors. The other wound is on the left malleolus and that is a facility-acquired unstageable wound too with the same treatment. Surveyor asked if R148 had any wounds upon admission, V7 and V8 both replied, She did not have any. Surveyor asked whether R148 was provided any heal lifts or boots to prevent wounds on her lower extremities at the time, V7 stated, No we didn't do that till after she got the wounds. V8 (Wound nurse #2) stated, Sometimes, she refuses to wear them. R148 upon hearing V8's comments, R148 stated to surveyor, I do not refuse to wear boots, that's not true. The boots get hot and I ask to have them to remove them when they get hot, but I never refuse them. After the wound treatment was completed, V8 approached surveyor and stated, I'm sorry I misspoke, she does not refuse the boots, she does request to take them off when her feet gets hot. On 3/23/22 at 3:07 PM, V36 (Wound director) was asked for any pertinent documentation about when wounds are discovered and when her wound team and physician are notified. V36 stated, Nurses should be documenting in the progress notes when they discover any new pressure ulcers. They would document this in the initial admission or readmission notes, and whenever they discover one during care. On 3/24/22 at 2:00 PM, V36 (Wound director) was asked again for any pertinent documentation regarding when a new pressure sore is discovered by nursing staff to prompt the wound doctor and wound team to assess and treat any resident. V36 stated, I'm sorry, all I have is the actual wound assessment and visit. It does not show which staff alerted me to see the patient but I understand what you mean. 3. R153 is a [AGE] year old resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility wound report provided to survey team on 3/21/22, shows R153 with the following pressure ulcers: On 11/10/21, an unstageable lateral left foot was in-house-acquired; and on January 20, 2022, a Stage 3 pressure ulcer to the Sacrum. On 3/23/22 at 11:30 AM, V36 (Wound director) and V7 (Wound nurse #1) showed R153's wound treatment to surveyor. V36 stated, (R153) has a stage 3 pressure ulcer on the sacrum and it was after a hospital back in February and it's stable right now. He has a facility-acquired unstageable pressure sore to the lateral left foot and a sacral pressure ulcer present on admission. Surveyor asked about heel boots for R153, and whether R153 had them prior to the development of the facility acquired foot ulcer. V36 stated, No we provided it after he got them unfortunately. Surveyor asked if R153 was assessed as at high risk for pressure sores when R153 was admitted . V36 stated, Yes because he had a stage 3 in his sacral area when he was readmitted in last month. Records reviewed dispute V36's statement about R153's hospital acquired sacral pressure ulcer. On 2/17/22, R153's readmission assessment created by V39, Licensed Practical Nurse, read in part, discolored scar on coccyx area. Slight redness. There was no documented stage 3 sacral pressure ulcer upon admission on 2/17/22. Wound records found show a January 25, 2022 wound assessment for R153's sacrum as Deteriorating. 4. R111 is a [AGE] year old resident with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility wound report provided to survey team on 3/21/22 showed on 10/11/21 a Stage 4 left Gluteus pressure ulcer to be in-house-acquired. MDS (Minimum Data Set), dated 11/4/21, and current annual MDS, dated [DATE], showed R111 is not on any turning and repositioning program and requiring maximum assistance and 2 person physical assistance to move in bed to off load pressure on her gluteal area and other pressure points. On 3/22/22 at 9:00 AM, V7 (Wound nurse #1) and V8 (Wound nurse #2) showed surveyor R111's treatment. R111 was observed in a extra large bariatric bed with a blue overlay air mattress. The bed was in disarray and with multiple food stains and soiled linens strewn about the bed and under R111's body. V17 (CNA) and V18 (CNA) turned R111 to the left side revealing a large golf-sized hole. Layers of moist linens were bundled up from under R111, and appeared to have food crumbs and urine stains on them. V18 (CNA) stated without being asked, She likes to have all those sheets under her. V7 stated, So (R111) has a stage 4 and it spreads right into her left buttocks as you can see. I'm not sure if she got it here or not. Surveyor asked about the linens observed on R111's bed, V7 stated, There should be a flat sheet and draw sheet but not all of these (pointing to all the linens on the bed). Surveyor asked what interventions the wound team put in place to prevent R111 from obtaining other wounds and healing her existing wounds, V7 stated, We see her every other day and the doctor sees her every Thursday. Surveyor asked what nursing staff should be doing on a daily basis for R111. V7 stated, She should be repositioned often. 5. R167 is a [AGE] year old long term resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility wound report provided to survey team on 3/21/22 showed on January 2, 2022, a Stage 3 pressure ulcer to the coccyx to be in-house-acquired. MDS assessment, dated 12/2/2021, showed R167 assessed as at risk for developing pressure ulcers, and with no unhealed pressure ulcers or injuries at this time. This same assessment showed R167 to have pressure reducing device for his chair and for his bed, nutrition and hydration but no turning or repositioning program to prevent any skin breakdown. A wound evaluation record, dated 1/2/22, showed R167 with Pressure-Stage 3. Body location: Coccyx. New-minutes old. Acquired: in House Acquired. Area: 0.31 centimeters squared, Length 0.81 centimeters, Width 0.53 centimeters. There were no recent hospitalization s found in the records prior to the discovery and/or development of this new coccyx pressure ulcer. V36's wound surveillance list provided to the survey team on 3/21/22 affirms R167's Stage 3 Coccyx pressure ulcer to be in-house acquired. On 3/24/22 at 11:24 AM V33, Medical Director, stated, We do discuss wounds during QA (Quality Assurance) and we did have sort of an explosion of wounds since the pandemic and we've have many residents that have had too much bed rest than we should have allowed, and patients should be repositioned often while in bed or in a chair if they are not capable of doing so. That may be the reason for the amount of facility-acquired wounds. Surveyor asked about specialty mattresses and linen management regarding wounds,V33 stated, Staff should ensure that linens aren't layered up or crumpled up under the resident. This causes undue pressure points. Staff should not over- layer linens and have minimal sheets under the resident. This is something that I inservice the CNA's on as they are the ones that are providing the direct care. On 