Every finding on record at Lotus Care Center

Based on observation, interview, and record review, the facility failed to: Ensure the lid on an opened container of jelly was closed.Ensure a package of sandwich meat was stored in a closed container after being opened.Ensure staff were monitoring temperatures in 2/2 dry food storage rooms by placing thermometers inside. These deficient practices had the potential to result in contamination of food served to the residents.Findings: During an observation on 2/11/2026 at 8:20 am of the kitchen refrigerator, there was a square plastic container labeled jelly with a lid not closed on all four sides, and there was an opened plastic bag of sliced meat uncovered. During a concurrent observation and interview on 2/11/2026 at 8:20 am in the kitchen with the [NAME] (CK), the CK stated the lid of the jelly should have been closed on all four sides and the sandwich meat should have been put into a closed container. The CK stated the food could grow bacteria or become contaminated from not being in a closed container. During an observation on 2/11/2026 at 11:30 am in the kitchen's dry storage rooms, there were no thermometers or logs to monitor and document the temperature. During a concurrent observation and interview on 2/11/2026 at 11:30 am in the dry storage room with the Dietary Assistant (DA), the DA stated there was no thermometer to monitor the temperature. The second storage room does not have a thermometer either. The DA stated there should be one in each room because if it gets too hot, the food could become contaminated and make the residents sick. During a review of the facility's policy and procedure (P&P) titled Food Receiving and Storage indicated all foods stored in the refrigerator will be covered, labeled and dated. The P&P also indicated that non-refrigerated foods.will be stored in a designated dry storage unit which is temperature and humidity controlled.

Based on interview and record review the facility failed to:1. Ensure one of five sampled residents (Resident 30) Practitioner Orders for Life-Sustaining Treatment ([POLST] - a medical order form that documents specific medical treatment in the event of a medical emergency) part D of the form was completed.This deficient practice of not having the POLST completed had the potential for Resident 30's wishes not to be carried out in the time of distress. During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 30's diagnoses included pleural effusion (accumulation of excess fluid in the pleural spaces between the lungs), heart failure (heart muscle cannot pump enough blood to meet the body's metabolic needs), and chronic obstructive pulmonary ([COPD]- a chronic lung disease causing difficulty in breathing).During a review of Resident 30's History and Physical (H&P), dated 2/9/2026, the H&P indicated Resident 30 had the capacity to make decisions for activities of daily living. During a review of Resident 30's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 12/22/2025, the MDS indicated Resident 30 cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired.During a review of Resident 30's POLST, dated 4/17/2025, the POLST part D information and signatures were incomplete. During a concurrent interview and record review on 2/12/2026 at 1:31 p.m., with Social Services Director (SSD), Resident 30's POLST, dated 4/17/2025, was reviewed. The POLST indicated part D information and signatures were incomplete. The SSD stated the POLST part D was incomplete. The SSD stated the POLST not being complete will have a big impact on how to move forward with Resident 30's care. During a concurrent interview and record review on 2/12/2026 at 2:44 p.m., with Director of Nursing (DON), Resident 30's POLST, dated 4/17/2025, was reviewed. The POLST indicated part D information and signatures were incomplete. The DON stated when the residents were admitted the Social Service were to assist with the POLST to make sure it was completed. The DON stated it was important to make sure that life sustaining form was completed to provide and honor Resident 30's wishes. During a review of the facility's policy and procedures titled, Practitioner Orders for Life-Sustaining Treatment (POLST), unknown date, the P&P indicated a process for nursing homes to follow when a person who resides or is considered residency, has a POLST form. The P&P indicated at the time of admission, the facility will determine whether the individual has completed a POLST form. The P&P indicated the facility will review the existing POLST for completeness.

Based on observation, interview, and record review the facility failed to: 1. Report to the physician a change in condition when sediments (the solid matter that settles to the bottom of a liquid, such as urine) and cloudy urine were observed in the indwelling urine catheter (a medical device inserted into the bladder to drain urine continuously) tubing for one of one sampled resident (Resident 2). This deficient practice had the potential to delay clinical assessment and timely medical intervention. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/17/2023 and readmitted on [DATE] with diagnoses including malignant neoplasm of prostate (prostate cancer), chronic kidney disease (CKD - condition which the kidneys are damaged and cannot filter blood as well as they should), benign prostatic hyperplasia (BPH - enlargement of the prostate gland that compresses the urethra[a tube that lets urine leave your body], causing symptoms such as weak stream, frequent urination, and difficulty emptying the bladder), and unspecified dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 2's History and Physical (H&P), dated 12/13/2025, the H&P indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2025, the MDS indicated Resident 2 sometimes understands, responds adequately to smple direct communication only. The MDS indicated Resident 2 was maximal assistant (helper does more than half the effort) from staff for activities of daily living (ADLs) such as toileting hygiene, showering, and dressing. The MDS indicated Resident 2 had an indwelling catheter. During an observation on 2/11/2026 at 2:55 p.m. in Resident 2's room, Resident 2's indwelling urinary catheter tubing contained visible sediment and cloudy urine. During an observation on 2/13/2026 at 8:16 a.m. in Resident 2's room, Resident 2's indwelling urinary catheter tubing contained visible sediment and cloudy urine. During a review of Resident 2's Order Summary Report (physician order), dated 12/11/2025, the physician order indicated to monitor signs and symptoms of UTI, urine output, color, odor and sediments every shift, notify physician as needed. During a review of Resident 2's Resident Care Plan titled, Indwelling Catheter, dated 12/11/2025, the care plan indicated, was at risk for UTI, injury, etc. due to indwelling catheter. Monitor urine for sediment, cloudy, odor, blood and amount. Report promptly to the physician. During a concurrent interview and record review on 2/13/2026 at 10:00 a.m., with Registered Nurse (RN) 1, RN 1 reviewed Resident 2's medical record and did not find documentation of a change in condition assessment or physician notification for cloudy urine and sediment in the catheter tubing. RN 1 stated nursing staff assessed indwelling urinary catheters for abnormalities such as cloudy urine or sediment. RN 1 stated these findings signified a change in condition and required staff to notify the physician and implement new orders as received. During an interview on 2/13/2026 at 2:24 p.m., with the Director of Nursing (DON), the DON stated staff are expected to monitor urine in an indwelling catheter and notify the physician when changes such as cloudy urine or sediment are observed. The DON stated early notification allows the physician to evaluate the resident and provide treatment as indicated. During a review of facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated October 2010, the P&P indicated, The purpose of this procedure was to prevent catheter-associated urinary tract infections. Observe the resident for complication's associated with urinary catheters; Observe for other signs and symptoms of urinary tract infection and to report findings to the physician or supervisor immediately. During a review of facility's P&P titled, Change in a Resident's Condition or Status, dated April 2011, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been; instructions to notify the physician of changes in the resident's condition.

Based on observation, interview, and record review, the facility failed to: 1. Maintain equipment in the kitchen when it was observed that the freezer was not kept at a temperature less than or equal to 0 degrees Fahrenheit. This deficient practice had the potential to result in contamination of food served to the residents.Findings: During an observation on 2/11/2026 at 8:40 am in the kitchen, 1/2 freezer's thermometer indicated a temperature of 48 degrees Fahrenheit (F). During a concurrent observation, interview, and record review on 2/11/2026 at 8:30 am in the kitchen with the [NAME] (CK), the thermometer inside the freezer indicated a temperature of 48 degrees F. The CK stated the freezer temperature should be 0 degrees F or less to keep bacteria from growing on the food. A review of the temperature log taped to the freezer titled Reach-In Refrigerator, dated February 2026 was reviewed. The temperature on days labeled 7 through 11 indicated temperatures of -4, 20, 28, 50, and 50 degrees F. The CK confirmed the log was for the freezer and stated that it had been broken for a few days. During a concurrent observation and interview on 2/11/2026 at 11:20 am in the kitchen with the Dietary Supervisor (DS), the DS stated he was aware of the freezer temperature, and that maintenance told him someone was coming to fix it today. The DS agreed that the freezer temperatures of 20 - 50 degrees F were too high for frozen food and that he would move the food to a second working freezer until it was fixed. During an interview with the Maintenance Supervisor (MS), the MS stated that he called for service over the weekend, and someone did come out for repair and arranged to come back with the necessary parts today. During a review of the facility's policy and procedure (P&P) titled Maintenance Service revised December 2009, indicated The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During a review of the facility's P&P titled Food Receiving and Storage indicated Refrigerated foods must be stored below 41 degrees F unless otherwise specified by law.

Based on observation, interview, and record review the facility failed to: 1. Ensure the Minimum Data Set (MDS) resident assessment accurately reflected tobacco use status for two of 13 sampled residents (Residents 8 and 17). The MDS coded the residents as non-tobacco users despite documentation and staff confirming tobacco use within the required look-back period. This deficient practice had the potential to affect the accuracy of resident assessment data used for care planning, quality measures, and facility monitoring of smoking-related safety needs. Findings:A.During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 6/4/2025 and readmitted on [DATE] with diagnoses including epilepsy (recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), schizoaffective disorder-bipolar type (a mental illness that can affect thoughts, mood, and behavior) unspecified dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 8's History and Physical (H&P), dated 2/8/2026, the H&P indicated Resident 8 had fluctuating capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/4/2025, the MDS indicated Resident 8 was assessed to have moderate cognitive (difficulty with thinking) impairment in daily decision making. The MDS indicated Resident 8 was independent for activities of daily living (ADLs) such as eating, oral and toileting hygiene and supervision assistance from staff for showering, upper body dressing and transferring. B.During a review of Resident 17's admission Record, the admission Record indicated the facility admitted Resident 17 on 12/5/2024 and readmitted on [DATE] with diagnoses including epilepsy (recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) unspecified dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 17's History and Physical (H&P), dated 7/29/2025, the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was assessed to have moderate cognitive impairment in daily decision making. The MDS indicated Resident 17 needed supervision for ADLs such as eating, oral and toileting hygiene, showering, dressing and transferring. During a review of Resident 17's Smoking Safety Evaluation, dated 9/10/2025, the smoking safety evaluation indicated Resident 17 does utilize tobacco. During an observation on 2/11/2026 at 1:00 p.m., at the designated smoking area, Resident 8 was observed smoking with staff supervision. During a concurrent interview and record review on 2/12/2026 at 2:15 p.m., with the MDS Coordinator, the MDS Coordinator reviewed Resident 8's admission MDS, dated 6/9/ 2025, the MDS was coded resident was not a tobacco user. The MDS Coordinator stated Resident 8 smoked at the time of the assessment and acknowledged the tobacco use item was coded incorrectly. The MDS Coordinator confirmed the MDS did not accurately reflect the resident's tobacco use status within the required look-back period. During the same interview, the MDS Coordinator reviewed Resident 17's annual MDS dated [DATE], the MDS was coded resident was not a tobacco user. The MDS Coordinator stated Resident 17 smoked at the time of the assessment and acknowledged the tobacco use item was coded incorrectly. During an interview on 2/12/2026 at 2:45 p.m., with the Director of Nursing (DON), the DON stated the MDS must be coded accurately and used to guide resident care planning. The DON stated inaccurate MDS coding would result in an inaccurate plan of care. During a review of facility's policy and procedure (P&P) titled, Resident Assessment Instrument: Minimum Data Set and Comprehensive Care Plan, dated 9/2024, the P&P indicated, A registered nurse shall be responsible for coordinating the input from the appropriate health disciplines to complete the Minimum Data Set (MDS). The RN Shall sign and certify the completion of the assessment.

