Every finding on record at Legacy Health and Rehab

Based on facility policy review, observation, and interview, the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The facility's failure had the potential to affect 49 of 49 residents.The findings include: Review of the facility policy titled, Dietary Cleaning and Sanitation Policy, undated, revealed, .The Dietary Department shall maintain all kitchen, food storage, food preparation, service, and dishwashing areas in a clean and sanitary condition at all times. Cleaning and sanitizing activities shall be performed according to established schedules and procedures. All dietary staff are responsible for maintaining sanitation standards .equipment shall be cleaned and sanitized after each use . The Dietary Manager (DM) is responsible for the oversight and implementation of this policy. During the initial kitchen tour, observation, and interview on 6/22/2026 at 10:35 AM, with the Dietary Manager (DM) revealed the gas oven range and griddle appeared in unsanitary condition as evidence by: 1. The 2 food debris trays (beneath the burners and griddle) of the stove were lined with aluminum foil. On top of the foil in the debris tray, on the stove side (Left), was food debris of many food groups, multiple colors, textures, and in different stages of burning/charring. The food debris tray on the griddle side (Right) of the stove had dark brown/black debris present. Upon observation of the back of the stove, revealed an opening where copious amount of charred, black, granular food debris was observed. 2. The top convection oven of the unit (2 ovens in 1 unit), the front glass pane doors were observed to be covered by a reddish/orange, brown, burned on film. The operator was unable to view the cooking food contents from the front view of the glass panes of the doors. The bottom convection oven of the unit had the same reddish/orange, brown debris present, which appeared to have been a spill which became over time, a dried on hard, putty-like substance. During an interview on 6/22/2026 at 10:50 AM, The DM confirmed the kitchen equipment (stove/griddle, and convection ovens) were in unsanitary condition.

Based on review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interviews, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 2 residents (Resident #5 and #51) of 9 residents reviewed.The findings include:Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, Schizophrenia, and Conversion Disorder with Seizures or Convulsions. Review of a Notice of PASRR Level II Outcome for Resident #5 dated 4/2/2025, revealed .You had a Level II PASRR evaluation .you need special services for your mental health .your PASRR Level II evaluation remains good during your stay .Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 5 on the Brief Interview for Mental Status (BIMS) Assessment, which indicated the resident had severe cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition .No .Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Bipolar Disorder, Primary Insomnia, Delusional Disorders, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of a Notice of PASRR Level II Outcome for Resident #51 dated 7/8/2025, revealed .You had a Level II PASRR evaluation .you need special services for your mental health .your PASRR Level II evaluation remains good during your stay .Review of an annual MDS assessment dated [DATE], revealed Resident #51 scored a 99 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have a serious mental illness .No .During an interview on 6/24/2026 at 3:50 PM, the MDS Coordinator confirmed Resident #5 and Resident #51 were coded inaccurately on the MDS and did not reflect the residents' Level II PASRR status. During an interview on 6/24/2026 at 4:07 PM, the Director of Nursing confirmed the MDS assessments for Resident #5 and Resident #51 were inaccurate.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was in reach for 1 resident (Resident #20) of 49 residents observed.The findings include: Review of the facility's policy titled, Call Light Policy, dated 2025-2026, revealed .the call light is within .reach .ensure it remains within .reach of the resident . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Hemiplegia Left Side, Contracture Left Hand, and Epilepsy. Review of a comprehensive care plan dated 4/15/2026, revealed Resident #20 had .cognitive impairment . left-sided hemiplegia .requires assistance .Bed mobility .Transfer .Dressing .Toilet use .Personal Hygiene .Bathing .At risk for fall related injury related to: weakness, hemiparesis .Call light within reach . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and required substantial to maximal assistance of staff for ADL's (Activities of Daily Living) and mobility. During an observation on 6/22/2026 at 10:57 AM, revealed Resident #20 was lying in the bed on left side with head of bed elevated, call light draped over headboard resting on the floor under frame of the bed out of reach of the resident. During an observation on 6/22/2026 at 4:03 PM, revealed Resident #20 was lying in the bed on left side with head of bed elevated, call light was draped over headboard resting on the floor under frame of the bed out of reach of the resident. During an observation and interview on 6/22/2026 at 4:07 PM, with Registered Nurse (RN) A in Resident #20's room, the call light was draped over headboard resting on the floor under frame of the bed out of reach of the resident. RN A confirmed the call light was out of the Resident #20's reach. During an interview on 6/22/2026 at 4:09 PM, the Director of Nursing stated call lights were to be within reach of the resident at all times.