3/24/22 at 2:00 PM, V36 was asked again if there were any other nursing documentation's for residents with pressure ulcers presented to the survey team that showed when a pressure ulcer was discovered to prompt the wound team and V34 (wound doctor) to treat a resident. V36 stated, I know what you mean but I gave you everything, but it looks like we need to ensure the nurses document this in the progress notes. On 3/24/22 at 2:15 PM, V34, Wound Physician, stated, I round here regularly and I actually have done training for your department (public health) and I oversee all the wound doctors for this company. Surveyor asked about R111, V34 stated, Oh she is very non-compliant and not a nice person. Her husband is worse and he shouts at staff and throws them out. I know she has MS ([CONDITION(S)]) and she is morbidly, morbidly obese if you saw her. She has psoriasis and contact [CONDITION(S)]. Surveyor asked about R167's wound, V34 stated, Well (R167) has [CONDITION(S)] and Alzheimer's disease and a very anxious man with constant hallucinations and he is a fall risk. In fact I think he fell recently. Surveyor asked regarding his wound visits for R167, V34 stated, You'll have to refer to the facility's own protocol on that. I know he needs 1:1 care. Anything else you want to ask? Surveyor asked about the specialty air mattresses in the facility and how they should be made up, V34 responded, It's important that the specialty mattresses be prepared with minimal linens. There should be a non-fitted sheet and just a draw sheet, that's it.' Surveyor asked what the rationale is for this, V34 stated, If there are multiple linens used on the specialty air mattress, it can cause the mattress to lessen the effect of the low air loss mattress to offload pressure on the wound. Facility's undated policy titled Pressure Sores reads, in part, It is the policy of this facility that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Upon admission complete the Braden Scale pressure ulcer assessment tool. This is to assess resident's risk for the development of pressure ulcer. Perform complete body check or head-to-toe assessment on the day of admission to assess for existing skin breakdown or skin conditions and to determine the need for intervention and further re-evaluation and to direct proper plan of care. Perform skin checks during showers and fill out the skin assessment form during showers. The CNA will report to the nurse if any skin issues or skin breakdown are noted during routine daily care such as during peri-care, changing of incontinent pads, changing clothes, etc. The interdisciplinary care plan team will develop a comprehensive plan of care based on the assessments that has been performed and conducted. If a pressure ulcer is present, the wound care team will develop and confer with medical professional to determine appropriate treatment plan based on the assess,meant and clinical condition of the resident. Continuous assessment,ent is done by the wound care team and changes in the plan of care will be made accordingly. Preventative measures such as turning/repositioning, pressure relieving devices, and others as determined by interdisciplinary team will be implemented as written in resident's/ patient's plan of care.

Based on observation, interview, and record review, the facility failed to follow its policy on fall prevention management by failing to revise a resident's care plan based upon individual resident's needs using root cause analysis after each fall incident, and the facility failed to develop new fall interventions to residents who are at risk for falls and had several fall incidents to prevent future fall occurrence. This failure affects four ( R4, R5, R6 and R7) of five residents reviewed for fall prevention management. As a result of this failure, R4 fell sustaining a cut to R4's left eyebrow, requiring sutures. Findings include: 1. R4 was admitted on [DATE], with admission fall assessment indicating a moderate risk for fall. R4 has diagnosis listed in part: [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting left non dominant side, [CONDITION(S)], Muscle Weakness, Lack of Coordination, Reduced Mobility. Minimum Date Set (MDS) assessment, dated 7/12/21, indicated she has Brief Interview for Mental Status (BIMS) score of 15 ( alert and oriented x 3). R4 needs extensive assistance of 2 persons for bed mobility and transfers. R4 needs extensive assistance with 1 person assist for Locomotion. R4 uses wheelchair for mobility. R4's Fall Care plan, initiated on 7/5/21, indicated : At risk for falls related to impaired mobility due to [CONDITION(S)]. Care plan interventions were not updated after the fall incidents on the following dates: 7/14/21 and 7/31/21. Fall incidents: 7/14/21 at 8:30am, heard R4 calling for help from R4's room. Observed her sitting in front of R4's recliner. R4 stated R4 tried to lean forward to pick up things from the floor and slipped from R4's recliner. 7/31/21 at 8:25am, Certified Nurse Assistant (CNA) reported R4 is on the floor. Observed R4 sitting on the floor leaning on R4's side of bed. R4 stated R4 was sitting on the edge of the bed while eating, then started to slide towards R4's left side then fell off the bed. Noted moderate bleeding as R4 has cut about ½ inch to R4's left eyebrow. Noted about 1-inch x 2 inch bump on R4's left side of head. Pressure applied to stop bleeding and cold compress on bump. R4 is alert and oriented x3, verbally responsive, able to move all extremities with R4's left side weakness. R4 complained of mild pain on left shoulder and left lower leg. R4 was given pain medication as ordered. R4 was sent to the hospital as ordered and family was notified. R4 returned to the facility after sutures done to the left eyebrow. Facility did not report injury to IDPH. V1, Administrator, and Fall coordinator/Nursing Supervisor stated they only report to IDPH if resident has fracture and subdural hemorrhage. 2. R5 is admitted on [DATE], with admission fall assessment indicated moderate risk for fall. R5 has diagnoses listed in part: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant side, [CONDITION(S)], [CONDITION(S)], History of Falling, Muscle Weakness, Gait and Mobility Abnormality, Unsteadiness on feet, Lack of Coordination. Minimum date Set ( MDS) Assessment, dated 7/17/21, indicated R5 needs extensive one-person assistance in bed mobility, transfer, ambulation/locomotion. R5 uses walker and wheelchair for mobility . R5 has Brief Interview for Mental Status (BIMS) score of 7 out of 15. R5's Fall Care plan, initiated on 7/10/21, indicated: R5 is at risk for fall due to unsteady gait, [CONDITION(S)] and history of falls . Care plan interventions were not updated after numerous falls incident on the following dates: 8/6/21, 8/8/21, 8/10/21, 8/28/21 and 8/31/21. Fall incidents: 8/6/21 at 4:30pm, R5 found lying on the floor next to his wheelchair and bed. He unable to explain what happened, R5 stated I just fell . 