Based on observation, interview, and record review the facility failed to: 1. Ensure each resident had at least 80 square feet ([sq. ft.]- is a unit of, area measurement) of measured living space in rooms 1, 6, 7, 8, 9, 11,12,15,16, and 17.This deficient practice had the potential to result in residents not being able to move around freely, store personal items, and for staff to have difficulty providing care for the residents due to the lack of space. During an observation on 2/13/2026 at 2:15 p.m., room [ROOM NUMBER] had three occupied residents' beds with a total of four beds in the room.During a review of the Client Accommodations Analysis (form that indicates room measurements and capacity), dated 2/13/2026, the client accommodations analysis indicated the facility had the following room measurements:Room Number Sq Ft Number of Beds 1 125 2 6 138 2 7 156 2 8 156 2 9 141 2 11 295 4 12 295 4 14 295 4 15 295 4 16 295 4 17 295 4 During an interview on 2/13/2026 at 3:14 p.m., with Director of Nursing (DON), the DON stated the residents that occupied these rooms may have limited space to move around. The DON stated the limited space had the potential for the residents to move around in the room and the staff could potentially have limited space to care for the residents.During a review of the room wavier request letter, dated 1/9/2026, submitted by the Administrator (ADM), the waiver request letter indicated resident Rooms 2,3, 4,5, and 10 measured more than the required 80 square feet per resident. The room waiver request letter indicated the waiver will not adversely affect the health, safety, and welfare of each resident.

Based on observation, interview, and record review, the facility failed to ensure the laundry room was free from personal food items. This deficient practice had the potential to spread infection throughout the facility. Findings: During an observation on 10/17/2024 at 7:49 AM, in the laundry room, a bag of dried food items was observed on a chair next to a table where clean linens were folded and where clean residents clothing were stored below. There was also a small orange and a jar of sugar packets in the drawer where personal protection equipment (PPE) was stored. During an interview on 10/17/2024 at 8:01 AM with the Laundry Aide (LA) and Certified Nurse Assistant (CNA) 1, the LA stated staff stored their food in the laundry room, but did not eat it in the laundry room. The LA stated staff ate in the break room. CNA 1 stated having food around clean linen and PPE was an infection control risk which could also cause bad odors in the laundry room. During an interview on 10/18/2024 at 10:33 AM with the Director of Nursing (DON), the DON stated if food items were kept in the laundry area amongst clean linen and PPE it was a potential risk for infection due to cross contamination. The DON stated PPE should be kept in a clean area and ready to use and all food items should be placed in the breakroom with clean and potentially dirty linens. During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated 10/2018, the P&P indicated soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control.

Based on observation, interview, and record review, the facility failed to ensure food items were stored in a manner to prevent the growth of microorganisms that could cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficient practice had the potential to cause food borne illnesses for residents in the facility. Findings: During an observation on 10/15/2024 at 8:40 AM, in the kitchen dry storage room, the following findings were observed: 1. One container of peanut butter was found to have sticky residue and jelly like substance on the outside of the container. 2. One bottle of liquid smoke was found to have sticky residue on the outside of the container. During an interview on 10/15/2024 at 8:48 AM with the Dietary Supervisor (DS), the DS was shown the container of peanut butter and bottle of liquid smoke. The DS stated the container had sticky residue on both the containers and it was important to ensure food containers were clean to prevent attracting pests and roaches to food storage areas. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 12/2008, the P&P indicated food services will maintain clean food storage areas at all times.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) had a care plan developed to address smoking. This deficient practice had the potential to result in a lack of monitoring and risk of injury. Findings: During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 15's History and Physical (H&P), dated 8/15/2024, the H&P indicated Resident 15 could make her needs known but did not have capacity to consent. During a review of Resident 15's Minimum Data Set ([MDS] a standardized federally mandated assessment tool) dated 9/6/2024, the MDS indicated Resident 15's cognition (gaining knowledge and understanding) was intact. During a concurrent interview and record review with the Registered Nurse (RN) 1, Resident 15's care plans were reviewed. RN 1 could not show a care plan was developed for smoking. RN 1 stated a care plan was needed to make goals and interventions to care for the resident. RN 1 stated if there was no care plan for smoking it could be a safety risk because the resident may not receive appropriate monitoring. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated care plans help staff identify potential problems that could affect resident care. The DON stated a smoker should have a care plan because there was a risk for injury and staff needed to create interventions. The DON stated staff could implement interventions to provide proper care and promote quality of life. During a review of Resident 15's Smoking Safety Evaluation, dated 10/17/2024, the evaluation indicated it would be utilized to create the resident's smoking care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated December 2016, the P&P indicated a baseline care plan to meet the resident's immediate needs shall be developed within 48 hours of admission. During a review of the facility's P&P titled, Smoking Policy-Residents, dated July 2017, the P&P indicated any smoking related privileges, restrictions, and concerns shall be noted on the care plan.

Based on observation, interview, and record review, the facility failed to complete a change of condition and notify the doctor of bruising for one out of one sampled resident (Resident 24) who was receiving Eliquis (a blood thinning medication). This deficient practice had the potential to delay necessary care and services for Resident 24. Findings: During a concurrent observation and interview on 10/15/2024 at 3:29 PM, with Resident 24 outside of his room, observed both of Resident 24's hands. Resident 24's hands were observed with a dark purplish discoloration by the thumb with the left side being worse than the right. Resident 24 stated he did not know where the bruising came from, and denied falling, being hit, or accidentally hitting his hands against something. Resident 24 stated the nurses were aware of the bruising but did not recall which nurse knew about it. During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic ischemic heart disease (a condition where the blood vessels in the heart narrow over time and reduces blood flow to the heart muscle). During a review of Resident 24's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 9/13/2024, the MDS indicated Resident 24 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn). During a review of Resident 24's Order Summary Report, the Order Summary Report indicated Resident 24 was receiving Eliquis to prevent deep vein thrombosis (a blood clot that forms in the vein), and staff were to monitor for bruising, skin discoloration, gum bleed, bowel movement, and urine output every shift. During a review of Resident 24's Baseline Care Plan Skin Condition, dated 9/10/2024, the baseline care plan indicated Resident 24 was admitted to the facility with no skin problems. During an interview on 10/17/2024 at 10:47 AM with Registered Nurse (RN) 1, RN 1 stated anything that deviates from the baseline of the resident could be considered a change of condition, and the baseline could be determined by prior documentation and assessment of the resident. RN 1 stated when there was a change in condition, the nurse needed to fill out the change of condition form and notify the doctor to see what the next steps were regarding treatment and monitoring for the resident. RN 1 stated she did not see a change of condition completed for the bruising on Resident 24's hands and did not see documentation that the doctor was notified. RN 1 stated Resident 24 was at risk for bruising because the resident was receiving an anticoagulant (a medication to reduce blood clots from forming in the blood vessels). RN 1 stated there was an order for the charge nurse to monitor for bruising and if they signed off on it, it means they monitored on their shift for bruising. RN 1 stated that by not completing the change of condition form and notifying the doctor, it could delay care for Resident 24. During an interview on 10/17/2024 at 2:12 PM with Licensed Vocational Nurse (LVN), LVN 1 stated nurses document every shift on Resident 24's Medication Administration Record that monitoring was done for bruising regarding Resident 24 receiving Eliquis. LVN 1 stated she was aware that Resident 24 had bruising on both hands but believed they were old and had been there for a long time. During an interview on 10/17/2024 at 2:46 PM with the Director of Nursing (DON), the DON stated if there was a change from the resident's baseline, the staff needed to complete a change of condition form and notify the doctor. The DON stated failing to do so could result in delay of care and treatment for the resident. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 5/2017, the P&P indicated the nurse will notify the resident's Attending Physician when there has been a significant change in residents condition, and need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the Physician, the nurse will make detailed observations and gather relevant information for the provider. During a review of the facility's P&P titled, Anticoagulation- Clinical Protocol, dated 11/2018, the P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. The P&P indicated if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on interview and record review, the facility failed to ensure one out of five sampled employees had an annual skills checklist completed. This deficient practice had the potential to result in substandard quality of care to residents due to a lack of training/assessment. Findings: During a concurrent interview and record review on 10/16/2024 at 3:57 p.m. with the Director of Staff Development (DSD), the employee file for Certified Nursing Assistant (CNA) 2 was reviewed. The DSD stated CNA 2 was hired on 12/21/2022. The DSD could not provide a completed annual skills checklist. The DSD stated CNA 2 should have had an annual skills checklist completed in December 2023. The DSD stated the checklist was important to ensure CNA 2 was competent and understood her job. The DSD stated the check list helped make sure things were done accurately. The DSD stated if the skills check list was not completed, care for the resident may not be done properly. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the skills check list should be completed upon hire and annually. The DON stated the checklist was needed to identify what areas the employee needed to improve. The DON stated if there was no skills checklist completed, staff may not be able to provide appropriate care to the resident. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated May 2019, the P&P indicated facility and resident-specific competency evaluations will be conducted upon hire and annually.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 27) received a monthly Medication Regimen Review ([MRR] evaluation of medications to identify issues) by the pharmacist. This deficient practice put Resident 27 at risk for an adverse drug reaction (harmful response). Findings: During a review of Resident 27's Admission Record, the Admission Record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 27's History and Physical (H&P), dated 6/3/24, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment tool) dated 9/7/24, the MDS indicated Resident 27 had moderate cognitive impairment (problems with the ability to think, learn, and make decisions). During a concurrent interview and record review 10/17/24 at 2:34 p.m. with the Director of Nursing (DON), the facility's MRR binder was reviewed. The DON could not show an MRR was completed for Resident 27 for the month of August 2024. The DON stated the MRRwas needed to identify if a medication needed to be clarified, and if it was given for the right diagnosis. The DON stated if there was no MRR completed there was a potential for the resident to have adverse reactions. During an interview on 10/17/24 at 9:15 a.m. with Registered Nurse (RN) 1, RN 1 stated the MRR was used to identify if medications were the correct dose/frequency. RN 1 stated if the MRR was not completed the resident's safety was compromised. RN 1 stated the resident could have an adverse reaction. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, dated May 2019, the P&P indicated medication regimen reviews are done upon admission and at least monthly.

Based on observation, interview, and record review, the facility failed to ensure three bottles of Enulose (medication used to help with a brain disorder caused by liver disease) in medication Cart 1 was free of sticky residue. This deficient practice put residents at risk for infection related to cross contamination (transfer of bacteria from one object another). Findings: During an observation on 10/15/24 at 12:30 p.m at Medication Cart 1, three bottles of Enulose were found with sticky residue on the outside of the container. During a concurrent observation and interview on 10/15/24 at 12:35 p.m. with Licensed Vocational Nurse (LVN) 1 at Medication Cart 1, LVN 1 picked up the Enulose bottle and stated, It's sticky. LVN 1 stated there was a risk of cross contamination from the hands to bottle. LVN 1 stated a resident could be injured if they were allergic to the medication, and it was transferred to them from the nurse's hands. LVN 1 stated per policy, the bottle should be wiped off. During an interview on 10/17/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated after administering medications the nurse had to ensure there was no spillage on the bottle. The DON stated a sticky bottle was a risk for cross-contamination. The DON stated the resident was at risk for an adverse side effect if they came in contact with the medication. During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Labeling, (no date), the P&P indicated no contaminated drugs shall be available for use.