Based on facility policy review, observation and interview the facility failed to maintain a safe, clean, homelike environment for 4 residents (Residents #4, #6, #32, and #36) of 24 residents observed. The findings include: Review of the facility's policy titled, Homelike Environment, revised 2/2021, revealed .Residents are provided with a safe, clean .and homelike environment .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting .The characteristics include .clean, sanitary and orderly environment . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Congestive Heart Failure, and Acute Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 6/23/2025 at 11:39 AM and on 6/24/2025 at 11:41 AM, Resident #4's bathroom revealed the floor behind the toilet was missing a large area of flooring, with a dark colored substance noted in the area. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Diabetes, and Dependence on Wheelchair. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 6/23/2025 at 10:00 AM, in Resident #6's room, revealed 2 large holes and 2 small holes in the resident's closet doors that penetrated through the wood. Resident #6 stated he accidently put the holes in the closet doors with his wheelchair about 6 months ago. Resident #6 stated he did not like the looks of the closet doors and offered to pay to have them fixed but the facility would not allow him and they had not offered to repair the damage. Resident #6 stated he would like to have the holes repaired. During an observation on 6/24/2025 at 8:05 AM, revealed Resident #6's closet doors had 2 large and 2 small holes that had penetrated through the door. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Wasting and Atrophy, and Major Depressive Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 was unable to participate in a BIMS assessment due to severe cognitive deficit. During an observation on 6/23/2025 at 11:00 AM and on 6/24/2025 at 9:00 AM, in Resident #32's room, revealed a 3-drawer nightstand which revealed the 2nd drawer was broken and would not close completely and the 3rd drawer was unable to be opened. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Essential Hypertension, and Stage 3 Chronic Kidney Disease. Review of a annual MDS assessment dated [DATE], revealed Resident #36 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation on 6/23/2025 at 11:37 AM and on 6/24/2025 at 3:15 PM, Resident #36's room revealed the right end of the footboard had a large piece which was broken off at the corner, and the long rubber trim was hanging off the footboard. During an observation and interview on 6/24/2025 at 3:35 PM, Registered Nurse (RN) C confirmed Resident #36's footboard had a piece broken off at the corner, and the rubber trim was hanging off the footboard. During an observation and interview on 6/24/2025 at 3:40 PM, the Administrator confirmed Resident #36's footboard had a piece broken off at the corner, and the rubber trim was hanging off the footboard. The Administrator further confirmed that in Resident #4's bathroom, the floor behind the toilet was missing a large area of flooring, with a dark colored substance in the area. The Administrator confirmed these observations were not indicative of a home-like environment. During an observation and interviews on 6/25/2025 at 10:30 AM, with the Administrator and Maintenance Director revealed Resident #6's closet doors had 2 large and 2 small holes that had penetrated through the door. Resident #32's room, revealed a 3-drawer nightstand which showed the 2nd drawer was broken and would not close completely and the 3rd drawer was unable to be opened. The Administrator and Maintenance Director confirmed Resident #6 and #32's room's were not maintained in a safe, homelike environment.

Based on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan for 1 Resident (Resident #34) of 14 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Planning - Interdisciplinary Team, dated 9/2013, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Diabetes. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and received dialysis services. Medical record review of the Comprehensive Care Plan for Resident #34 dated 3/26/2025, revealed .observe shunt site by palpating for thrill and auscultating for bruit every shift . Review of current physician orders for Resident #34 revealed the resident did not have an order to observe shunt site by palpating for thrill and auscultating for bruit every shift. During an interview on 6/24/2025 at 2:00 PM, the 600 Hall Unit Manager (UM) stated Resident #34 received dialysis treatments 3 times per week. The UM stated Resident #34's shunt located in his left arm was no longer being used and an alternate access site was obtained. The UM stated assessment of Resident #34's shunt site for bruit and thrill was discontinued on 3/19/2025. The UM confirmed the facility failed to revise Resident #34's care plan to reflect the discontinued order.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered care plan related to smoking for 1 resident (Resident #39) of 14 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2006, revealed .develops and implements .person-centered care plan for each resident .identifying problem areas .developing interventions .targeted .to the resident . Review of the facility's policy titled, Smoking Policy - Residents, revised 7/2017, revealed .any smoking privileges .concerns .shall be noted on the care plan . Review of the medical record revealed Resident #39 was admitted to facility on 8/14/2024 with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Nicotine Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed Resident #13 used tobacco products. Review of the comprehensive care plan for Resident #39 dated 4/4/2025, revealed Resident #39's current smoking use was not developed on the care plan. Review of the facility's document titled, Smoking Risk Assessment, dated 6/6/2025, revealed, Resident #39 had been assessed for smoking and was safe to smoke at designated times under staff supervision. During an interview on 6/24/2025 at 8:30AM, Registered Nurse (RN) C stated Resident #39 smoked at the designated smoking times daily at the facility. During an observation on 6/24/2025 at 10:35 AM, in facility's designated outside smoking area, revealed Resident #39 sitting up in chair with smoking apron on and was smoking a cigarette under staff supervision. During an interview on 6/24/2025 at 11:00 AM, Resident #39 stated that he had been a smoker for years and went to the designated smoking times while a resident at the facility. During an interview on 6/24/2025 at 4:22 PM, RN D confirmed that smoking was not developed on Resident #39's comprehensive care plan. During an interview on 6/24/2025 at 4:45 PM, the Director of Nursing (DON) confirmed smoking had not been developed on Resident #39's comprehensive care plan.