8/8/21 at 6:30pm, CNA reported to nurse R5 was found lying on his back in the dining room beside his walker. Assisted back to chair with 2 staff after assessment. R5 unable to give description of what happened. 8/10/21 at 6:15pm, observed R5 walking back to his room with walker and went off balance and fell . R5 is leaning by the bathroom door. Assisted to his wheelchair and back to his room with 3 persons assist after assessment. 8/28/21 at 12:05am, reported to nurse R5 was on the floor. Observed him lying on floor mat in a supine position, on the right side of the bed. R5 verbalized R5 wanted to go to the bathroom. 8/31/21 at 3:30am, CNA reported R5 was on the floor. When nurse came to the room, R5 was already up. Assisted R5 back to bed after assessment. R5 stated R5 just went to the bathroom. 3. R6 is admitted on [DATE], with admission fall assessment indicating high risk for fall. R6 has diagnoses listed in part: [CONDITION(S)], Repeated Falls, Unsteadiness on feet, Difficulty Walking, [CONDITION(S)] with Behavioral disturbance. Minimum date Set ( MDS) Assessment, dated 7/20/21, indicated R6 needs extensive one-person assistance in bed mobility, transfer and locomotion. R6 uses wheelchair for mobility. R6 has Brief Interview for Mental Status (BIMS) score of 15. R6's Fall care plan Care plan indicated: R6 is at high risk for falls related to agitation, and other behaviors, gait/balance problems, history of falls, incontinence and disease process. R6 has had an actual fall with minor injury related to poor balance and unsteady gait. Care plan interventions were not revised/updated after each fall on the following dates: 4/20/21, 6/30/21, 7/6/21, 7/21/21, and 7/24/21. Fall incidents: 4/20/21 at 12:00pm, found R6 on the floor on right side lying position. Found a bump on the right side of the forehead. R6 stated R6 bent down to pick up paper from the floor. 6/30/21 at 6:15pm, Nurse observed R6 pushing R6's wheelchair in the hallway, R6 suddenly reached for the siderail on her left side and started lowering herself to the floor and lay down. R6 was assisted back to R6's wheelchair. R6 unable to explain what happened. 7/6/21 at 3:30pm, CNA reported R6 was sitting on the floor. Observed R6 sitting on the floor by R6's toilet, leaning on the wall. R6 stated R6 attempted to transfer R6 but lost balance and fell on the floor, hitting R6's head on the wheelchair armrest. 7/21/21 at 6:30pm, R6 heard calling for help from R6's room. Observed R6 lying on R6's right side facing the bed. R6 was assisted back to the wheelchair after assessment. R6 refused going back to bed. R6 unable to explain what happened. 7/24/21 at 6:10pm, CNA observed R6 lying on the floor in front of the closet with wheelchair on R6's left side. R6 was assisted back to wheelchair after assessment. R6 stated R6 sat on the floor. 4. R7 is admitted on [DATE], with admission fall assessment indicating high risk for falls. R7 has diagnoses listed in part: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, [CONDITION(S)], Difficulty walking, limitation of activities due to disability. Minimum date Set ( MDS) Assessment, dated 7/18/21, indicates R7 needs extensive two-persons assistance in bed mobility. R7 needs extensive assistance with one-person assistance in transfer and locomotion. R7 needs limited one-person assistance in ambulation. R7 uses a walker and wheelchair for mobility . R7 has Brief Interview for Mental Status (BIMS) score of 13. R7's fall care plan, initiated on 7/11/21, indicates: R7 is risk for fall related to left sided weakness, gait impairment, psychoactive use and [CONDITION(S)]. Care plan interventions were not revise/update after each fall on the following dates: 8/2/21, 8/9/21 and 8/22/21. Fall incidents: 8/2/21 at 4:10pm, R7's roommate reported to CNA R7 was on the floor in the bathroom. CNA went to the room and observed R7 sitting on the floor in front of the toilet. R7 stated R7 went to the bathroom and saw toilet paper on the floor and bent down to pick it up. When R7 lost her balance, R7 sat on the floor. 8/9/21 at 1:10am, reported by CNA R7 was on the floor in her room. Observed R7 laying on R7's left side on the floor. R7 stated R7 wanted to get something out of the drawer. R7 stated R7 knew nothing would have happened if R7 did not get up alone. R7 denied pain. Observed bruise on left hand dorsal/back side. 8/22/21 at 4:15pm, heard R7 calling for help. Observed R7 on the floor. R7 stated R7 was walking, and R7 wanted to sit on the bed, but slid down on the floor. On 9/1/21 at 9:20am, surveyor reviewed fall incident with root cause analysis and fall care plan with V4, Fall coordinator of R4, R5 and R6. Records indicated fall care plan of 3 residents who had several falls were not updated. V4 stated after each resident's fall incident, investigation/ root cause analysis of the incident is done, and the individualized care plan is updated based on root cause analysis. New intervention is implemented to prevent future falls. V4 stated she does the root cause analysis, but V4 is not responsible for updating the care plan. V24 is the one updating the fall care plan after it was discussed in morning meeting. On 9/2/21 at 11:07am, V24, MDS/Case manager, stated he is responsible for updating the fall care plan. He is also responsible for infection control program. He is the infection Coordinator of the facility, and they had a COVID outbreak with an employee last month, and V24 got busy. V24 also works on the unit if needed. V24 works almost 50% on the unit as floor nurse for the last 1 and ½ months. V24 acknowledged not V24 was not able to update/revise the care plan of 4 residents after fall incidents due to V24's other responsibilities. Facility's policy on Fall Management Program documents: provides an environment that is free from accidental hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Procedure: h. Resident's care plan will be updated as necessary by the MDS/Care Plan/Case Manager based upon individual resident's needs. 4. The safety committee will conduct root cause analysis and will use date to analyze risk factors such as environment hazards, need to educate the staff, need to revise resident's plan of care, among others. Facility's policy on Fall Risk Management and Intervention : Procedure: 8. New intervention will be initiated and will be care planned. Facility's policy on Fall Prevention Committee: Resident who are considered at risk for falls are identified to ensure that residents are provided a safe environment and resident are identified as at risk for falls. Procedure: 3. Resident's plan of care will be updated as necessary.