Based on observation, interview, and record review, the facility failed to ensure all dumpsters were kept closed. This deficient practice had the potential to attract flies and rodents to the dumpster area. Findings: During an observation on 10/15/2024 at 9:15 a.m. one out of two dumpsters were noted to have the lid off. During an interview on 10/17/2024 at 8:02 a.m. with the Maintenance Supervisor (MS), the MS stated the dumpster should be closed at all times. The MS stated if the dumpster was left open it could attract flies and rats. The MS stated rats could get into the facility. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the dumpster should be closed at all times to prevent harboring of insects and odor. The DON stated an open dumpster could attract rodents and insects. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated October 2017, the P&P indicated all garbage containers must be kept covered.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 24). This deficient practice had the potential to negatively impact the continuity of care and delivery of services for Resident 24. Findings: During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels), and depression. During a review of Resident 24's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 9/13/2024, the MDS indicated Resident 24 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn). During a review of Resident 24's Licensed Nurses Progress Notes, dated 9/10/2024 at 5:05 AM, 9/10/2024 at 9:25 AM, 9/10/2024 at 10:10 AM, 9/10/2024 at 10:20 AM, the notes did not contain the name or title of the staff member who wrote the note, only an illegible (unable to read) initial. During a concurrent interview and record review on 10/17/2024 at 10:30 AM with Registered Nurse (RN) 1, Resident 24's Licensed Nurses Progress Notes dated 9/10/2024 at 5:05 AM, 9/10/2024 at 9:25 AM, 9/10/2024 at 10:10 AM, 9/10/2024 at 10:20 AM were reviewed. RN 1 stated the standard for handwritten documentation should be just like if it was documented electronically. RN 1 stated the documentation needed to contain information about what was done and needs to include the date, time, signature, name, and title of the staff member who documented. RN 1 stated all this information was necessary because it tells the reader who wrote the note and performed the task and if clarification was needed, the reader could reach out to that staff member. RN 1stated there was no name or title for the entries made on the Licensed Nurses Progress Notes and if she needed to figure out who wrote the note, sometimes she could recognize the handwriting, or would have to go back and find the staff assignment for the date of the documentation to figure out who wrote the documentation. RN 1stated if there was a printed name and title, then the reader could easily tell who documented in the resident's medical records. During an interview on 10/17/2024 at 2:24 PM, the Director of Nursing (DON), the DON stated handwritten documentation should be just as if it was entered electronically and that should include the note and the date, time, name, and title of the person who documented. The DON stated only licensed nurses such as registered nurses or licensed vocational nurses could document in the resident's progress notes, not certified nurse assistants. The DON stated it would be difficult to follow up with the writer who documented if the note did not have the name or title of the writer. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated documentation of procedures and treatment shall include at a minimum the signature and title of the individual documenting, name and title of the individual(s) who provided the care, and the date and time.

Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS]- a federally mandated assessment tool), for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in inaccurate care and services for Resident 1 due to inappropriate MDS care screening and assessment tool practices. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of uneasiness or fear), and depression. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 was receiving Risperidone (a medication for schizophrenia) 3 milligrams ([mg]- a unit of measurement) twice a day. During a review of Resident 1's care plan, dated 9/13/2024, the care plan indicated Resident had auditory hallucinations (hearing things that are not real) and talks to unseen persons. The care plan indicated Resident 1 was receiving Risperidone. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn), and did not have the diagnosis of schizophrenia checked off under Psychiatric/Mood Disorder. During an interview on 10/17/2024 at 9:44 AM with the Minimum Data Set Nurse (MDSN), the MDSN stated the purpose of the MDS was to provide an overall assessment of the resident. The MDSN stated the MDS contained information regarding the resident's diagnosis, treatment, and medication. The MDSN stated information recorded in the MDS was obtained by reviewing the resident's medical records, interviewing the resident and/or their representative, assessing the resident, and interviewing staff who were caring for the resident. The MDSN looked through Resident 1's medical record and stated Resident 1 had an active diagnosis of schizophrenia but schizophrenia was not checked off in the MDS and it should have been. During an interview on 10/17/2024 at 2:44 PM with the Director of Nursing (DON), the DON stated the MDS was to gather information that pertained to the resident's treatment plan, medication, and diagnosis. The MDSN stated an inaccurate MDS may result in the resident not having an appropriate plan of care in place. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments and the Care Delivery Process, dated 12/2016, the P&P indicated comprehensive assessment, and care planning involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. The P&P indicated the MDS will be completed within 14 days after admission, within 14 days after a resident had a significant change in condition, and annually.

Based on observation, interview, and record review, the facility failed to ensure each resident had at least 80 square feet (sqft, unit of measure of living space in Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17. This deficient practice had the potential to result in residents not being able to move around freely or store personal items, and staff may also have difficulty providing care due to a lack of space. Findings: During an observation on 10/17/2024 at 10:18 a.m., in room [ROOM NUMBER], room [ROOM NUMBER] was observed with four occupied beds. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the residents may have limited space to move around. The DON stated there was a potential less space could affect patient care. During a review of the Client Accommodations Analysis (form that indicates room measurement and capacity), dated 10/17/2024, the client accommodations analysis indicated the facility had the following room measurements: Room Number: Number of beds: Square Feet (sqft): room [ROOM NUMBER] 2 beds 125 sqft room [ROOM NUMBER] 2 beds 138 sqft room [ROOM NUMBER],8 2 beds 156 sqft room [ROOM NUMBER] 2 beds 141 sqft room [ROOM NUMBER] 4 beds 290 sqft room [ROOM NUMBER], 14, 15, 16, 17 4 beds 295 sqft During a review of the room waiver request letter, dated 10/17/2024, submitted by the Administrator (ADM), the waiver request letter indicated the following room measurements: Room Number: Number of beds: Dimensions: Sqft per resident: 1 2 13.9 x 9 ft 62.6 sqft 6 2 9.9 x 14 ft 69.4 sqft 7,8 2 11 x 14.2 ft 78.3 sqft 9 2 11.2 x 14.2 ft 70.6 sqft 10 2 11.2 x 14.2 ft 80.1 sqft 11 4 27.1 x 10.7 ft 72.4 sqft 12,14,15,16,17 4 27.6 x 10.7 ft 73.8 sqft The letter indicated resident Rooms 2, 3, 4, 5 and 10 measured more than the required 80 sqft per resident. The letter also indicated the waiver will not adversely affect the health, safety, and welfare of each resident.

Based on interview and record review, the facility failed to ensure the facility ' s telephone system was able to receive outside calls from one of three resident ' s (Resident 1) representative or an outside caller. This deficient practice had the potential for all the residents in the facility not receiving phone calls from family members. Findings: 1). During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones) on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 9/23/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as toileting hygiene, dressing, and bed mobility. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. During a phone interview on 9/25/2024 at 10:34 a.m., with Family Member 1 (FM 1), FM 1 stated she had been calling the facility ' s phone number at [PHONE NUMBER] every day since Resident 1 was admitted to the facility on [DATE], and her calls were sent to a voicemail. FM 1 stated she had left several voicemails; however, no one had returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/25/2024 at 10:50 a.m., however, the call was sent directly to a voicemail. Surveyor left a message to call back. No facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 9:54 a.m., no one answered the call. A voice message was left and no facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 11:29 a.m., no one answered the call. A voice message was left and no facility staff returned the call. This Surveyor placed a phone call to facility ' s phone number at [PHONE NUMBER] on 9/26/2024 at 3:53 p.m., no one answered the call. A voice message was left and no facility staff returned the call. During a phone interview on 9/26/2024 at 8:55 a.m., with Director of Nursing (DON), the DON stated she was not aware the facility had a voicemail set up for incoming phone calls. The DON stated she did not have access to the facility ' s voicemail. The DON stated when resident ' s family members call and the facility was unable to answer, and did not call back, it could cause the residents and residents ' families frustrations and worries.

Based on observation, interview and record review, the facility failed to provide the low air loss mattress ([LAL] special mattress for wound management) for one of three sampled residents (Resident 1), as ordered by the physician. This failure placed the resident ' s wound at risk for poor healing and worsening condition. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included Stage four (4) pressure ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones)on the sacral (tail bone) region and muscle weakness. During a review of Resident 1 ' s Order Summary Report dated 9/19/2024, the Order Summary Report indicated a LAL mattress every shift. During a review of Resident 1 ' s care plan titled, Alteration in skin condition, dated 9/19/2024, the interventions indicated to provide pressure relieving surface as ordered. During a review of Resident 1 ' s Pressure Sore Risk assessment dated [DATE], Pressure Sore Risk Assessment indicated Resident 1 was at high risk of developing pressure ulcers. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardize care screening and assessment tool) dated 9/23/2024, the MDS indicated Resident could understand and be understood by others. The MDS indicated Resident 1 was dependent and required a two or more person ' s assist with activities of daily living (ADLs) such as toileting hygiene, dressing, and bed mobility. The MDS indicated Resident 1 had a Stage 4 pressure ulcer. During a concurrent observation and interview on 9/25/2024 at 12:04 p.m., with Resident 1, Resident 1 was observed laying on a regular mattress. Resident 1 stated he was supposed to get an air loss mattress 7 days ago because he had a pressure ulcer stage 4 on his back, and he did not get the mattress. During a concurrent observation, interview and record review on 9/25/2024 at 2:00 p.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s physician order dated 9/19/2024 was reviewed. LVN 1 stated the physician ' s order indicated LAL mattress every shift for Resident 1. LVN 1 stated Resident 1 was not on LAL as per physician order. LVN 1 stated the LAL mattress was important for Resident 1 to prevent worsening of current pressure ulcer and to prevent future skin breakdown. During a review of the facility ' s undated policy and procedure (P&P) titled, Physicians Orders, the P&P indicated the facility should provide care and services to the resident in accordance with the physician ' s order.