Based on medical record review and interview, the facility failed to refer 2 residents (Residents #4 and #25), after the residents were diagnosed with a serious mental disorder, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) evaluation and determination of 10 residents reviewed for PASARR. The findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Congestive Heart Failure, and Depression. The diagnoses of Major Depressive Disorder, Insomnia, and Anxiety Disorder were added on 7/9/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a PASARR for Resident #4 submitted on 12/12/2023, revealed diagnoses .depression-mild or situational . The PASARR outcome was .Negative, No Level II Required . Review of the medical record for Resident #4 revealed a new PASARR was not submitted for a Level II Evaluation to be completed after the new diagnoses of Major Depressive Disorder, Insomnia, and Anxiety Disorder was added on 7/9/2024. Resident #25 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety and Mood Disturbance. A diagnosis of Schizoaffective Disorder was added on 7/27/2023. Review of a Notice of PASARR Level I Screen Outcome dated 3/17/2021, revealed .No mental health diagnosis is known or suspected . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident # 25 had severe cognitive impairment. During an interview on 6/24/2025 at 10:50 AM, the 600 Hall Unit Manager confirmed a new PASARR had not been submitted to the state-designated authority for Resident #32 after a diagnosis of Schizoaffective Disorder had been added on 7/27/2023. During an interview on 6/24/2025 at 12:10 PM, Licensed Practical Nurse (LPN) B confirmed Resident #4's current PASARR dated 12/12/2023 was the latest PASARR submitted, did not include the diagnosis of Schiozoaffective Disorder and confirmed a new PASARR had not been submitted.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a Physician's Order was obtained for oxygen therapy for 2 residents (Residents #4 and #255) of 6 residents reviewed for oxygen therapy. The findings include: Review of the facility's policy titled, Oxygen Administration, revised 10/ 2010, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration .Preparation .Verify that there is a physician's order for this procedure . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Acute Kidney Disease. Review of a facility document titled Report Sheet [report given to facility nurse from hospital nurse] for Resident #4 dated 1/27/2025, revealed .O2 [oxygen] 2 L/M [liters/minute] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and the resident did not receive oxygen therapy. Review of the Nurse Practitioner (NP) Note for Resident #4 dated 6/13/2025, revealed .Review of systems .Respiratory: Chronic shortness of breath .Wearing supplemental oxygen via [by] NC [nasal cannula] . During an observation on 6/23/2025 at 11:37 AM and 6/24/2025 at 2:00 PM, Resident #4 had oxygen in place by nasal cannula at 2 L/M. Review of the current Physician Orders for Resident #4 dated 6/24/2025, revealed no order for oxygen therapy. During an observation and interview on 6/24/2025 at 3:10 PM, Resident #4 was lying in bed receiving oxygen. Licensed Practical Nurse (LPN) A confirmed Resident #4 was receiving oxygen at 2 liters per minute by nasal cannula, and confirmed there was not a Physician's Order for oxygen administration. During an interview on 6/24/2025 at 3:20 PM, Licensed Practical Nurse Unit Manager (LPN UM) G confirmed Resident #4 did not have a Physician's Order for oxygen therapy. Review of the medical record revealed Resident #255 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. Review of an admission MDS assessment dated [DATE] revealed Resident #255 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact and the resident received oxygen. Review of a facility document titled Report Sheet, for Resident #255 dated 6/13/2025, revealed .O2 2 L/M . During an observation on 6/23/2025 at 2:38 PM and on 6/24/2025 at 2:15 PM, Resident #255 had oxygen in place by nasal cannula at 4 L/M. Review of the current Physician Orders for Resident #255 dated 6/24/2025, revealed no orders for oxygen therapy. During an observation and interview on 06/24/2025 at 3:15 PM, in Resident #255's room revealed the resident was receiving oxygen. Registered Nurse (RN) C confirmed Resident #255 received oxygen per nasal cannula at 4 liters per minute and confirmed there was no current Physician's Order for oxygen administration. During an interview on 6/24/2025 at 3:20 PM, LPN/UM G confirmed Resident #255 did not have a Physician's Order for oxygen therapy. During an interview on 6/24/2025 at 3:50 PM, the Director of Nursing (DON) confirmed all residents receiving oxygen therapy should have an active Physician's Order.

Based on review of the facility policy, review of kitchen equipment cleaning documentation, observation, and interview, the facility failed to ensure kitchen equipment was maintained in a clean and sanitary condition and failed to ensure dietary staff wore protective hair coverings during food preparation in the kitchen, which had the potential to affect 53 of 53 residents residing in the facility. The findings include: Review of the facility's policy titled, Sanitation, revised 10/2008, revealed .food service area shall be maintained in a clean and sanitary manner .equipment should be kept clean .all equipment .shall be washed to remove or completely loosen soils .using the manual or mechanical means necessary .for fixed equipment .removable components will be scraped to remove food particle accumulation .Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen .areas . Review of the facility's policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised 12/2017, revealed .Food and nutrition services employees will follow appropriate hygiene .to prevent the spread of foodborne illness .Hair nets .beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . During an observation of the cooking area and interview on 6/23/2025 at 10:50 AM, with the Dietary Manager (DM), revealed a grease-like, brownish black food debris with multiple splatters of a brown substance present to the top perimeter and both sides of the deep fryer, blade of can opener, and the control panels of the steamer and warmer. The DM confirmed the deep fryer, can opener blade, and control panels of the steamer and warmer needed .deep cleaning . and was not maintained in a sanitary condition. During an interview on 6/23/2025 at 11:00 AM, the DM stated the kitchen was to be cleaned daily and deep cleaned each week. The DM acknowledged the food debris and build up on the kitchen equipment and confirmed the kitchen equipment was not maintained in a clean and sanitary condition. During an observation on 6/23/2025 at 11:55 AM, Dietary Aide (DA) E was on the serving line preparing the residents' lunch meal trays. Further observation revealed DA E did not have a hair net or beard covering in place (DA E had on beanie cap with hair protruding at both ears and back of neck, and had facial hair). During an observation on 6/23/2025 at 11:57 AM, DA F was on the serving line preparing residents' lunch meal trays. Further observation revealed that DA F did not have a hair net or beard covering in place (DA F had on cap that did not contain the hair above ears and back of neck, and had facial hair). During an interview on 6/25/2025 at 10:30 AM, the Administrator stated all dietary staff should have the hair completely covered while in the food preparation areas in the kitchen. The Administrator confirmed DA E and DA F failed to ensure their hair was appropriately covered while preparing food in the kitchen for residents. During an interview on 6/25/2025 at 11:44 AM, the DM stated that all dietary staff should have the hair completely covered while in the food preparation areas in the kitchen. The DM confirmed DA E and DA F failed to ensure their hair was appropriately covered while preparing the food in the kitchen for residents.