Based on observation, interview and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding isolation of COVID-19 residents related to cohorting of COVID-19 residents, ensuring signage for the specific use of PPE (personal protective equipment) was posted, and ensuring staff wore the appropriate PPE to prevent the spread of COVID-19. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to 6 of 13 residents (R23-R28) reviewed for infection control in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility began receiving positive COVID-19 results. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility roster, dated [DATE], showed 5 residents are COVID-19 positive and 10 residents are listed as PUI's, patients under investigation for COVID-19 due to exhibiting COVID-19 symptoms, being a new admission to the facility, or being exposed to a resident that is COVID-19 positive. A facility form, dated [DATE], showed as of [DATE], 72 residents and 35 staff members had tested positive for COVID-19. The form also showed 12 residents with COVID-19 had expired. 1. On [DATE] at 9:00 AM, V2, Director of Nursing/DON, stated the facility's designated COVID-19 unit was located on the fifth floor/memory care unit. On [DATE] at 9:30 AM, the initial tour of the fifth floor memory care unit showed a central nurses station with 2 small hallways and a central dining area to the right of the station. Thirteen residents were seated in the central dining area. Six of the residents had masks on. Nine residents had no mask on. Two residents were seated in wheelchairs in the hallways on the right side of the unit, one with a mask on, one resident without a mask. To the left of the nurse's station was a long hallway (COVID-19 unit), separated by double doors. The left door of the double doors was propped open with no isolation signage noted on the doors. On [DATE] at 9:35 AM, V15, Registered Nurse (RN), pointed at the hallway with the open double doors and stated, Behind those doors is our designated COVID unit but this floor is also our memory care unit. All of residents up here have dementia so they either wear masks, refuse to wear masks, or eat the masks. We also have residents that wander up here. On [DATE] at 9:40 AM, an initial tour of the designated COVID-19 unit was completed with V16, Activity Director, and V17, RN. The door to the COVID unit remained propped open. No isolation signage was noted on the doors entering the unit. No PPE (personal protection equipment) or isolation cart was noted outside of the unit. When V16 was asked for PPE to wear on the COVID unit, V16 stated, I have to go get you some. You need to wear a blue isolation gown, an N95 mask, and eye protection on the unit. If you go into a COVID positive room, you need to put a surgical mask over your N95 and remove the surgical mask and blue gown before you leave the room. The doors to the unit should be closed. We need a sign on the doors too. V16 walked down the hallway of the COVID unit to obtain a blue isolation gown for this surveyor to wear during the initial tour. This surveyor, V16, and V17 then entered the COVID-19 unit. It was noted that V16 and V17 did not don blue plastic protective gowns prior to entering the unit. Prior to entering the unit, it was also noted that V17, RN, was wearing a surgical mask over her N95 mask. When V17 was asked when she should change her surgical mask, V17, RN, stated, We change our surgical masks every hour. On [DATE] at 9:45 AM, upon entrance to the COVID-19 unit, R23 and R24 were seated in their room with the door open. R23 and R24 wear not wearing masks. No isolation sign was noted on the door to their room. The door to R29's room, immediately next door to R23 and R24's room, had an STOP sign on the door. When V16, Activity Director, was asked why there was no isolation sign on the door to R23 and R24's room, V16 stated, The resident in room (R29) is currently COVID-19 positive. (R23) and (R24) are COVID-19 negative. (R23) last had COVID in [DATE] and (R24) had it in [DATE]. They (R23 and R24) should have the door to their room closed or at least have masks on .We have some COVID-19 negative residents on the COVID unit too. I think we currently have 5 or 6 COVID-19 positive residents along with 3 or 4 residents that have either never had COVID or had COVID a long time ago on the unit. Upon continuation of the tour of the COVID unit, it was noted the COVID-19 positive residents were not in a separate designated area of the unit but spread throughout the unit. Some COVID-19 residents were in rooms right next to or across from rooms containing COVID-19 negative residents. On [DATE] at 10:00 AM, V17, RN, stated she was the assigned nurse caring for the residents on the COVID-19 unit which included both COVID-19 positive and COVID-19 negative residents. When V17 was asked why COVID-19 positive and negative residents weren't on separate units or why the COVID-19 positive residents weren't clustered together in rooms towards the end of the hallway of the unit, V17 stated, I don't know. A fifth floor facility map, dated [DATE], showed 6 COVID-19 negative residents (R23-R28) residing on the designated COVID-19 unit of the facility. R25, R26, and R27 had never been diagnosed with [REDACTED]. R24 was last diagnosed with [REDACTED]. R28 was last diagnosed with [REDACTED]. The map showed 5 COVID-19 positive residents (R21, R22, R29, R30, R31) residing on the COVID unit. On [DATE] at 2:15 PM, V14, Infection Preventionist (IP), stated R23-R28 were currently COVID-19 negative residents residing on the COVID unit. V14 stated R25-R27 had never been diagnosed with [REDACTED]. When V14 was asked why the COVID-19 negative residents were not separated from the COVID-19 positive residents, V14 stated, When don't have enough staff or rooms to move those residents. We have not moved the negative residents (R23-R28) off the unit because they have dementia and wander so we just assume they have already been exposed to COVID-19. V14 stated the doors to the COVID unit should be kept shut to prevent the dementia residents on the floor from wandering onto or off of the COVID unit. V14 stated an isolation sign should be posted on the