Based on observation, interview and record review, the facility failed to ensure, two of seven sampled residents (Resident 3 and Resident 32), were assisted with nail hygiene and Resident 32 did not have a dry and scaly feet. This deficient practice had the potential for Resident 3 and Resident 32 to scratch themselves, result in itchy skin and can result in skin breakdown. Findings: a. During a review of Resident 3's admission record, the admission record indicated Resident 3 was admitted on [DATE], with a diagnosis that included cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness.), diabetes (abnormal blood sugar), and hypertension (high blood pressure) During a review of Resident 3's history and physical (H&P) dated 5/3/2023, the H&P indicated Resident 3 had the mental capacity to make needs known but cannot make medical decisions. During a review of Resident 3's minimum data set ([MDS] a standardized care assessment and care screening tool), dated 8/25/2023, the MDS indicated Resident 3's cognitive skills (thought process) was adequate and could understand and be understood by others. The MDS indicated Resident 3 required extensive assistance with activities of daily care such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 3's care plan for Activity of Daily Living (ADL) Functional, dated 8/25/2023, the care plan indicated impaired functional mobility as manifested by: Personal Hygiene, goal indicated grooming hygiene at sink with/without assistance, interventions indicated staff will provide grooming and hygiene. During an observation on 10/21/2023 at 4:19 p.m., in Resident 3's room. Resident 3 was sitting on a wheelchair next to her bed. Resident 3 had both hands nails untrimmed and dirty inside of nails. During an interview on 10/22/2023 at 2:36 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, I assisted Resident 3 with daily care such as shower, change of clothes, diaper change, and making her bed. CNA 1 stated, Resident 3's hands nails are long and needs to cut the nails. CNA 1 stated, we must check the Resident 3 's hands nails during ADL care. CNA 1 stated, it is important to cut the hand nails to Resident 3, so she does not scratch herself or the nurses while proving care. During an interview on 10/22/2023 at 4:56 p.m., with Registered Nurses (RN)1, RN 1 stated the CNAs are responsible in checking the nails while providing ADL care and in trimming them (nails). RN 1 stated it is important to trim the hand nails for Resident 3's safety. RN 1 stated, Resident 3 can scratch herself and could potentially cause skin infections. b. During a review of Resident 32's admission record, the admission record indicated Resident 32 was admitted on [DATE], with a diagnosis that included vascular dementia (cognitive impairment/loss), other abnormalities of gait and mobility (a change to your walking pattern), and other symptoms and signs involving the musculoskeletal system (very common and may arise from joints, bones, muscles, ligaments, tendons, or bursas). During a review of Resident 32's H&P dated 9/8/2023, the H&P indicated Resident 32 had the mental capacity to make needs known but cannot make medical decisions. During a review of Resident 32's MDS, dated [DATE] the MDS indicated Resident 32's cognitive skills (thought process) was adequate and could understand and be understood by others. The MDS indicated Resident 32 required limited assistance with activities of daily care such as dressing, toilet use, personal hygiene, transfer and bed mobility. During a review of Resident 32's care plan for activity of daily living (ADL) Functional, dated 9/8/2023, the care plan indicated impaired functional mobility. One of the interventions indicated staff will provide grooming and hygiene. During a review of Resident 32's care plan dated 9/8/2023, indicated Resident 32 is at risk for skin breakdown related to: history of skin breakdown. The goal indicated Resident 32 will be free from signs and symptoms (s/s) of skin breakdown. One of the interventions indicated to check skin for s/s of breakdown such as redness, open areas daily during care, skin care every shift. During a concurrent observation and interview on 10/21/2023 at 2:17 p.m., in Residents 32's room. Resident 32 was observed sitting on his bed. Resident 32 had dryness on feet and hands. Resident 32 stated, I need some lotion on my legs for my dry skin. Resident 32 hands and feet nails untrimmed. Resident 32 stated, you can cut my nails. Resident 32 stated, I would like my nails to be cut. During an interview on 10/22/2023 at 4:48 p.m., with Resident 32, Resident 32 stated, today the nurse cut my nails on my both hands but not my feet. Resident 32 stated, I want nurse to cut my nails from my feet but not today, tomorrow. During an interview on 10/22/2023 at 4:48 p.m., CNA 2 stated, the CNAs are responsible in cutting residents hands nails. CNA 2 stated, the Podiatrists comes and cuts the nails on the feet. CNA 2 stated, when Resident 32's takes a shower, nurses must assist in putting lotion for the dryness on the skin. CNA 2 stated, they will notify the charge nurses if any issues with skin are found. CNA 2 stated the importance of applying lotion to Resident 32's feet is to keep the skin moist because dry skin can cause skin breakdown. CNA 2 stated, if Resident 32 had dryness in his feet, the nurses need to apply lotion. CNA 2 stated, Resident 32 can be at risk for a cracked skin and could lead to infection. During an interview on 10/22/2023 at 4:56 p.m., with Registered Nurses (RN) 1, RN 1 stated, the CNAs are responsible in assessing resident's hygiene while providing the ADL care and in trimming the nails if needed. RN 1 stated, if the hand nails are long, they should cut it. RN 1 stated it was important to cut Resident 32's hand nails because Resident 2 could scratch himself and as well as the staff, it could prevent any potential skin infection and provide Resident 32 safety. RN 1 also stated, if CNA observed Resident 32 had dry skin during ADLs, the CNAs must apply body lotion to keep the skin moisturized. RN 1 also stated, it could prevent skin tears, or skin infection. During an interview on 10/22/2023 at 5:45 p.m., with Director of Nursing (DON), the DON stated, the CNAs are responsible in cutting the nails during the ADL care. If resident refused, they need to notify the DON or charge nurses. The DON stated, nurses need to trim residents' nails to prevent bacteria getting harbored under the nails, prevent the resident from scratching themselves and prevent skin injuries, and are important for Resident 3 and Resident 32's safety. DON stated, when CNAs see residents' dry skin, CNAs must apply lotion on the skin. The DON stated, if something major was observed during residents' care, the CNAs need to notify the charge nurses. The DON stated, CNAs can apply baby oil or lotion to keep the skin moist. If the skin is dry, it is more prone for skin tears, and itchy skin. The DON also stated, residents' skin and nails must be assessed daily while performing ADL care. During a review of the facility's policy and procedure titled, Nail Care, dated 4/2020, it indicated, All Residents shall provide with basic nursing care that includes good personal hygiene. Certified nursing assistance may provide hygiene services such as cutting of fingernails as directed by the licensed nurse. During a review of the facility's policy and procedure titled, Skin Care, dated 4/2020, it indicated to Inspect the skin on a daily basis when performing or assisting with personal care or ADL. Moisturize dry skin daily. Keep the skin clean and hydrated.

Based on interviews and record reviews, the facility failed to provide residents with a safe environment and failed to perform visual checks, at least every two hours for one of three sampled residents (Resident 1) to prevent Resident 1 from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the facility on 3/18/2023. Resident 1 had impaired cognition with diagnosis including Alzheimer ' s disease (a progressive mental deterioration that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), anxiety (intense, excessive, and persistent worry and fear about everyday situations), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dysphagia (difficulty swallowing foods or liquids), and chronic obstructive pulmonary disease [(COPD) a group of lung diseases that block airflow and make it difficult to breathe]. Resident 1 was assessed as moderate risk for elopement. It was unknown how Resident 1 left the facility with his wheelchair and cane. As a result, Resident 1 left the facility unsupervised and was exposed to harsh environmental conditions including cold weather and rain, had a potential of being hit by a car, and had a potential for medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (a harmful reduction in the amount of water in the body), and death. There is a potential for Resident 1 to be without medications from 3/18/2023-3/28/2023, a total of ten (10) days. Resident 1 has still not been found on 3/29/2023. On 3/22/2023 at 10:44 a.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (Admin) due to the facility ' s failure to closely monitor and document Resident 1 ' s whereabouts to prevent Resident 1 from leaving the facility unsupervised. On 3/24/202 at 9:51 a.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed on 3/24/23 at 1:20 p.m., in the presence of the DON. The IJRP included the following immediate actions: 1. After Resident 1 eloped from the facility on 3/18/23, the facility immediately conducted a head count on an hourly basis and implemented and documented on a head count log signed by Licensed nurses, Certified Nursing Assistance (CNAs) and department heads 2. The facility contacted the police department at approximately 8:00 am., to notify of Resident 1 disappearance. Facility has been searching since 3/18/23 exhaustively through today and will continue efforts to locate Resident 1. The facility ' s staff has contacted and kept a log of all hospitals and emergency room s (ERs) contacted daily, various neighborhoods in multiple counties, as well as visiting numerous homeless shelters, parks and tents, local shopping centers and stores. The Metro station was provided a description of Resident 1 to check all railways and buses. Resident 1 has not been located however facility is continuing to call and visit locations and neighborhoods. 3. Facility contacted an outside security agency to provide additional monitoring of the facility on 3/19/23. 4. The facility has hourly head count documented on a log since 3/18/23. The Director of Nursing (DON) and Director of Staff Development (DSD) provided in-service to all staff regarding the importance of conducting and documenting the head count hourly using the facility ' s daily census. Licensed nurses and CNAs continue to utilize the facility daily census in accounting each resident in the building during the hourly head count. Licensed nurses and CNAs, under the instruction of the DON, are responsible for conducting hourly rounds. The facility department managers, during their shift, will also conduct hourly rounds and ensure compliance. Licensed Nurses are primarily responsible to conduct and document hourly rounds on all shifts. Residents assessed to be moderate to severe risk for elopement will be identified to staff using a green sticker on their door tag. Residents identified as moderate to severe risk for elopement now have and continue to have a green sticker next to their name plate on the resident ' s door. An in-service was provided to all staff regarding the green sticker notification by the DSD and DON on 3/22/23. The DON provided in-services on 3/22/23 to all department heads (Administrator, Director of Staff Development, Minimum Data Sheet Nurse, Social Services Designee, Medical Records Director, Rehab coordinator, Activities Director, Dietary Supervisor, Business Office Manager) to visually check residents with a green sticker on their door tag during rounds. 5. As of 3/19/23, the facility has 24 hours/7 days a week security personnel monitoring the facility. In the event staff calls off, the outgoing security personnel will stay while awaiting a replacement or until the agency can provide a security personnel. In the event staffing proves challenging, a department head will be called in to monitor until the contracted security agency provides a replacement to ensure 24 hours monitoring. During the daily huddle on each shift licensed nurses will document and inform CNAs which residents are at risk for elopement for additional oversight and monitoring of those residents. The DON provided in-services to licensed nurses on 3/19/23 and will ensure sustained compliance during daily rounds. Security personnel during their rounds document on each shift ensure alarms are tested and functioning and documented on a log, in-services provided on 3/22/23 by DON and DSD. Maintenance Supervisor, weekly checks alarms to ensure functioning and in good working order. Should alarm malfunction the maintenance supervisor will be immediately notified, and the supervisor will change alarm with extra new alarms kept in the maintenance office. 6. All residents assessed to be at moderate to severe risk for elopement will have individualized care plans with interventions in place upon admission and reviewed quarterly and as needed by the Minimum Data Set ([MDS] an assessment and care screening tool) nurse and DON. During daily huddle, each shift licensed nurses will discuss with CNAs interventions and identify residents at risk for elopement. The facility will continue to provide education to the residents regarding the risks of leaving the facility. The facility will develop a care plan for residents when verbalizing they want to leave the facility, and their physicians will be notified for further interventions. Findings: During a review of Resident 1 ' s Face Sheet (admission record), dated 3/20/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Alzheimer ' s disease (a progressive mental deterioration that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), anxiety (intense, excessive, and persistent worry and fear about everyday situations), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dysphagia (difficulty swallowing), cognitive communication deficit, protein -calorie malnutrition (low energy intake, weight loss, loss of subcutaneous fat [a type of fat that's stored under the skin], loss of muscle mass, fluid accumulation, and decreased hand grip strength), and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that blocks airflow and make it difficult to breathe). During a review of Resident 1 ' s general acute care hospital (GACH) Psychiatric Initial Evaluation (Psych Eval), dated 2/10/2023, the GACH Psych Eval indicated Resident 1 was admitted to the GACH on 2/10/2023 with psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). and suicidal ideation ([SI] when someone thinks about killing themselves) by overdosing on medication. During a review of Resident 1 ' s GACH History and Physical (H&P), dated 2/10/2023, the H&P indicated Resident 1 was placed on AWOL (absent without leave)/Assaultive/Suicidal Precautions. During a review of Resident 1 ' s, H&P from the facility, dated 2/16/2023, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance (staff provided non-weight-bearing assistance) activities of daily living (ADLs) such as transferring, walking, and moving in the unit. The MDS indicated Resident 1 required extensive assistance (staff provided weight bearing support) for dressing and toilet use. The MDS also indicated Resident 1 used a wheelchair for movement. The MDS indicated Resident 1 used an antipsychotic (medication primarily used to manage psychosis [mental disorder characterized by a disconnection from reality], particularly in schizophrenia) for seven out of the seven days of the week. During a review of Resident 1 ' s physician ' s order dated 2/16/2023, the physician ' s order indicated Risperdal (medication used to treat certain mental/mood disorders such as schizophrenia), 1 milligram ([mg] unit of measurement), two times daily (BID), and Neurontin (medication used to relieve nerve pain) 200 mg, 1 capsule three times daily (TID) for polyneuropathy (a condition in which a person ' s peripheral nerves are damaged). During a review of Resident 1 ' s Elopement Risk Evaluation dated 2/16/2023, the evaluation indicated Resident 1 was at moderate risk for elopement and required care planning for elopement. Resident 1 ' s history of elopement from a previous facility and diagnosis of Alzheimer ' s disease, were not considered during the elopement risk assessment to place the resident at high risk for elopement. During a review of Resident 1 ' s care plan, titled Elopement Risk, dated 2/16/2023, the interventions indicated staff will encourage Resident 1 to notify the nurse if he had to leave the facility for any reason, assess/record/report to the doctor (MD) risk factors for potential elopement like wandering, repeated requests to leave facility, statements such as I am leaving and I wanna go home, attempt to leave the facility, elopement attempts from previous facility or hospital. The care plan intervention also indicated staff would observe Resident 1 ' s location with visual checks, at least every two hours. During a review of Resident 1 ' s Change in Condition (COC), assessment dated [DATE] and timed 6:30 a.m., the COC indicated Licensed Vocational Nurse (LVN) 1 noticed that on 3/18/2023 at 6:30 a.m., Resident 1 was not in his bed when LVN 1 was doing rounds. The COC indicated LVN 1 looked around the facility and gathered incoming staff to drive around the neighborhood to look for Resident 1 but did not find the resident. During an interview on 3/20/2023 at 2:14 p.m., with LVN 2, LVN 2 stated Resident 1 was alert and aware but had episodes of confusion and during those episodes of confusion, Resident 1 would say he had to go to work. LVN 2 stated she performed visual checks on Resident 1 ' s location at least every 2 hours during her shift but did not document anywhere in the resident ' s medical record that visual checks were done. LVN 2 stated, it was important to document all care given, to indicate it was done. During an interview on 3/20/2023 at 3:13 p.m., with the Director of Nursing (DON), the DON stated there were two security guards during the day in charge of monitoring residents. The DON stated at night, the nursing staff were supposed to monitor exit doors of the facility during rounds to prevent residents from leaving the facility unsupervised. The DON stated staff was to perform visual checks on Resident 1 at least every two hours and document on the resident ' s chart. The DON stated unfortunately, staff did not document. During an interview on 3/20/2023 at 3:45 p.m., with LVN 1, LVN 1 stated Resident 1 had dementia, was confused, and had sundowning syndrome (a state of confusion that can cause restlessness, agitation, irritability occurring in the late afternoon and lasting into the night). After dinner, Resident 1 would get up from his wheelchair and state he had to go to work. LVN 1 stated on 3/18/2023 she noticed Resident 1 was no longer in his room at 6:30 a.m. while she (LVN 1) was doing her final rounds. She was looking for Resident 1 and noticed his wheelchair and his cane were missing. LVN 1 stated she did not remember the last time she performed visual checks on Resident 1. LVN 1 stated she did not document Resident 1 ' s whereabouts in the resident ' s medical record. LVN 1 stated she did not hear the door alarms that night. LVN 1 said if the alarm on the doors were on, it would have sounded, if Resident 1 went through the doors. During an interview with the Administrator (Admin) on 3/21/2023 at 9:59 a.m., the Admin stated the facility ' s security footage was not available because the recordings reset every Sunday. The Admin stated he forgot to review the recordings before it reset. The Admin stated on 3/20/2023, he called the previous facility where Resident 1 resided prior to hospitalization and was told Resident 1 would repeatedly sign himself out and not come back to that facility. The Admin stated the facility was unaware of Resident 1 ' s previous behavior because the facility did not call Resident 1 ' s previous facility to inquire. During a concurrent interview and record review on 3/21/2023 at 12:27 p.m., with the DON, Resident 1 ' s Elopement Risk Evaluation dated 2/16/2023 was reviewed. The DON stated Resident 1 was admitted to the GACH for SI and feelings of hopelessness on 2/9/2023. The DON stated an elopement risk evaluation was done for the resident on 2/16/2023 and a care plan written. The DON stated staff was supposed to perform visual checks on Resident 1 but were not required to document routine visual checks. The DON stated on weekends, the entrance to the facility was through the main entrance, ambulance entrance, and hallway exit. The DON stated the three main entrances/exits had alarms on the door. The DON also stated the facility did not know how Resident 1 eloped from the facility on 3/18/2023, because the wires of the facility ' s security cameras were damaged by the rain and did not work well. The DON stated there is a likelihood Resident 1 had not been medicated since eloping from the facility on 3/18/2023 because the resident had still not been located. During an interview on 3/21/2023 at 1:30 p.m., with the Maintenance Supervisor (MS), the MS stated all alarm doors were tested on Wednesdays every week. The MS stated if Resident 1 eloped from any of the exit doors, the alarms would have gone off and the staff would have been alerted to stop the resident from leaving the facility unsupervised. The MS stated there were no alarms on the windows, and that the windows could be opened from residents ' rooms including Resident 1 ' s room. During an interview on 3/21/2023 at 1:44 p.m., with the MS, the MS stated Resident 1 ' s room window can be opened from the resident ' s room. The MS stated Resident 1 could push the window open and get out through the window to the alley. During an interview on 3/21/2023 at 2:16 p.m., with LVN 2, LVN 2 stated Resident 1 would say he had to go to work. LVN 2 stated she did not document Resident 1 ' s statement and did not report it to the MD. LVN 2 stated Resident 1 had a history of suicidal ideation and should have been monitored or supervised more often than just every two hours, per the resident ' s elopement risk care plan, to prevent the resident from eloping. LVN 2 stated staff should have monitored Resident 1 every two hours because the resident stated he wanted to go to work. During a concurrent interview and record review on 3/21/2023 at 4:30 p.m., with LVN 1, Resident 1 ' s Elopement Risk care plan dated 2/16/2023, was reviewed. LVN 1 stated the care plan interventions indicated to document and report to the MD risk factors for wandering, such as Resident 1 stating he needed to go to work. LVN 1 stated she did not document Resident 1 saying that he had to go to work and did not report to the MD because she redirected Resident 1 successfully. LVN 1 stated that when Resident 1 stated he wanted to go to work, she should have educated the resident on the risk of leaving the facility. LVN 1 stated Resident 1 had Alzheimer ' s and was at risk for elopement. LVN 1 stated she was not concerned about the resident leaving the facility at the time because Resident 1 was redirectable. LVN 1also stated Resident 1 ' s Elopement Risk Evaluation was inaccurate because it scored the resident as a 15 instead of an 18 or more, considering Resident 1 ' s diagnoses of Alzheimer ' s and statement I want to go to work. During a telephone interview on 3/23/2023 at 10:45 a.m., with CNA 1, CNA 1 stated the last time she saw Resident 1 was on 3/18/2023 at 6 a.m., while she was doing her hourly rounds and Resident 1 was in his room in his wheelchair. CNA 1 stated she did not document anywhere when she saw Resident 1 because the charge nurse did not tell her to document Resident 1 ' s visual checks. CNA 1 stated she did not hear any alarms go off during that shift. CNA 1 stated the alarm was very loud and if it went off, everyone would have heard it. CNA 1 stated Resident 1 would talk about missing his wife and that his daughter was coming to see him. During a record review of the Accuweather forecast report for Los Angeles area from 3/18/2023 to 3/24/2023 Los Angeles, CA Monthly Weather | AccuWeather, the temperature was in the low 60's degree Fahrenheit ([ F] unit of measurement) to high 50's F. It also indicated some days were, rainy, cloudy and with thunderstorms. During a record review of https://crimegrade.org/murder-90043, the Los Angeles city's overall crime grade for violent crimes for zip code 90043, where the facility was located, was an F grade (meaning most dangerous). During a review of the facility ' s policy and procedure (P&P) titled Gate Monitoring, dated 2/18/2018, the P&P indicated the facility will protect residents ' safety in the facility. During a review of the facility ' s P&P titled Elopement Risk Assessment, undated, the P&P indicated interventions for elopement include notification of physician for changes in behavior, such as increasing insistence or attempts to leave and environmental controls such as a functional alarm system for egresses.