Based on facility policy review, observation, and interviews the facility failed to ensure the outside dumpster area was maintained in a sanitary and orderly condition. The findings include: Review of the facility's policy, Food-Related Garbage and Refuse Disposal, revised 10/2017, revealed .outside dumpsters .will be kept .free of surrounding litter .storage areas will be kept clean at all times .shall not constitute a nuisance . During an observation of the outside dumpster area on 6/23/2025 at 10:08 AM, with the Dietary Manager (DM) revealed the area behind dumpster A and B had 2 broken light fixtures, 2 broken chairs, 1 broken office chair, 1 walker, 1 broken window air conditioner, and mop bucket on the ground. During an interview on 6/23/2025 at 10:11 AM, the DM stated the 2 broken light fixtures, 2 broken chairs, 1 broken office chair, 1 walker, 1 broken window air conditioner, and mop bucket on the ground were not disposed of properly and was unsure how long those items had been there. The DM confirmed the dumpster area had not been maintained in a sanitary condition.

Based on facility policy review, observation, and interview, the facility failed to provide a sanitary environment by failing to clean and store soiled items in a multi-resident bathroom for 1 Resident (Resident #4) of 10 residents observed. The findings include: Review of the facility's police titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised 6/2011, revealed .Rinse bedpan or urinal with cool water to remove feces and urine .Rinse with hot running water .Return bedpan or urinal to resident's bedside cabinet . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Acute Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 6/23/2025 at 11:37 AM, Resident #4's bathroom revealed 2 urinals on the grab bar next to the toilet, both unlabeled. 1 urinal had an orange/brown colored substance dried inside. During an observation on 6/24/2025 at 2:00 PM, Resident #4's bathroom revealed 2 urinals on the grab bar next to the toilet, both unlabeled. 1 urinal had an orange/brown colored substance dried inside. During an observation and interview on 6/24/2025 at 3:30 PM, in Resident #4's bathroom, Licensed Practical Nurse (LPN) A confirmed Resident #4's bathroom had 2 urinals on the grab bar next to the toilet, unlabeled. 1 urinal had an orange/brown colored substance dried inside. LPN A confirmed the urinals did not appear clean, and were not stored properly.

Based on review of the facility's Payroll Based Journal (PBJ) report dated 10/1/2023-12/31/2023, daily nursing staff posting sheets, time clock punches, and interviews, the facility failed to provide the minimum requirement of 8 hours per day of Registered Nurse (RN) coverage on 20 days reviewed on the PBJ report and 12 days reviewed on 1/1/2024-4/10/2024 (not a PBJ report). The findings include: Review of the facility's PBJ dated 10/1/2023-12/31/2023 showed the following dates with no RN coverage: 10/7/2023 (Saturday), 10/14/2023 (Saturday), 10/15/2023 (Sunday), 10/29/2023 (Sunday), 11/4/2023 (Saturday), 11/5/2023 (Sunday), 11/12/2023 (Sunday), 11/18/2023 (Saturday), 11/26/2023 (Sunday), 12/2/2023 Saturday), 12/10/2023 (Sunday), 12/24/2023 (Sunday), and 12/31/2023 (Sunday). Review of the facility's daily staffing posting sheets, and time clock punches showed: 10/1/2023 (Sunday): 1.25 hours of RN coverage 10/21/2023 (Saturday): 3.02 hours of RN coverage 10/28/2023 (Saturday): 5.25 hours of RN coverage 11/11/2023 (Saturday): 2.83 hours of RN coverage 11/23/2023 (Monday): 1.48 hours of RN coverage 12/16/2023 (Saturday): 2.5 hours of RN coverage 12/23/2023 (Saturday): 1.13 hours of RN coverage Review of the facility's daily staffing posting sheets showed the following: 1/6/2024 (Saturday), 1/17/2024 (Wednesday), 1/18/2024 (Thursday), 3/10/2024 (Sunday), 3/16/2024 (Saturday), 3/23/2024 (Saturday), 3/24/2024 (Sunday), 3/30/2024 (Saturday), 3/31/2024 (Sunday), 4/5/2024 (Friday), 4/6/2024 (Saturday), and 4/7/2024 (Sunday): no RN coverage. During an interview on 4/8/2024 at 10:40 AM, the Staff Development Coordinator (SDC)/Infection Control Nurse stated the facility typically had an RN daily Monday-Friday. The RN who was scheduled to work Saturday and Sundays quit a few weeks ago and the facility was actively trying to hire a replacement. The SDC/Infection Control Nurse confirmed the facility did not have consistent RN coverage currently on Saturday and Sundays During an interview on 4/10/2024 at 1:35 PM, the Administrator, Assistant Administrator, Director of Nursing, and the Controller confirmed the facility failed to meet the minimum requirement of 8 hours RN coverage per day.