doors leading into the COVID unit. V14 stated, When entering the COVID unit, staff should don a blue disposable gown, N95 mask, and eye protection. Surgical masks are placed over N95 masks when entering a COVID-19 positive room and must be removed before exiting that room. The blue disposable gown should be taken off before exiting the unit. PPE should be available in a cart located outside the door of the unit. If staff see other staff or contracted staff not wearing the proper PPE, they are to correct that staff immediately. On [DATE] at 11:30 AM, V12, Infectious Disease Nurse Practitioner, stated, Ideally, COVID-19 negative residents should be separated from COVID-19 positive residents but we don't have enough staff to open up a separate COVID unit .The doors to the COVID unit must be kept closed because we have dementia residents that wander and don't wear masks on that floor. If the doors to the COVID unit are open and a resident wanders onto or out of the unit, we aren't containing [MEDICAL CONDITION] . 2. R9's Admission record, printed on [DATE], showed R9 was admitted on [DATE]. R9's physician's orders [REDACTED]. On [DATE] at 9:30 AM, R9's room had a stop sign on the door and an isolation cart next to the door way. R9'S doorway had no designation of what type of isolation R9 was on. V24 (Phlebotomist) was standing close to R9 in his room. R9 was positioned in a wheelchair between the rooms 2 beds. V24 had on a white lab coat with no disposable gown over the lab coat. V24's eye protection was safety glasses located on the back of his head. V24 had a phlebotomy tote inside R9's room which held blood drawing equipment. When V24 left R9's room he did not wipe down the phlebotomy tote, and there were no disinfection wipes present in R9's doorway. During V19's interview, V24 left R9's room, reported to V19 that R9 did not want her blood drawn, and left down the hall. V24 still had his eye protection (safety glasses) on the back of his head. V19 did not stop and re-educate V24 to put his eye protection on correctly before V24 walked down the hall. On [DATE] at 9:35 AM, V19 stated R9 was admitted yesterday ([DATE]), and is on a 14 day quarantine isolation. V19 stated quarantine isolation the same as COVID-19 isolation which needs personal protective equipment (PPE) of a N95 mask (for direct care), a gown, eye protection, and gloves when entering a room and interacting with a resident. On [DATE], at 1025 AM, V23, Certified Nursing Assistant, stated residents who are new admissions get put on a 14 day quarantine which uses full PPE before entering the room. The PPE includes mask, gown, eye protection, and gloves. V23 stated any equipment coming out of an isolation room needs to be disinfected before leaving the room. On [DATE] at 10:20 AM, V24 walked off the elevator onto the 5th floor with the same white lab coat on, and carrying the phlebotomy tote. The facility's Lab Draw list, printed on [DATE], showed 4 residents R4 and R29-R31 were seen by R24 for lab draws. R9 resides on the second floor, and R29-R32 resident on the 5th floor. The facility's undated COVID-19 policy stated .In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected [DIAGNOSES REDACTED].Provide the right supplies to ensure easy and correct use of PPE .Post signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE. The facility's Disinfecting Durable Medical Equipment reviewed on [DATE] showed All DME (Durable Medical Equipment) should be cleaned before and after each use. The Centers for Disease Control's website, updated on [DATE], showed the PPE needed for suspected or positive COVID patients include N95, eye protection, protective gown, and gloves. The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy: 1. In-service was given to all departments, outside vendors, attending physicians, NPs (nurse practitioners), and PAs (physician assistants) on facility notification and practices related to infection prevention and control including but not limited to contact isolation, droplet isolation, and donning and doffing of PPE to include in-service with contracted service phlebotomist (completed [DATE]). 2. In-service was given to all departments on proper placement of infection related postings, location and content of isolation carts and supplies. Signs will be posted outside the COVID-19 unit and outside the room of residents with confirmed C-19 and PUIs (completed [DATE]). 3. Facility added barrier screen to end of COVID area to separate COVID recovered and COVID positive residents (completed [DATE]). All COVID negative residents were moved to negative COVID area on [DATE]. In-service was conducted to all nursing managers and Infection Preventionists on cohorting residents. 4. The facility infection preventionist and nurse managers will make infection control rounds (at least 5 days per week) to confirm proper infection control and isolation standards are in place. The infection preventionist and nurse managers will review new, ongoing, and resolved infections daily as part of communication processes. 5. Infection control standards and practices will be addressed during all employee orientations. Random QA observations will be done to monitor that there is no breach in infection control practices and to re-educate on point of observation. A calendar of infection control education has been established to cover 12 key areas throughout the calendar year. Infection control related competencies will be completed upon orientation and at least annually. Hand sanitizer dispensers will be installed in all resident rooms. 6. In addition, all staff will receive education on the facility infection control processes, including those related to COVID-19. Education will focus on appropriate hand hygiene. 7. Plan established to ensure COVID-19 positive residents are separated from negative residents. 8. The facility DON and Infection Preventionist will be responsible for periodic rounding and communication with physicians and staff. In addition, they will continue to educate and consult with all staff members. Ongoing process and benchmarking will be reported to the Quality Assurance Committee during regularly scheduled reports and meetings.