Based on observations, clinical record reviews, and interviews with staff, of two medication passes on 6/9/12 and 6/10/12 at 8:15 a.m., the facility's nursing staff failed to ensure that it was free of a medication error rate of 5 percent (%) or greater. The facility had a cumulative medication error rate of 23.5% consisting of twelve errors in a sample size of 51 opportunities for error. Included in the 23.5% medication error rate were observations of significant medication errors involving the administration omission of [MEDICATION NAME] 0.1 mg, a medication to treat high blood pressure that was indicated as a stroke preventative for Random Sample (RS) 3. [MEDICATION NAME] was ordered as whenever necessary (PRN) when the resident's systolic blood pressure was more than 160 millimeter mercury (mmHg), however, the licensed nursing staff consistently were not administering the medication to the resident as ordered. The medication error rate of 23.5% also included the following medication errors: 1. Administration of [MEDICATION NAME], a cough [MEDICATION NAME], to residents without physician's orders for Resident 9. This deficient practice had the potential to cause adverse reactions and complications. 2. Administration omissions of [MEDICATION NAME] eye drops for [MEDICAL CONDITION] (an eye condition related to high pressure in the eye that lead to [MEDICAL CONDITION]) for Random Resident (RS) 1. This deficient practice had the potential to cause increased pressure to the resident's eye. 3. Administration of eye drops, used for treatment of [REDACTED]. This deficient practice had the potential for the artificial tears to wash out the [MEDICAL CONDITION] eye drops previously given. 4. Administration of calcium without vitamin D as ordered (vitamin D is used in conjunction with calcium for better absorption) and administration of multivitamin in tablet form that was crushed instead of the liquid form that was administered through a gastrostomy tube (GT, a tube inserted through a small surgical incision in the abdomen into the stomach and is used for long-term nutrition and medication administration) for Resident 1. This led to difficulty administering the medications through the GT, and had the potential for clogging the GT. 5. Administration of incorrect form of aspirin to RS 2. This deficient practice had the potential to cause different absorption time. 6. Administration omission of a multivitamin for Resident 3. This medication was given as nutritional supplement for Resident 3's [MEDICAL CONDITION]. Omission in administration had the potential to cause delay in treatment. 7. Administration omission of two stool softeners for RS 3. This deficient practice had the potential to cause constipation. A situation of Immediate Jeopardy (IJ) was declared by the survey team on 6/11/12 at 2 p.m. The facility administrator, assistant administrator, director of nursing (DON), quality assurance nurse and the owner were immediately notified of these serious findings involving medication errors. During the IJ notification meeting, the facility representatives stated that they were aware of the high medication error rate and would start in-servicing care staff with medication pass observations. Following the facility submission of an acceptable immediate plan of correction (POC) on 6/12/12 at 1 p.m. to address the immediate jeopardy concerns, notification to family and attending physician of the residents involved, in-service given to the licensed nurses by the pharmacy consultant, medication observations conducted by the pharmacy nurse consultant, replacement of licensed nurses involved, and implementation of a 2-medication carts and 2 licensed nurses system for conducting the medication pass, another medication pass observation was performed on 6/12/12 at 1 p.m. The facility had a cumulative medication error rate of 4.76 % consisting of one error in a sample size of 21 opportunities for error. The medication error rate of 4.76 % included omission to check heart rate before administration of [MEDICATION NAME], a medication to reduce high blood pressure for RS 5. In summary, the cumulative facility medication error rate from 6/9/12 to 6/12/12 was 18 %consisting of 13 errors with 72 opportunities for error. The situation of immediate jeopardy was lifted on 6/12/12 at 5 p.m. and the facility administrator, assistant administrator, director of nursing, quality assurance nurse and the owner of the facility were notified. After the situation of immediate jeopardy was lifted on 6/12/12 at 5 p.m., the scope and severity for F332 was reduced to F (substandard quality of care). Findings: 1. During the morning medication pass observation on 6/9/12, Licensed Vocational Nurse (LVN) 1 administered medications to RS 1, Residents 9 and 1, and RS 2. Following the observation of the medication pass, a review of the residents' clinical records revealed the following information: a. A review of the physician's order dated 8/3/11 revealed an order for [REDACTED]. On 6/9/12, at 2:46 p.m., during an interview, LVN 1 stated the [MEDICATION NAME] was not in the cart, and he could not find the medication since yesterday. He stated he did not administer the [MEDICATION NAME] eye drop to the resident on 6/8/12. However, a review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation for the reason why the medication was not administered. There was no documented evidence of notification to the physician for missed doses. A clinical record review for RS 1 revealed a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. Review of the physician's order dated 2/17/12 revealed an order for [REDACTED]. During the medication pass observation on 6/9/12 at 8:20 a.m., LVN 1 gave [MEDICATION NAME], then artificial tears consecutively to Resident 9's right eye one minute apart. On 6/10/12 at 10:50 a.m., during an interview, LVN 1 stated the consultant told him to wait for one minute between eye drops. Review of the facility's undated policy and procedure on eye medications indicated when two or more different eye medications must be administered at the same time, staff were to allow a five minute period between each administration of eye medication. During the medication pass observation on 6/9/12, at 8:20 a.m., LVN 1 gave Resident 9 [MEDICATION NAME] (a cough [MEDICATION NAME]) 100 milligrams (mg) per 5 milliliters (ml), 25 cubic centimeters (cc). However, a review of the physician's orders did not indicate an order for [REDACTED]. On 6/9/12, at 2:46 p.m., during an interview, LVN 1 stated, "If one time use, can give a cough medicine when the resident requested for it." On 6/11/12, at 11:51 a.m., during an interview with Resident 9, she stated she still coughs a lot. She stated she had the cough for 5 or 6 days and had been receiving cough medication every day. A review of the MAR for June 2012 revealed LVN 1 did not document the administration of the cough medication to Resident 9. A clinical record review for Resident 9 revealed a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. c. A review of physician's order dated 3/22/12 revealed an order for [REDACTED]. On 6/9/12 at 2:46 p.m., during an interview, LVN 1 stated, "Maybe I have not seen the orders very well." A clinical record review for Resident 1 revealed a [AGE] year- old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. d. A review of physician's order dated 1/17/11 revealed an order for [REDACTED]. On 6/9/12 at 2:46 p.m., during an interview, LVN 1 did not make any comment why he gave chewable aspirin to the resident and let the resident swallow the pill without instructing the resident to chew the pill. A clinical record review for RS 2 revealed a [AGE] year- old male, who was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. 2. During the morning medication pass observation on 6/10/12, LVN 2 administered medications to Resident 3 and RS 3. Following the observation of the medication pass, a review of the residents' clinical records revealed the following information: a. A review of physician's order dated 11/29/11 revealed an order for [REDACTED]. A review of the MAR for June 2012 revealed LVN 2 signed the MAR indicated [REDACTED] On 6/10/12 at 4:08 p.m., during an interview, LVN 2 stated their policy and procedure was to pour, pass, and sign. However, LVN 2 did not pour and pass but signed that the multivitamin was given. A clinical record review for Resident 3 revealed a [AGE] year- old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. b. A review of the physician's order dated 4/3/12 revealed an order for [REDACTED]. During the medication pass observation on 6/10/12, at 8:40 a.m., LVN 2 took RS 3's blood pressure and got a reading of 165/108 mmHg. However, LVN 2 failed to administer [MEDICATION NAME] 0.1 mg PRN to the resident. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 6/3/12, the resident's sbp was 188 at 9 a.m., on 6/4/12, the sbp was 187 at 9 p.m., on 6/5/12, the sbp was 168 at 9 a.m., and on 6/10/12, the sbp was 165 at 9 a.m. however, RS 3 never received [MEDICATION NAME] 0.1 mg according to physician's order. Diastolic blood pressure (dbp (bottom number)) ranged from 69-90, however during the medication pass observation on 6/10/12, RS 3's dbp was 108, abnormally high for the resident and the physician was not notified. Further review of the physician's order dated 4/3/12 revealed an order for [REDACTED]. On 6/10/12, at 4:08, during an interview, LVN 2 did not make any comment why she failed to give [MEDICATION NAME] to RS 3. Later, LVN 2 stated, "Maybe I did not see it. Maybe I was in a hurry to do the med pass." LVN 2 also stated she rechecked the resident's blood pressure but could not remember the reading and did not document it. However, LVN 2 was still observed passing medications to other residents due for 9 a.m. at 11:12 a.m., more than two hours past the scheduled time. A review of the MAR for June 2012 indicated LVN 2 signed the MAR indicated [REDACTED]. On 6/10/12, at 4:08 p.m., during an interview, LVN 2 stated she did not give the [MEDICATION NAME] and [MEDICATION NAME] sodium. She stated their policy and procedure was to pour, pass, and sign. However, LVN 2 did not pour and pass, but signed the MAR indicated [REDACTED]. Cross refer to F309 and F333.