Based on facility policy review, observation and interview the facility failed to post accurate staffing information to reflect daily staffing levels. The findings include: Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 7/2016, showed .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents During an observation on 4/8/2024 at 7:40 AM, of the daily nurse staffing showed the staffing information posted was the staff scheduled for 4/5/2024 and had not been updated to reflect the current staff in the facility on 4/8/2024. During an interview on 4/10/2024 at 2:035 PM, the Director of Nursing stated the Unit 1 Charge Nurse was responsible for posting the daily staffing sheet.

Based on facility policy review, observations, and interviews, the failed to ensure there was hot water was available for staff to wash/sanitize their hands in 1 of 2 kitchen hand washing sinks. The facility failed to maintain kitchen equipment in a sanitary manner and failed to ensure the kitchen floor was maintained in a sanitary manner, which had the potential to affect 52 of 52 residents. The findings include: Review of the facility policy titled, Sanitization, revised 10/2008, showed .All .kitchen areas .shall be kept clean .free from litter and rubbish .all equipment shall be kept clean .washed to remove soils .using mechanical means necessary . Observation and interview on 4/8/2024 at 8:35 AM, with the Dietary Manager (DM), at the kitchen handwashing station (located at the entry door), showed this surveyor attempted to wash her hands and the water remained cold. Further observation showed the water temperature did not change. The DM stated this sink had been transitioned from an eye wash station into a hand washing sink and the hot water had not been hooked up. Observation of the food preparation area on 4/8/2024 at 8:50 AM, with the DM, showed the outer door and bottom edge of the food warmer and the 6 temperature dials had thick layers of sticky, black food debris. Observation of the dishwashing area on 4/8/2024 at 8:55 AM, with the DM, showed the floor area under the dishwasher had food debris scattered on the floor. Further observation showed a plastic cup and plastic fork was on the floor beneath the dishwasher. Observation of the dishwashing area on 4/9/2024 at 9:00 AM, with the DM, showed the floor area under the dishwasher had food debris scattered on the floor. Further observation showed a plastic cup and plastic fork was on the floor beneath the dishwasher. During an interview on 4/9/2024 at 9:10 AM, the DM stated it was her expectation the kitchen equipment and kitchen floors were cleaned daily and deep cleaned weekly. The DM confirmed the kitchen equipment and kitchen floors were not maintained in a sanitary condition. During an interview on 4/9/2024 at 9:59 AM, the DM stated it was her expectation hot water would be available for kitchen staff use at the handwashing station. The DM confirmed hot water was not available for the kitchen staff at the handwashing station.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure the call light was in reach for 1 resident (Resident #7) of 52 residents observed for call light accessibility. The findings include: Review of the facility's policy titled, Answering the Call Light, dated 3/2021, showed .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Resident #7 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Anxiety, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident was moderately cognitively impaired and required substantial/ maximum staff assistance with personal hygiene. Review of Resident #7's comprehensive care plan revised 4/2/2024, showed .Resident has need for extensive to total care related to .decreased functional status .call light within reach . During an observation and interview on 4/8/2024 at 9:50 AM, in Resident #7's room, showed Resident #7 was seated in a reclining chair with her call light clipped to the privacy curtain. Further observation showed Resident #7's call light was out of her reach. Resident #7 stated when she needed help from the staff, she used her call button to alert them. Further interview showed Resident #7 did not know where her call light was located. During an observation and interview on 4/8/2024 at 9:52 AM, in Resident #7's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #7's call light was not within the resident's reach and was not accessible for the resident's use. During an observation and interview on 4/9/2024 at 10:25 AM, in the resident's room, with Certified Nursing Assistant (CNA) #1, showed Resident #7 was seated in a reclining chair with the call light draped over the side of the bed. Further observation showed the resident's call light was out of her reach and not accessible for use. CNA #1 stated the call light is supposed to be within the resident's reach and confirmed the call light was not accessible to Resident #7. During an interview on 4/10/2024 at 1:05 PM, the Director of Nursing (DON) stated it was the facility's expectation when residents are in the bed or sitting up in the chairs in their rooms, the call lights would be in their reach and available for use. DON confirmed the facility failed to ensure the call light was accessible for Resident #7's use.

Based on facility policy review, medical record review, and interview, the facility failed to provide a resident with information regarding a resident's right to formulate an advanced directive upon admission to the facility for 1 resident (Resident #3) of 18 residents reviewed for advanced directives. The findings include: Review of the facility policy titled Advance Directives, revised 12/2016, showed .Upon admission, the resident will be provided with written information .to formulate an advance directive . Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Review of Resident #3's Advanced Directive Acknowledgement form showed the resident nor the resident representative had not signed the form upon the resident's admission to the facility on [DATE]. During an interview on 4/10/2024 at 8:22 AM, the Admissions Director stated Resident #3 nor the resident's representative was provided information regarding the right to formulate an advanced directive upon the resident's admission to the facility on [DATE].