Based on observation, interview, and record review, the facility failed to identify a resident's correct fall risk, failed to use a gait belt during transfer of a resident as per their care plan fall interventions, failed to adequately monitor a resident at risk for falls, and failed to revise and implement resident specific fall interventions for two (R1, R4) of three residents reviewed for accidents. This facility failure resulted in R1 sustaining a [MEDICAL CONDITION] requiring sutures, a fractured left clavicle, and subarachnoid hemorrhage (bleeding in the brain) that necessitated hospitalization , and in R4 sustaining a right dorsal hand skin tear and a fractured left hip. Findings include: 1.) R1 is a [AGE] year old, verbal resident with [DIAGNOSES REDACTED]. R1 is alert and oriented, but forgetful. On [DATE] at 11:22 AM, surveyor observed R1 seated in her wheelchair in the dining area. Surveyor asked R1 about her fall on [DATE]; R1 said she only remembered being on the floor and saying, get me up! They don't want me to go to the bathroom without someone with me. But I cannot go in my diaper, I need to use the toilet. If I use the buzzer, I can wait at least a half hour before someone comes to help. I have a really weak bladder. R1 asked V15 (Certified Nursing Assistant/CNA) to take her to the toilet. V15 assisted R1 to a standing position (no gait belt was applied) and seated her on the toilet. V15 told R1 she would come back and help her when she was done, and left R1 alone in the bathroom. V15 returned and assisted R1 off of the toilet and back into her wheelchair (no gait belt was applied). On [DATE], surveyor reviewed R1's medical records: R1 fell on [DATE] and on [DATE] in the bathroom after attempting to transfer self (no injuries were sustained), fell on [DATE] in her room sustaining a [MEDICAL CONDITION], fractured left clavicle and subarachnoid hemorrhage (was hospitalized four days), and fell on [DATE] in her room (no injury sustained). R1 was alone during all her falls, and all falls were unwitnessed. [DATE] Fall Risk assessment notes R1 at 11 (moderate risk - had fall on [DATE]). On [DATE], R1 assessed at 9 (moderate risk - had fall on [DATE]); On [DATE], R1 assessed at 10 (moderate risk - had fall on [DATE] with significant injuries); on [DATE] R1 assessed at 19 (high risk); on [DATE], R1 was assessed at 21 (high risk - had fall on [DATE]). [DATE] MDS (Minimum Data Set) Section G (Mobility) indicates R1 needing extensive, one person physical assistance for bed mobility, transfers and toileting. (R1 fell on [DATE]; MDS [DATE] remains at one person physical assistance). [DATE] MDS G (completed after [DATE] fall with significant injuries) indicates R1 needing extensive, two person physical assistance for bed mobility and transfers, and remaining with extensive, one person assistance for toileting. [DATE] MDS G indicates R1 needing decreased assistance, requiring extensive, one person physical assistance for bed mobility, transfers, and toileting (R1 fell on [DATE] in her room). Care plan documents focus area R1 is at risk for falls, with interventions including: Be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance. Ensure wearing appropriate footwear when ambulating or mobilizing in wheelchair. PT evaluate and treat as ordered or PRN (as needed). Review information on past falls and attempt to determine cause of falls. Educate resident/family/caregiver/IDT (interdisciplinary team) as to causes. Focus area: The resident has had an actual fall with no injury/minor injury related to poor balance, unsteady gait with interventions: Continue interventions on the at-risk plan (no information documented of what the actual interventions are on the at-risk plan). Focus area: Restorative Ambulation Program: R1 has limited mobility . due to bilateral lower extremity weakness . poor standing balance .and includes intervention. Use gait belt, obtain permission from the resident before applying. During interview on [DATE] at 11:50 AM with V2 (Director of Nursing/DON), V3, and V4 (both MDS Coordinators), surveyor asked what does at-risk fall interventions mean on R1's care plan? V2 said the at-risk interventions are those that are named on the care plan's first page. Surveyor asked V2, V3 and V4 if it was an appropriate intervention for a resident with a [DIAGNOSES REDACTED]. All agreed it would be difficult to expect a resident with dementia and memory issues to remember to ask for assistance. Surveyor asked what was considered a prompt response time frame. V2 stated it means Immediately. Anyone can answer a light. I would consider it a prompt response if a call light was answered within five to ten minutes. Surveyor informed V2, V3, and V4 R1 said it can take at least a half an hour for assistance. V2 stated we know R1 is a fall risk, and we should have prioritized her to have assistance more quickly. Surveyor reviewed with V2, V3, and V4, the multiple fall risk assessments, MDS Section G sections, and current care plan for R1. Surveyor asked V2, V3, and V4 if R1's current care plan was accurate and progressive in its fall interventions to prevent further falls, considering R1's fall risk assessments increased from moderate to high risk, yet her MDS Section G assessments decreased her from an extensive, two person physical assist for transfers to one person physical assistance, and R1 has since fallen on [DATE]. All agreed that MDS information needs to be correct because it guides the resident's care plan, and agreed R1's current care plan did not reflect any intervention changes after R1's falls or with an increasing fall risk. V2 stated, I admit, you're right - the interventions are not showing progression for fall prevention, even though R1's fall risk has increased. I do agree a care plan needs to be individualized to address the specific care needs, and R1's present care plan isn't individualized. During interview on [DATE] at 2:20 PM, V14 (Medical Director) was informed of the multiple falls sustained by R1 with the fall on [DATE] resulting in multiple injuries, and surveyor asked How important are the fall interventions in a resident's plan of care? V14 said the interventions need to address the resident's safety concerns, and if a resident is having multiple falls the interventions need to address the increasing safety needs of that particular resident. 