Based on observation, interview, and record review, the facility's nursing staff failed to ensure that residents were free of significant medication errors for two randomly selected (RS) residents (RS 3 and RS 4). Prescribed antihypertensive medications were not consistently being administered as ordered by the physician for extended periods of time. This deficient practice could lead to complications including chest pain and stroke. RS 3 was prescribed a [MEDICATION NAME] (treats high blood pressure) 0.1 milligrams (mg) one tablet orally every six hours for systolic blood pressure (the top number) more than 160 millimeter mercury (mmHg) whenever necessary (PRN). This medication was not administered and omitted for four instances in June 2012 and five instances in May 2012. RS 4 was prescribed [MEDICATION NAME] (treats high blood pressure) 0.1 mg orally whenever necessary (PRN) for systolic blood pressure more than 160 mmHg. This medication was not administered and omitted for four instances in June 2012, five instances in May 2012, seven instances in April 2012, three instances in March 2012, three instances in February 2012, and six instances in January 2012. The facility nursing staff also failed to reassess and evaluate the residents during episodes of high blood pressure and to notify the physician accordingly. On 6/11/12, at 2 p.m., the facility administrator, assistant administrator, director of nursing, quality assurance nurse and the owner were notified that a situation of Immediate Jeopardy (IJ) existed due to the facility's failure to consistently administer antihypertensive medications accurately as prescribed for RS 3 and RS 4. Record reviews conducted on 6/12/12 following an afternoon medication pass observation revealed no additional significant errors. The situation of immediate jeopardy was lifted on 6/12/12, at 5 p.m. After the situation of immediate jeopardy was lifted on 6/12/12, at 5 p.m., the scope and severity for F333 was reduced to F (substandard quality of care). Findings: 1. On 6/10/12, at 8:15 a.m., Licensed Vocational Nurse (LVN) 2, who was the nurse assigned to administer medications to all 30 residents in the facility that morning, was oberved passing medications. Random sample (RS) 3 was waiting for his medications by the medication cart while sitting in his wheelchair. LVN 2 took RS 3's blood pressure (BP), and got a reading of 165/108 millimeter mercury (mmHg). LVN 2 told RS 3 he had a very high blood pressure. LVN 2 did not verify the findings by rechecking the resident's blood pressure again using another BP apparatus and did not assess for any accompanying symptoms. LVN 2 administered routine medications to RS 3. A review of the physician's orders [REDACTED]. On 6/10/12, at 4:08 p.m., during an interview, LVN 2 did not make any comment why she failed to give [MEDICATION NAME] to RS 3. Later, LVN 2 stated, "Maybe I did not see it. Maybe I was in a hurry to do the med pass." LVN 2 also stated she rechecked the resident's blood pressure but could not remember the reading and did not document it. However, LVN 2 was still observed passing medications to other residents due for 9 a.m. at 11:12 a.m., more than two hours past the scheduled time. On 6/11/12, at 2:23 p.m., during a telephone interview, RS 3's physician stated his expectation for the nurses to monitor the resident's blood pressure more frequently if needed for high blood pressure. A review of RS 3's medical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 4/3/12 for RS 3's risk for exacerbation (recurrence) of elevated blood pressure and its acute (sudden) and chronic (persisting for a long time or constantly recurring) complications and [DIAGNOSES REDACTED]. These were not implemented. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 6/3/12, the resident's sbp was 188 at 9 a.m., on 6/4/12, the sbp was 187 at 9 p.m., on 6/5/12, the sbp was 168 at 9 a.m., and on 6/10/12, the sbp was 165 at 9 a.m. however, RS 3 never received [MEDICATION NAME] 0.1 mg according to physician's orders [REDACTED]. Further review of the MAR for RS 3 indicated for the month of May 2012, there were 5 instances the resident's systolic blood pressures were more than 160 mmHg however, the resident was not given the PRN [MEDICATION NAME] as ordered. 2. On 6/10/12, at 8:54 a.m., RS 4 was observed approaching the medication cart in his wheel chair. He had left sided weakness and a splint applied to his left hand. RS 4 requested his medications. LVN 2 took RS 4's blood pressure and got a reading of 158/107 mmHg. LVN 2 told the resident he had a very high blood pressure. LVN 2 did not verify the findings by rechecking the resident's blood pressure again using another BP apparatus and did not assess for any accompanying symptoms. On 6/10/1,2 at 4:08 p.m., during an interview, LVN 2 stated she did not reassess RS 4 nor recheck his blood pressure. A review of the physician's orders [REDACTED]. On 6/11/12, at 2:32 p.m., during a telephone interview, RS 4's physician stated high blood pressure could lead to stroke and [MEDICAL CONDITION]. A review of RS 4's medical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan, dated 10/30/11 for RS 4's risk for exacerbation of elevated blood pressure and its acute and chronic complications and [DIAGNOSES REDACTED]. These were not implemented. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 6/5/12, the resident's sbp was 168 at 9 a.m. and 9 p.m., and on 6/7/12 sbp of 184 at 9 a.m. and 9 p.m. however, RS 4 never received [MEDICATION NAME] 0.1 mg according to physician's orders [REDACTED]. Further review of the MARs for RS 4 indicated for the month of May 2012, there were 5 instances the resident's systolic blood pressures were more than 160 mmHg, however, the resident was not given the PRN [MEDICATION NAME]. On April 2012, there were 7 instances and no [MEDICATION NAME] was given. On March 2012, there were 3 instances and no [MEDICATION NAME] was given. On February 2012, there were 3 instances and no [MEDICATION NAME] was given. On January 2012, there were 6 instances and no [MEDICATION NAME] was given. A review of the facility's undated policy and procedure titled, "Vital Signs Monitoring" indicated if abnormal findings were obtained, verify the findings by rechecking the blood pressure again using another bp apparatus. The Licensed nurse was to notify the physician of the abnormal findings and any corresponding symptoms or complaints. Cross Refer to F332.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment was free of accident hazards; and each resident receives adequate supervision and assistance to prevent accidents for three of six sampled residents (15, 16, and 12). For Resident 15, who had an actual fall, was determined to be high risk for fall, and was using a front wheel walker for ambulation, did not receive adequate supervision and monitoring of his whereabouts in the facility. On March 24, 2011, the resident was left unsupervised, went out to the patio using his front wheel walker and fell . Also, the resident, who was a smoker, was not assessed by the interdisciplinary team (IDT) for the smoking program for safety. These deficient practices resulted in a fall for Resident 15, who sustained a left distal radius fracture on March 24, 2011, and was transferred to an acute hospital and underwent a Closed Reduction Percutaneous Pinning. According to the Canadian Orthopaedic Foundation, not dated, indicated percutaneous pinning is an insertion of pins into the bone through small puncture wounds in the skin for stabilization of a fracture of a dislocated joint that was realigned by closed reduction: Source:https://www.canorth.org According to the MD Guidelines, not dated, indicated a closed reduction was accomplished by applying traction at or across the fracture to relax and lengthen the muscles then manipulating the bone fragments back in position and holding this newly achieved position with cast or splint. Source:http://www.mdguidelines.con/reduction-of-fracture-or-dislocation For Resident 16, who was determined to be high risk for fall, was using a front wheel walker as an assistive device for ambulation and with a left leg brace, the facility failed to ensure during the physical therapy (PT) ambulation exercises that it was provided in areas free of pools of water. This deficient practice had the potential for the resident to slip/fall and sustain an injury. For Resident 12, who was high risk for fall and smoked in the patio, was not assessed for smoking safety and was not provided adequate supervision. The facility failed to identify hazard in the resident's environment by failing to ensure seat cushion used as pressure relieving device in the wheelchair was secured and would not slip underneath the resident. Resident 12 had sustained a fall from his wheelchair on June 13, 2011 around 4 p.m. in the patio and sustained an abrasion to the left cheek when he attempted to pick up his cigarette off the floor. The ill fitting seat cushion slid from underneath the resident when the resident moved contributing to his fall. The facility also failed to complete a post fall assessment according to the facility's policy and procedure. Therefore, the facility failed to accurately identify the reason for the fall and this could be a potential for another fall. Findings: 1a. According to the admission record, Resident 15 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Full Admission Minimum Data Set (MDS), an assessment and care screening tool, dated July 30, 2010, indicated the resident had a short term memory problem, and the resident's cognitive skills for daily decision making were independently modified (some difficulty in new situations). The resident was usually able to make himself understood and sometimes understood others. The resident's vision was impaired and required glasses. The resident's mode of locomotion was a walker. Under Disease Diagnoses, indicated [DIAGNOSES REDACTED]. Under Health Conditions, indicated the resident had an unsteady gait. According to the MDS, dated [DATE], the resident required extensive assistance (weight bearing support and at times required full staff performance) for activities of daily living (routine activities that people tend do everyday involving personal care and functional mobility) such as bed mobility, transferring, and walking in the corridor and locomotion on and off the unit. A review of the Fall Risk Assessment, dated January 18, 2011, indicated the staff determined Resident 15 was high risk for a fall with risk factors that included an incident of a fall in the last months. The resident's vision was poor. The resident had a gait and balance problem while standing and walking. The resident had decreased muscular coordination, with a change in his gait pattern when walking through a doorway. The resident was jerking or unstable when making turns. The resident required the use of assistive devices, a front wheel walker, or a wheelchair. The resident had seizure disorder and was taking antiseizure medication. A review of the resident's Joint Mobility Assessment, dated January 19, 2011, the resident's right shoulder and right knee had 75 percent to 100 percent minimal (barely adequate) limitations for range of motion (reduction in the joint's normal range of movement). Source: arthritis/od/exercise/g/rangeofmotion. A review of the Physical Therapy Plan of treatment for [REDACTED]. The resident required moderate to maximum assistance from sitting to standing. A review of the Investigation Report, dated March 24, 2011, completed by the 3 p.m. to 11 p.m. shift, Licensed Vocational Nurse 1 (LVN 1) indicated the resident was assigned to Certified Nursing Assistant 2 (CNA 2) and the fall occurred in the patio. The resident was walking in the patio with his front wheel walker. The resident stopped to pick up a cigarette butt. The resident held onto the long table in the patio and while trying to pick up the cigarette butt, the resident lost his balance and fell on his left hand to support the fall. There was no documentation that a staff was in the patio providing supervision. A review of the facility's Witness Statement, dated March 24, 2011, indicated the resident fell in the patio and the fall was not witnessed. A review of the Licensed Nurses Progress Notes, dated March 24, 2011 at 3:45 p.m., indicated a CNA reported to LVN 1 that the resident fell in the patio. The resident was found in the patio on the ground in a sitting position leaning backwards and his left arm on his stomach. The resident's right arm was raised upwards, his feet extended forward and with his front wheel walker next to his feet. The resident was assessed with [REDACTED]. CNA 2 and LVN 1 assisted the resident back into his wheelchair and the resident was wheeled chair back to the nursing station. At 4 p.m., the resident stated, "mucho dolor", (much pain), a pain scale of 10/10 on the pain scale of 0/10 (zero for no pain; 10 for severe pain). The resident was medicated with Vicodin (a narcotic pain reliever) 500/50 milligrams, orally. The resident's left wrist was immobilized with a splint. At 4 p.m., LVN 1 notified the physician and received an order to transfer the resident to the acute hospital. At 4:30 p.m., LVN 1 assessed the resident's pain to a pain scale of 5/10. At 5 p.m., the resident stated the pain was 5/10 and LVN 1 administered Tylenol 325 milligrams, 2 tablets to equal 650 milligrams. At 5:30 p.m., the ambulance arrived and transported the resident to the acute hospital. In an interview with the director of physical therapy, on June 17, 2011 at 9 a.m., stated, "The resident had no problem picking up something from the ground; however, to get back to a standing position, the resident required assistance. The resident was not yet to an independent level." During a telephone interview with CNA 2 on June 20, 2011 at 1 p.m., she stated a visitor visiting Resident 15's roommate told the staff that Resident 15 fell in the patio. CNA 2 stated there was no facility staff when she arrived in the patio, then CNA 3 arrived to the patio. CNA 3 went to call LVN 1 to the patio area. During a telephone interview on June 20, 2011 at 3:30 p.m., with CNA 3, she stated the long patio table moved and the resident fell trying to balance himself with one hand and put his left hand outward to catch himself. A review of the facility's policy and procedure, Fall Prevention and Reduction, not dated, indicated the facility's policy was to prevent