Based on facility policy review, medical record review, and interview the facility failed to ensure appropriate notifications were conducted following a resident fall for 1 resident (Resident #454) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Assessing Falls and Their Causes, revised 3/2018, showed .Notify the following individuals when a resident falls .The resident's family .The Attending Physician .The Director of Nursing Services .The Nursing Supervisor on duty . Resident #454 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Depression with Psychotic Features, Anxiety, Hypotension, and Urinary Tract Infection. Review of a Progress Note dated 1/27/2024 at 8:44 PM, showed Resident #454 was .ambulatory with a mostly steady gait, transfers herself numerous times and is at a high safety risk for all ADL's [activities of daily living] related to her severe cognitive decline related to her progressing Lewy Body Dementia [dementia that leads to a decline in thinking, reasoning, and independent function] . Review of a Fall Risk Acuity dated 1/27/2024, showed Resident #454 had a Fall Risk Score of 24, which indicated the resident was at risk for falls. Review of a Brief Interview for Mental Status assessment dated [DATE], showed Resident #454 was moderately cognitively impaired. Review of Resident #454's Progress Note dated 1/30/2024 at 1:56 AM, showed the resident was found on the floor in the doorway of her room. Further review showed there was no documentation to indicate the resident's physician, nurse practitioner (NP), Director of Nursing (DON), or the resident's family representative were notified of the resident's fall. Review of Resident #454's history and physical note dated 1/30/2024 at 2:51 PM, showed no documentation to indicate the Nurse Practitioner was notified of Resident #454's fall on 1/30/2024. Review of Resident #454's event report dated 1/30/2024, showed the resident had an unwitnessed fall with no injuries on 1/30/2024 at 1:00 AM. Continued review showed .NOTIFICATIONS .Physician Notified: No .Resident Representative Notified: No . During an interview on 4/10/2024 at 8:45 AM, the DON stated staff were expected to notify the physician, DON, and family representative of a resident's fall with or without injury. The DON stated .even during the night .some [staff] will wait until the morning if there is no injury .I've told them [staff] not to do that . The DON confirmed Resident #454's physician, family, and the DON were not notified of the resident's fall on 1/30/2024.