2.) R4 was a [AGE] year old, verbal resident with [DIAGNOSES REDACTED]. R4 was admitted into hospice care on [DATE], and expired on [DATE]. Review of R4's closed medical record documents the following falls: [DATE]: fell in room, no injuries; [DATE]: fell in room, no injuries; [DATE]: fell in room, no injuries; [DATE]: fell in room, sustained a left subcapital [MEDICAL CONDITION], and a skin tear to his dorsal right hand. R4 was alone during all falls, and falls were unwitnessed. [DATE] Fall Risk assessment notes R4 was assessed at 21 (high risk - had fall on [DATE]). On [DATE], R4 was assessed at 15 (moderate risk - had fall on [DATE]). On [DATE], R4 was assessed at 19 (high risk - had fall on [DATE] resulting in the left [MEDICAL CONDITION] and right dorsal hand skin tear). [DATE] Admission MDS (Minimum Data Set) Section C (Cognition) indicates a BIMS (Brief Interview Mental Status) of 6, indicating R4 had severe cognitive impairment. Section G (Mobility) indicates R4 needed extensive, two person physical assist for bed mobility and transferring. [DATE] MDS Section C indicates 00, Section G remained at an extensive, two person physical assist. R4's care plan had the focus areas of, R4 is at risk for falls related to cognitive decline from dementia, impaired vision, [MEDICAL CONDITION] . with interventions Anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance. Ensure wearing appropriate footwear when ambulating or mobilizing in wheelchair. Follow facility fall protocol. PT evaluate and treat as ordered or PRN (as necessary). Review information on past falls and attempt to determine cause of falls. Educate resident/family/caregiver/IDT as to causes. Focus area Has had a fall due to unsteady gait and weakness with interventions to Continue interventions on the at-risk plan (no information documented of what the actual interventions are on the at-risk plan). Focus area Restorative Ambulation Program: R4 has limited ability or willingness to initiate or participate in mobility related task of ambulation due to cognitive deficit. Needs assist with ambulation. Poor safety judgement. Poor sitting and/or standing balance related to [MEDICAL CONDITIONS], muscle weakness and others with interventions including Have resident in standing position for few seconds before taking steps for balance. Ensure that resident is wearing appropriate footwear. Use gait belt, obtain permission from the resident before applying. During interview on [DATE] at 11:50 AM with V2 (Director of Nursing/DON), V3, and V4 (both MDS Coordinators), surveyor asked, What does 'At-risk fall interventions' mean on R4's care plan? V2 said the at-risk interventions are those that are named on the care plan's first page. Asked V2, V3, and V4 if it was an appropriate intervention for a resident with a [DIAGNOSES REDACTED]. All agreed it would be difficult to expect a resident with dementia and memory issues to remember to ask for assistance. Surveyor asked what was considered a prompt response time frame. V2 stated, It means immediately. Anyone can answer a light. I would consider it a prompt response if a call light was answered within five to ten minutes. Reviewed with V2, V3, and V4 the multiple fall risk assessments, the MDS Section G sections (consistently indicating R4 required extensive, two person physical assistance for mobility and transfer), and R4's care plan. Surveyor asked V2, V3, and V4 if R4's care plan was accurate and progressive in its fall interventions to have prevented further falls, considering R4's fall risk assessment initially was noted at a high risk, then R4 had two separate falls and was assessed to be a moderate risk falls, and then R4 fell again and sustained a [MEDICAL CONDITION] and was reassessed on [DATE] again to be a high risk for falls? All agreed R4's fall risk assessments and most recent care plan did not reflect any intervention changes after R4's falls or note R4's increasing fall risk. V2 stated, I admit, you're right. The interventions are not showing progression for fall prevention, and R4 was at a high fall risk. I do agree a care plan needs to be individualized to address the specific care needs, and R4's care plan wasn't individualized. Review of facility policy Fall Management (reviewed [DATE]) states Definitions: Avoidable Accident: means that an accident occurred because the facility failed to . Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan . in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident, and/or monitor the effectiveness of the interventions and modify the care plan as necessary .

Based on interview and record review, the facility failed to follow the policy changes in patient's/resident condition and notify the physician in timely manner of significant change in mobility status [REDACTED]. This failure resulted in R1 experiencing pain 2 days resulting hospitalization where R1 was diagnosed with [REDACTED]. Findings include: Fall incident report of 8/31/14 documents R1 had an un-witnessed fall in her room. While initial x-ray report of 8/31/14 was negative for fracture, R1 started exhibiting inability to ambulate on 9/1 and 9/2 and both verbal and nonverbal complaints of pain which were not alleviated by [MEDICATION NAME]. By 9/3/14 R1 is being sent to the hospital for evaluation. Nursing note of 9/4/14 documents R1 was admitted to the hospital with [REDACTED]. On 9/11/14 at 4:30 pm E3(Registered Nurse) stated, " 9/2 in evening I sent fax to M.D saying patient (R1) complaining of pain on left leg. Reminded her of fall and not exact sure where pain is. [MEDICATION NAME] didn ' t help. I was sending him notice it didn ' t help. After dinner she kept saying ok, I ' m not in pain but she was grimacing. " Fax by E3 was sent to Z1(Attending physician for R1) on 9/2 at 7:08 pm, according to the fax confirmation. E3 notes she did not speak directly with Z1, communicating only by fax and no communication with the medical director was attempted. On 9/12/14 at 6:30 am E2, who was the night shift nurse per schedule on 9/1 and 9/2/14 reports R1 had pain which continued post [MEDICATION NAME] administration and the intervention was to endorse to the oncoming shift. E2 continued, " In morning endorse need something stronger for pain. Because ([MEDICATION NAME])relief 2 to 3 hours. After 2 to 3 hours would complain of pain again. Didn ' t give relief for whole time; she would be in pain again. She would tell me in pain. No ([MEDICATION NAME]) to give her. There would be period of time she would have pain. No, I didn ' t call M.D. I just endorsed to am nurse. Doctor just wanted fax. " In addition E2 is noting R1 who could walk pre fall 8/31/14 could not walk 9/1/14 or 9/2/14. On 9/12/14 at 10:45 am E5 (Certified Nursing Assistant) who took care of R1 on 9/3/14 during the morning stated she went to room to try and get R1 up but she refused because of pain at 7:30 am. Z1 responds to fax sent by E3 on 9/2 at 7:08 pm, 12 hours later on 9/3/14 at 7:56 am, with question, " Is she able to stand and walk? " E4(Registered Nurse for R1 on dayshift of 9/3/14) faxes a response back on 9/3/14 at 11:03 am, " Resident (R1) can stand but unable to walk. Slightly S.O.B(short of breath) complains of pain in left hip. Can we have stronger pain med or please advise. " Z1 faxes back at 9/3/14 at 11:36 am, " Send her to (hospital) for evaluation. " On 9/16/14 at 3:15 pm Z1(Attending Physician) for R1 described R1 as having " advanced dementia. " Z1 acknowledged could get a disconnect between pain and verbalizations in advanced dementia. In relation to pain and change in mobility status, Z1 felt these were significant symptoms which should have been communicated sooner for more thorough assessment. Z1 stated she would have sent R1 to the hospital as soon as she knew mobility status had changed. Z1(Attending Physician) reported she had spoken to the orthopedic physician in the hospital who stated, " she would be in pain all the time if didn ' t fix fracture. " Facility statement of policy with revision date of 4/28/14 indicates, " It is the policy of (facility) that changes in patient ' s/resident condition will be relayed to the attending physician in a timely manner. "