falls and would implement corrective measures to reduce incidence of a fall. Upon admission, the resident at risk for a fall would be assessed and would have a plan of care developed to minimize or reduce the risk factors for a fall. This was not followed. A review of the clinical record on June 16, 2011 at 11 a.m., there was no plan of care developed (prior to resident falling on March 24, 2011) that addressed the resident's risk for fall, with no identified indicators that could lead to a fall with nursing interventions. During an interview on June 17, 2011 at 1:30 p.m., with the director of nursing (DON), he stated there were no plans of care with nursing interventions in the clinical record for risk of fall or for safety for smoking program. The DON stated all residents that are high risk for falls and smoke in the facility should have plans of care with nursing interventions. b. On June 16, 2011 at 8 a.m., there were at least three residents in the patio, smoking. One resident was sitting at the long table, which was not affixed (physically attached) to the concrete surface, smoking. There was no facility staff member monitoring the residents in the patio. There were cigarette butts on the ground on the South/East-West entrance walkway, on the ground near the facility's West wall, on the ground in the residents' patio area; on the ground along the residents' residential entrance and exit doors and cigarette butts on the ground at the facility's North/East-West entrance/exit walkway. A smoking schedule was observed posted on the wall adjacent to the patio indicating smoking time to start at 9 a.m. to 9:30 a.m., 11 a.m. to 11:30 a.m., 1 p.m. to 1:30 p.m., 3 p.m. to 3:30: p.m., 5:30 p.m. to 6 p.m. and 8 p.m. to 8:30 p.m. This was not being followed. A review of the facility's follow-up letter regarding the resident's reported fall incident to the Department of Public Health, dated March 31, 2011, indicated the facility's multi-disciplinary approaches were to have housekeeping clean the patio after each smoking schedule, making sure that there were no cigarette butts left on the ground, and to post a smoking schedule in the resident's room and the resident will adhere to the schedule. A review of the clinical records indicated Resident 15 fell in the patio at 3:45 pm, 15 minutes after the 3 p.m. to 3:30 p.m. smoking schedule. The resident fell while trying to pick up a cigarette butt from the patio floor. In an interview with LVN 1 on June 17, 2011 at 3 p.m., when asked, she stated the smoking hours on her shift were from 3 p.m. to 3:30: p.m. and 5:30 p.m. to 6 p.m. LVN 1 also said, "I did not witness the resident's fall in the patio." A review of Resident 15's clinical record, there was no documentation of a smoking safety assessment. There was no documentation the facility determined the resident's risk factors for injury during smoking. There was no plan of care addressing safety during smoking with nursing interventions. During an interview with the director of social services (DSS) on June 17, 2011 at 4:30 p.m., she stated the resident smoked cigarettes on the patio and was on the resident's smoking list to be supervised. The DSS also stated the interdisciplinary team did not assess the resident for the smoking program. A review of the policy and procedure on Smoking Apron, not dated, indicated the Interdisciplinary Team would assess the resident who smoked for their safety awareness and safe practices for smoking. The resident's assessment would include the resident's cognitive ability to retain information and exercise good judgment, and the alertness of the resident and orientation to the environment, and assess the resident for short term memory impairment. Assess the resident's physical ability, the resident's motor skills, muscle coordination and mobility. This was not implemented for Resident 15. The facility's policy and procedure on Protocol for Prevention, Monitoring and Recording of Accidents and Incidents, not dated, indicated the facility would implement and enforce all safety procedures and rules to ensure safety and well-being of the residents. The Maintenance Supervisor and Environmental Services Director would conduct regular rounds to monitor for environmental hazards. The Director of Nursing and the Director of Staff Development, Nurse Supervisor, Charge Nurses and Certified Nurse Assistants would also be responsible for monitoring resident's immediate environment for any safety or accident hazards. A review of the acute hospital's x-ray of Resident 15's left wrist, dated March 24, 2011, indicated the resident presented with pain with a history of a fall. There was considerable soft tissue swelling thenar eminence (thenar, palm of the hand, eminence a raised fleshy area on the palm of the hand near the base of the thumb - Medical Free Dictionary). There was also some soft tissue swelling over the dorsum (back) of the wrist. A review of the operative report, dated March 27, 2011, indicated a [DIAGNOSES REDACTED]. The operation was performed under a general anesthesia, and a closed reduction was performed and two wires were placed across the distal radius and pins were bent/broken. Summary: Closed reduction percutaneous pinning of the distal radius fracture. 2. According to the admission record, Resident 16 was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident required extensive assistance from the nursing staff with transferring, walking in the corridors. Under Balance during Transition and Walking, indicated the resident was not steady and only able to stabilize with human assistance with moving from sitting to a standing position, walking with an assistive device, and surface to surface transfer (transferring between the bed and chair or wheelchair). Under Functional Limitation in Range of Motion ((ROM) the normal amount a joint can be moved in certain directions), indicated the resident's left shoulder, elbow, and hand was impaired and the resident's left hip, knee, ankle, and foot was impaired. The resident used walker or wheelchair as mobility devices. Under Special Treatment, Procedure and Programs, indicated the resident was on Restorative Nursing Assistant Program for passive range of motion (the moving of a joint through its range of motion without exertion by the resident usually done by a therapist who moves the resident's body part manually), and splint or brace assistance, training and skilled practice with walking. A review of the Fall Risk Assessment, dated April 18, 2011, indicated the resident was high risk for a fall, had balance problems with standing, walking, with decreased muscular coordination, and changes in his gait pattern when walking through a doorway, jerking and unstable when making turns, required the use of an assistive device and currently taking antihypertensive (could cause dizziness) and narcotic (could cause drowsiness) medications. A review of the Joint Mobility Assessment, dated April 19, 2011, indicated the resident's left shoulder joint mobility limitations for range of motion were between minimal (75 to 100 percent) and moderate (50 to 75 percent). The Physical Therapy Plan of Treatment, dated April 19, 2011, indicated the resident's functional standing balance was poor. A review of the physician's orders [REDACTED]., everyday, five times a week for four weeks. A review of the physical therapy plan of care, dated April 16, 2011, indicated a decline in transfer, gait, balance, postural alignment, left-sided hemiparesis (weakness to one side of the body), and safety awareness. The physical therapy interventions were to provide physical therapy four days a week for gait training and therapeutic exercises and neuromuscular re-education (posture control instructions). The plan of care, dated April 2011, indicated the resident was at risk for falls and injury due to CVA (stroke) with impaired cognition, poor body balance and received antihypertensive medication. The nursing interventions were to provide the resident with a safe and clutter free environment and provide safety instructions regarding ambulation and transferring. This was not followed. On June 16, 2011 at 9:30 a.m., Resident 16 was observed with a left leg brace, a gait belt around his waist, ambulating using his platform front wheel walker with the rehabilitation technician (helps residents improve their movement, stamina, and coordination) in front of the facility. The rehab technician ambulated the resident on a concrete walkway in the South-East-West entrance walkway and in the residents' patio area, with pools of water. This had the potential to cause slip and fall. During an interview, on June 17, 2011 at 8:30 a.m., with the rehabilitation technician, he stated Resident 16 used a platform front wheel walker to rest his left hand due to hemiparesis. He also stated he ambulated the resident from his bed, to outdoors and through the resident's patio and around the building to the front of the facility, one time on June 16, 2011. On June 17, 2011 at 9 a.m., the director of physical therapy and the maintenance supervisor accompanied the surveyor outside to the patio area and the South-East-West walkway and saw the pools of water on both areas. The maintenance supervisor measured the front of the facility's East walkway and the distance measured approximately 60 feet. The director of physical therapy stated the resident should not be ambulating in pools of water. During an interview with Resident 16 on June 17, 2011 at 1:30 p.m., stated, "I wear a left leg brace and I have platform on my front wheel walker. This helps me so I can grab the walker." The surveyor asked the resident had he walked in pools of water using his platform front wheel walker during his PT exercises with the rehab technician. The resident said, "Yes, and I tried to walk around the pool of water and sometimes I walked into the pool of water." The facility's undated policy and procedures on Protocol for Prevention, Monitoring and Recording of Accidents and Incidents, indicated the Maintenance Supervisor and Environmental Services Director would conduct regular rounds to monitor for environmental hazards (Refer F465). The Director of Nursing. Director of Staff Development, Nurse Supervisor, Charge Nurses and Certified Nurse Assistants would also be responsible for monitoring the resident's immediate environment for any safety or accident hazards, such as wet/slippery and glaring floors. 3. A review of Resident 12's clinical records (face sheet), indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], indicated the resident usually understood others and usually made self understood. The resident needed total assistance from two staff members with bed mobility and transfers and needed extensive assistance with one person physical assist for locomotion on unit and supervision with set up help off unit. The MDS indicated the resident had impaired range of motion on one side of his upper extremity and on both lower extremities and was using a wheelchair. A review of the resident's Fall Risk Assessment, dated May 3, 2011, indicated the resident scored 20. On June 13, 2011, the resident scored 22. A total score of 10 and above represents high risk for falls. A care plan, dated May 3, 2011, for risk for fall due to impaired balance, poor safety awareness, and left sided hemiparesis had a goal for the resident to have no falls daily. Included in the approaches was to keep the environment free of clutter and safety hazards. There was no documentation that addressed the need for supervision and assistance. A review of Resident 12's clinical record indicated the resident had sustained a fall from his wheelchair on June 13, 2011 around 4 p.m. (30 minutes past the smoking schedule) in the patio and sustained an abrasion to the left cheek when he attempted to pick up his cigarette off the floor in the activity patio. A review of the Rehabilitation Assessment After Fall, dated June 14, 2011, indicated to hold the RNA program for three days; the resident had pain with range of motion. A review of the Incident Report Summary, dated June 16, 2011, indicated the resident was found (person not indicated) on the floor at the activity patio in a sitting position. The resident stated he was reaching for a cigarette that he dropped. The cause was determined for the resident trying to be independent beyond his ability. There was no indication that a staff was supervising the resident while smoking in the patio. An interview with Resident 12, on June 17, 2011 at 10:40 a.m., stated when he bent over in his wheelchair to pick up the cigarette he had dropped, the pressure reducing seat cushion, slid under him and he fell out of the wheelchair. The resident was sitting in his wheelchair and upon inspection, the resident pointed out how the pressure relieving seat cushion slid in the wheelchair when he moved. There was space between the pressure relieving seat cushion and the seat of the wheelchair. An interview with the director of physical therapy, on June 17, 2011 at 11:20 a.m., stated a pressure relieving seat cushion was ordered for Resident 12 but had not arrived. The surveyor was later informed by the director of nursing (DON) and the director of physical therapy the resident's pressure relieving seat cushion was replaced with another seat cushion, which fitted the wheelchair seat and had Velcro strips at the bottom of the cushion, so it did not slide. During an interview and record review with the social service director, on June 17, 2011 at 2 p.m., she stated smoking assessment for the resident was not done. This deficient practice had the potential for inability to determine risk factors for injury. During record review and interview with the DON, on June 17, 2011 at 11:45 a.m., the Post Fall Assessment form was not done and the 72 hour monitoring was not consistently conducted by the licensed nurses after the resident's fall on June 13, 2011. The DON stated the Post Fall Assessment form and the 72 hour monitoring should have been completed but were not. A review of the facility's undated policy and procedure titled, "Post Fall Assessment," indicated the resident was to be re-assessed after a fall incident and after a reported fall incident, and a licensed nurse would complete the Post Fall Assessment form. The DON or designee shall review the Post Fall Assessment with members of the IDT team on as needed basis. The Post Fall Assessment shall be filed in the resident's clinical record.