Based on facility policy review, review of a daily room cleaning check off sheet, observations, and interviews the facility failed to maintain a safe, clean, homelike environment for 6 residents (Residents #30, #25, #50, #3, #35, and #17) on 1 of 4 hallways observed. The findings include: Review of the facility's policy titled, Homelike Environment, revised 2/2021, showed .Residents are provided with a safe, clean .and homelike environment .The facility staff and management maximizes .the characteristics of the facility that reflect a personalized, homelike setting .The characteristics include .clean, sanitary .environment . Review of an Environmental Services/Housekeeping Daily Room Cleaning Check-Off sheet undated, showed .Toilet Cleaned .Floors Mopped . Resident #30 was admitted to the facility on [DATE] with diagnoses including Diabetes, Schizophrenia, Anxiety Disorder, and Depression. During an observation on 4/8/2024 at 8:05 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was missing. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. During an observation on 4/9/2024 at 7:50 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. During an observation on 4/10/2024 at 8:00 AM, showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. Resident #25 was admitted to the facility on [DATE] with diagnoses including Fracture of Femur, Acute Kidney Failure, Dementia, and Repeated Falls. Resident #50 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Hypertension, and Cognitive Communication Deficit. During an observation on 4/8/2024 at 8:10 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. During an observation on 4/9/2024 at 7:55 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. During an observation on 4/10/2024 at 8:23 AM, showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Dementia, Psychotic Disorder with Hallucinations, Anxiety Disorder, and Hypertension. During an observation on 4/8/2024 at 8:15 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. During an observation on 4/8/2024 at 8:05 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. During an observation on 4/10/2024 at 8:29 AM, showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint and there was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. Resident #35 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Chronic Pain, and Major Depressive Disorder. During an observation on 4/8/2024 at 8:30 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. During an observation on 4/9/2024 at 8:40 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. During an observation on 4/10/2024 at 8:30 AM, showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Psychosis, Anxiety Disorder, and Chronic Pain. During an observation on 4/8/2024 at 8:35 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation on 4/9/2024 at 8:48 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation on 4/10/2024 at 8:36 AM, showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. During an observation and interviews on 4/10/2024 at 8:37 AM, with the Assistant Administrator (AA), Housekeeping Director (HD), and the Maintenance Director (MD) showed Resident #3's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the closet door frame had chipped paint. There was a 4-drawer dresser which showed the 2nd and 4th drawer had missing handles. Further observation showed a 3-drawer nightstand with the 2nd and 3rd drawers broken. The AA, HD, and MD confirmed Resident #'3 room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:40 AM, with the AA, HD, and MD showed Resident #25 and #50 were roommates and shared a bathroom. The bathroom door frame and the closet door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Resident #25's bedside table had chipped wood around the edges of the top of the table and a black 2 drawer dresser with one handle missing on the top left drawer. The AA, HD, and MD confirmed Resident #25 and #50's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:44 AM, with the AA, HD, and MD showed Resident #30's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was missing. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor. Further observation showed the closet door frame and entry door frame had chipped paint. The AA, HD, and MD confirmed Resident #30's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:48 AM, with the AA, HD, and MD showed Resident #17's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed a 3-drawer metal dresser and the legs of the dresser had missing chipped paint with a rust substance showing where the paint was chipped. The AA, HD, and MD confirmed Resident #17's room was not maintained in a safe, clean, homelike environment. During an observation and interviews on 4/10/2024 at 8:53 AM, with the AA, HD, and MD showed Resident #35's bathroom door frame had missing, chipped paint and there was a rust like substance where the paint was chipped. Further observation showed the floor around the toilet had a brownish/black dirty residue at the crease around the toilet where it contacted the floor, and the toilet seat contained a black stain. The closet door frame had chipped paint. A 3-drawer metal dresser was observed, the legs of the dresser had missing chipped paint with a rust substance showing and a missing knob on the top drawer. The AA, HD, and MD confirmed Resident #35's room was not maintained in a safe, clean, homelike environment.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 Residents (Resident #31, #20, and #14) of 10 Residents reviewed for anticoagulant use, and failed to accurately capture active diagnoses for 1 resident (Resident #14) of 18 resident reviewed for accurate MDS assessments. The findings include: Review of the RAI Version 3.0 Manual, Chapter 3, dated 10/2023, showed .Anticoagulant [medication used to prevent blood clotting] .Which may or may not require laboratory monitoring .should be coded on MDS .during the 7-day look-back period .code if taking and indication noted .if the item was used . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, and Depression. Review of Resident #31's current physician order dated 1/5/2024, showed .Eliquis (anticoagulant medication) 2.5 mg [milligram] take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review showed the MDS did not include an anticoagulant medication. During an interview on 4/9/2024 at 3:50 PM, Licensed Practical Nurse (LPN) MDS Coordinator stated Resident #31 received an anticoagulant medication. LPN MDS Coordinator confirmed the anticoagulant medication was not captured accurately on the quarterly MDS assessment dated [DATE]. 49568 Resident #20 was admitted to the facility on [DATE] with Heart Failure, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. Review of Resident #20's current physician order dated 2/29/2024, showed .Eliquis 2.5 mg take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Further review showed the MDS did not include an anticoagulant medication. During an interview on 4/10/2024 at 9:10 AM, the Registered Nurse (RN) MDS Coordinator stated Resident #20 received an anticoagulant medication and confirmed the anticoagulant medication was not captured accurately on the quarterly MDS assessment dated [DATE]. 48100 Resident #14 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Venous Thrombosis (blood clot). Review of Resident #14's current physician order dated 8/26/2023, showed .Eliquis 5 mg take one by mouth twice daily . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired and the active diagnosis list did not include diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. Further review showed Resident #14 did not take an anticoagulant medication. During an interview on 4/10/2024 at 8:10 AM, the RN MDS Coordinator stated Resident #14 received an anticoagulant medication and had active diagnoses of Depression, Anxiety, and Bipolar Disorder. The RN MDS Coordinator confirmed the anticoagulant medication and the active diagnoses of Depression, Anxiety, and Bipolar Disorder was not accurately captured on the quarterly MDS assessment dated [DATE].

Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan to include a colostomy (a surgical procedure which places a hole in the abdominal wall which allows waste to leave the body) for 1 resident (Resident #31) of 18 residents reviewed for care planning. The findings include: Review of the facility's policy titled, CARE PLAN POLICY, dated 12/2016, showed .A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed .for each resident .person centered care plan will .incorporate identified problem areas .reflect the residents expressed wishes regarding care and treatment goals .reflect currently recognized standards of practice for problem areas and conditions . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pulmonary Embolism, Benign Prostatic Hyperplasia, Diverticulitis, Depression, and Dementia with Behavioral Disturbance. Review of an admission Minimum Data Set (MDS) dated [DATE], showed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact, required moderate assistance for activities of daily living (ADLs), and had an ostomy (colostomy). Review of Resident #31's comprehensive care plan revised 3/28/2024, showed the facility had not developed a care plan related to the resident's colostomy. Review of Resident #31's current physician orders dated 4/2024, showed .change colostomy and provide colostomy care . During an interview on 4/9/2024 at 3:50 PM, the Unit Manager confirmed Resident #31's colostomy was not identified on the comprehensive care plan.