Based on interview and record review, the facility failed to ensure adequate pain assessment/management and physician notification in a timely manner of significant symptoms for one resident (R1) out of three residents reviewed for fall. R1 was sent to the hospital after 2 days of significant symptoms and admitted with a [DIAGNOSES REDACTED]. Findings include: R1 face sheet documents [DIAGNOSES REDACTED]. Date of birth is listed as 4/24/22, making R1 [AGE] years old. Document dated 7/22/14 and titled, " Decisional capacity, " assesses R1 as having " moderately impaired " decision making. Power of Attorney for Healthcare documents are in R1 ' s medical record. On 8/31/14 at 7:15 am nursing note documents R1 is found on the floor in her room. R1 is complaining of pain with movement on left leg. X-ray is reported as negative for fracture per 9/1/14 6:00 am nursing note and radiology report. From 9/1 until 9/3 nursing notes document pain in the left hip. Administration of [MEDICATION NAME] as pain medication for complaints of pain is inconsistent in the record. A couple of nursing notes on 9/2 at 2:00 pm and 9/3 at 6:00am document complaints of pain with [MEDICATION NAME] given. However the Medication Administration Record [REDACTED]. According to E1(Director of Nursing) on 9/16/14 at 11:20 am, nursing personnel are to document response to pain medication in the back of the M.A.R There is no documentation of R1 ' s response to pain medication in the back of the M.A.R. Nursing notes of 9/1 at 10:00 pm indicate [MEDICATION NAME] given but no response is documented and 9/3 6:00 am nursing note by E2(Registered Nurse) indicates temporary relief of pain post [MEDICATION NAME] administration. On 9/12/14 at 6:30 am E2 is reporting R1 had pain(9/2) which continued post [MEDICATION NAME] administration and the intervention was to endorse to the oncoming shift. E2 continued, " In morning (9/2) endorse need something stronger for pain. Because ([MEDICATION NAME])relief 2 to 3 hours. After 2 to 3 hours would complain of pain again. Didn ' t give relief for whole time; she would be in pain again. She would tell me in pain. No ([MEDICATION NAME]) to give her. There would be period of time she would have pain. No, I didn ' t call M.D. I just endorsed to am nurse. Doctor just wanted fax. " In addition E2 is noting R1 who could walk pre fall 8/31/14 could not walk 9/1/14 or 9/2/14. On 9/11/14 at 4:30 pm E3(Registered Nurse) stated, " 9/2 in evening I sent fax to M.D saying patient (R1) complaining of pain on left leg. Reminded her of fall and not exact sure where pain is. [MEDICATION NAME] didn ' t help. I was sending him notice it didn ' t help. After dinner she kept saying ok, I ' m not in pain but she was grimacing. " Fax by E3 was sent to Z1(Attending physician for R1) on 9/2 at 7:08 pm, according to the fax confirmation. E3 notes she did not speak directly with Z1, communicating only by fax and no communication with the medical director was attempted. E3 acknowledged charting in nurses notes is to continue 72 hours post incident. On 9/2/14 for 3:00 pm to 11:00 pm shift there is no charting in the nursing notes as required by facility policy and procedure titled, " Fall Report, " dated as revised on March 2, 2014 which states, " Documentation should continue in the nurses ' notes for 72 hours following any incident. " On 9/12/14 at 10:45 am E5 (Certified Nursing Assistant) who took care of R1 on 9/3/14 during the morning stated she went to room to try and get R1 up but she refused because of pain at 7:30 am. Z1 responds to fax sent by E3 on 9/2 at 7:08 pm, 12 hours later on 9/3/14 at 7:56 am, with question, " Is she able to stand and walk? " E4(Registered Nurse for R1 on dayshift of 9/3/14) faxes a response back on 9/3/14 at 11:03 am, " Resident (R1) can stand but unable to walk. Slightly S.O.B(short of breath) complains of pain in left hip. Can we have stronger pain med or please advise. " Z1 faxes back at 9/3/14 at 11:36 am, " Send her to (hospital) for evaluation. " On 9/16/14 at 3:15 pm Z1(Attending Physician) for R1 described R1 as having " advanced dementia. " Z1 acknowledged could get a disconnect between pain and verbalizations in advanced dementia. In relation to pain and change in mobility status, Z1 felt these were significant symptoms which should have been communicated sooner for more thorough assessment. Z1 stated she would have sent R1 to the hospital as soon as she knew mobility status had changed. Z1(Attending Physician) reported she had spoken to the orthopedic physician in the hospital who stated, " she would be in pain all the time if didn ' t fix fracture. " Facility policy for fall report revised on March 2, 2014 notes under procedure: " 5. Follow-up assessment has to be done to ensure no underlying injuries are missed or overlooked. " Hospital physician documentation by Z5(Physician at hospital) on 9/5/14 documents under impression/plan, " [MEDICAL CONDITION], " and " we will plan for a left hip hemi-arthroplasty once the patient is cleared for surgery. " Facility policy titled, " Calling Physician RE: Resident ' s/Patient Condition, " states, " It is the policy of (Facility) that changes in patient ' s/resident ' s condition will be relayed to the attending physician in a timely manner. " The policy continues under procedures #2. " If the attending physician does not call back within 15 minutes after the call was made, place another call and wait for another 15 minutes, if there is no return call, place another call and place a call to the director of nursing as well as to the administrator, " and " 3. If the attending physician does not call back after 3 attempts within 15 minutes interval, the administrator or director of nursing will place a call to the Medical Director to obtain orders. E2 and E3 nurses who cared for R1 on 9/1/14 and 9/2/14 did not follow their policy and procedure which required the Director of Nursing to be called for R1 ' s symptoms of pain unrelieved by pain medication and change in mobility status. This delay in communication of significant changes in R1 ' s condition resulted in a delay in sending R1 to the hospital for treatment of [REDACTED]. Facility policy and procedure titled, " pain assessment " and dated September 5, 2005 states, " 1. Pain assessment will be done using the " Pain Assessment " tool. The form is generated on admission, re-admission, annual, quarterly, significant change and when there is new pain observed or noted by the staff. 2. Staff nurse on the floor completes the pain assessment tool. 3. Appropriate interventions will be initiated and carried out as necessary based upon the result of the assessment. 4. Documentation of the effectiveness of the interventions both pharmacologic and non-pharmacologic will be documented either in the nurses ' notes or in the pain flow sheet. 5. Pain Assessment tool and Pain flow sheet will be filed in the resident ' s/patient ' s medical record. Neither E2 or E3 contacted the physician in a timely manner when R1 was having pain unrelieved by [MEDICATION NAME].