Based on medical record review, review of facility documentation, observation, and interview, the facility failed to ensure adequate supervision while toileting for one resident (#1), failed to ensure adequate supervison for one resident (#4), failed to ensure safety device was functioning for one resident (#10) of twenty-three residents reviewed, and failed to ensure a safe enviornment for one shower room of two shower rooms observed. The facility's failure caused actual harm to resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the following: a score of ten on the Brief Interview for Mental Status (BIMS) indicating the resident had moderately impaired cognitive skills; was totally dependent for transfers, toilet use, and personal hygiene; did not walk; was not steady and only able to stabilize with human assistance moving from seated to standing position; and was not steady and only able to stabilize with human assistance moving on and off the toilet. Medical record review of the Assessment of Risk for Falls dated September 22, 2010, revealed the resident was at high risk for falls. Medical record review of the Care Plan reviewed on December 28, 2010, revealed "...potential for falls r/t (related to)...confusion, impaired sense of balance...hx (history) of falls, weakness...observe resident for signs of fatigue when sitting in chair..." Medical record review of the nursing notes dated January 24, 2011, at 9:00 a.m., revealed "In W/C (wheelchair) being taken to BRoom (bathroom) in W/C waiting for transfer, cushion in seat was over edge of seat, resident slipped out of chair to floor, small abrasion on (L) (left) shoulder, cleaned et (and) dressed..." Medical record review of a nursing note written on a Condition Change Form, dated March 5, 2011, no time noted, revealed "CNA (Certified Nursing Assistant) had resident on BSC (bedside commode)...was standing at the sink brushing...teeth (dentures), heard noise, resident had slid off BSC to floor on...face. Had cut on R (right) & forehead, bruised shoulder and nose bleeding-Lifted to gurney & transferred to ER (emergency room )." Medical record review of the hospital emergency record dated March 5, 2011, revealed the resident had a laceration over the left eyebrow and under the left eyebrow and the resident had received sutures to the laceration. Medical record review of a nursing note dated March 6, 2011, at 1:00 a.m., revealed "Resident returned to room from hospital. Transferred to own bed without awakening. Cut to (L) (left) cheek and stitches over left eye..." Medical record review of a nursing note dated March 6, 2011, at 12:10 p.m., revealed "...stitches (upper) (L) eye intact, noted a lot of bruising to eyes and area around. Noted cut to left cheek..." Observation on May 9, 2011, at 1:40 p.m., revealed the resident seated in a recliner beside the bed. Interview on May 10, 2011, at 3:25 p.m., with the Director of Nursing, in the Director of Nursing's office, revealed the resident required line of sight observation when on the commode. Interview on May 11, 2011, at 2:45 p.m, with Certified Nursing Assistant (CNA) #3, in the Director of Nursing's office, revealed on January 24, 2011, CNA #3 had placed the resident in the bathroom, in a wheelchair, with a cushion under the resident's buttocks, and locked the brakes on the wheelchair. Continued interview revealed CNA #3 left the resident in the bathroom and went to the doorway to obtain the assistance of another staff member to transfer the resident from the wheelchair onto the commode. Continued interview with CNA #3 revealed while at the doorway, to request assistance, the resident had unlocked the wheelchair brakes and the cushion under the resident's buttocks slid and the resident had fallen onto the floor. Continued interview with CNA #3 confirmed the resident was unattended at the time of the fall on January 24, 2011. Interview on May 11, 2011, at 3:00 p.m., with CNA #4, in the Administrator's office, with the Administrator present, revealed on March 5, 2011, CNA #4 had placed the resident on the bedside commode. Continued interview revealed while the resident was seated on the bedside commode, CNA #4 had turned away from the resident, and was washing the resident's dentures at the sink at the time of the fall. Continued interview revealed CNA #4 was aware the resident was sometimes dizzy and unsteady. Continued interview confirmed CNA #4 could not see the resident at the time of the fall. Resident #4 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated October 25, 2010, revealed the resident required extensive assistance with two plus persons physical assist for transfers. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance with two plus persons physical assist for transfers. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Review of the facility investigation dated December 26, 2010, revealed, "...CNA (certified nursing assistant) was putting resident to bed and resident was holding to bedrail panicky, said rail was coming off, CNA held (resident) (and) let (resident) to floor...staff educated to ensure adq (adequate) help to support/transfer resident (related to) obesity, (decreased) strength (and) unsteady gait (with) amb (ambulation)/transfer...(no injury)." Review of the facility investigation dated February 10, 2011, revealed, "...CNA was putting resident to bed, resident started going down CNA slid (resident) to floor...Staff educated either to use lift or 2 person transfer for any transfer...(no injury)." Review of the facility investigation dated March 15, 2011, revealed "...tech attempted to transfer resident from bed to w/c (wheelchair) (without) assist (and) did not use lift. (Patient) fell in front of w/c...Staff advised by DON (Director of Nursing) that lift is to be used (at) all times when transferring this resident...(no injury)." Interview on May 10, 2011, at 9:45 a.m., with the DON, in the DON's office, confirmed two person assistance or the lift was not used at the time of the falls on December 26, 2010, February 10, 2011, and March 15, 2011. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with two plus persons physical assist for transfers. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at high risk for falls. Review of the facility investigation dated April 24, 2011, revealed, "...Resident putting self back to bed (after) putting self on bedside commode (without) assist. Resident fell down to...knees...If the resident has a body/bed alarm, was it in place? Yes...Was alarm sounding? No..." (no injury) Interview on May 12, 2011, at 7:25 a.m., with the DON (Director of Nursing), in the DON's office, confirmed the safety device was not functioning at the time of the fall on April 24, 2011. Observation on May 10, 2011, at 1:45 p.m., of the 400 shower room, with the Maintenance Director, revealed a screw missing at the bottom of a corner strip of metal flashing. Further observation revealed the metal flashing protruding out at the bottom approximately ? inch. Interview on May 10, 2011, at 1:45 p.m., with the Maintenance Director, in the 400 shower room, confirmed the screw was missing and the metal flashing was protruding at the bottom.