Based on observation, interview, and record review, the facility failed to address the resident's [DIAGNOSES REDACTED]. occurrences of falls for one of 10 sampled residents (6). Resident 6, who was diagnosed as being mildly mentally retarded, was high risk for falls, and had an actual fall on June 28, 2010, the staff failed to follow the facility's policy and procedure for fall reduction by not implementing the above mentioned procedures prior to, and following the June 28, 2010, incident. These deficient practices resulted in the resident falling on August 9, 2010, and suffering a fractured right hip, fractured right wrist, and a subdural hematoma. Resident 6 was transferred to the acute hospital, admitted to the Intensive Care Unit and underwent orthopedic surgery. Resident 6 stayed in the hospital for a total of 14 days. Findings: During an observation on March 19, 2011 at 10 a.m., Resident 6 was observed lying in bed. He moved about gingerly and seemed to be in some pain. He stated that he was having pain on his right hip and got up out of bed and ambulated slowly towards the nurse's station holding onto the wall rail for support. He was observed not using any assistive devices. He stated his hip hurts all the time, and that he thought he had injured it in a fall, but did not remember what happened. The clinical record for Resident 6 was reviewed on March 19, 2011. According to the admission face sheet, Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet indicated Resident 6 was responsible for himself and his son was his next of kin. The Minimum Data Set (MDS), an assessment tool, dated July 5, 2010, (just prior to the resident's fall) indicated the resident had some difficulty with his cognitive skills for daily decision-making in new situations only. The MDS indicated Resident 6 required supervision/oversight/cueing for his activities of daily living including transfers, walking on and off his unit, dressing, eating, toileting, and personal hygiene. He required physical assistance with transfers for bathing. He was unsteady while standing, but was able to rebalance himself. His mode of locomotion was a cane/walker/crutch. He was continent of bowel and bladder, had a seizure disorder, muscle weakness, and unsteady gait. He complained of moderate back pain less than daily and had no falls in the past 180 days. He had recent weight loss, was taking antipsychotic, anti-anxiety, and antidepressant medications daily, and required reorientation/cueing for mood, behavior, and cognitive loss. A physician's history and physical from the acute hospital, dated April 21, 2010, indicated Resident 6 suffered from "mild mental retardation". A physician's history and physical, dated April 30, 2010, indicated Resident 6 "does not have the capacity to understand and make decisions". A Physician's Progress Record, dated July 5, 2010, indicated [DIAGNOSES REDACTED]. During an interview with the administrator on March 19, 2011 at 4 p.m., he stated he was not aware of Resident 6's [DIAGNOSES REDACTED]. A Fall Risk Assessment, dated April 25, 2010, indicated Resident 6 had intermittent confusion, 1-2 falls in the past 3 months, was chair bound- required restraints and assist with elimination, had poor vision, had a balance problem while standing and walking and required the use of assistive devices. The assessment failed to recognize the resident's use of anti-hypertensive and anti-seizure medications. However, he was identified as a high risk for falls. The assessment form indicated the resident was to be re-assessed at a minimum of every 90 days (quarterly). However, there was no further reassessment done. A care plan titled "Risk for Falls", dated April 25, 2010, indicated Resident 6 had poor safety awareness, weakness, history of falls in the last 6 months, seizure disorder, and was taking psychotropic, anti-seizure, and antihypertensive medications daily. Interventions included to assist the resident with mobility and transfers as needed and to notify the physician of any incidents, falls/injuries. This was not followed. Also, this care plan was not reviewed/revised after the resident's fall on June 28, 2010. A care plan titled "Risk for Injury", dated April 25, 2010, indicated the resident's risk for injury was related to poor balance, lack of awareness, medications, problems with understanding others and memory recall, gait disturbance, and loss of coordination. Among the generic (pre-printed) approaches, interventions selected included to "assist resident as necessary". This was not followed. Also, this care plan was not reviewed/revised after the resident's fall on June 28, 2010. A Licensed Nurses Progress Note (LNPN), dated June 28, 2010 at 10:40 a.m., indicated Resident 6 fell out of bed and was found on the floor by a certified nurse aide (CNA). The resident complained of left elbow pain, which was relieved after 30 minutes. Further review of the clinical record revealed no documented evidence of an investigative report, no notification to the primary physician, and no review and revision of care plans on June 28, 2010. A LNPN, dated July 7, 2010 at 4:50 p.m., indicated Resident 6 complained of lower back pain and the physician ordered x-rays of the area, which came back negative on July 12, 2010. Review of the resident's Medication Administration Records (MARs) for the month of July 2010 indicated the resident was medicated with Tylenol 325 milligrams (mg) two tablets for occasional back pain. Daily Certified Nurse Aide (CNA) Notes, dated August 1-9, 2010, on P.M. shift (no specific time) indicated the resident's mobility and ambulation needs required "Supervision/Cueing", (care plans also indicated to assist as necessary). A LNPN, dated August 9, 2010, indicated "Today at approximately 6:10 p.m., the patient (Resident 6) had a fall outside of facility. Patient was found on the ground by nurse assistant. Patient was assisted back to room via wheelchair." The LNPN indicated the resident had an abrasion over his right eye with slight bleeding. According to the note, the resident stated he was walking around the facility when he experienced dizziness and pain to both lower extremities and then he fell and hit the right side of his head on the ground. The physician was notified and the resident was transferred to the acute hospital. The facility's investigative report regarding the fall was requested on March 19, 2011. It was provided along with the incident report, dated August 9, 2010. The incident report indicated the resident was found on the ground outside the facility by a CNA with an abrasion over his right eye. The report indicated the resident's ambulation privilege was "limited without assist." The Interdisciplinary Resident Safety Investigation and Intervention report, undated, indicated Resident 6 fell "outside the facility" at 6:10 p.m., and that the incident could best be attributed to "unsteadiness" and "related to change in condition" (but did not explain the change in condition). Neither report provided documentation the facility had identified the reason for the fall. There was no documentation a staff was present with the resident to provide supervision, cueing, and to assist as necessary to prevent his fall and injuries. Nor was the resident using any assistive devices (such as a cane, walker, or wheelchair). The nurse assistant who found Resident 6 on the ground, outside the facility, was not interviewed, nor did she complete a narrative report describing the incident per facility policy. During an interview with CNA 7 on March 29, 2011 at 4:40 p.m., she stated that she found Resident 6 after his fall on August 9, 2010. She stated that a staff member (unidentified), who was leaving the facility around 6 p.m. to go home, called the nurse's station and reported to the charge nurse that Resident 6 was out, in front of the facility, walking on the sidewalk by himself. The charge nurse instructed CNA 7 to go and assist the resident. CNA 7 stated that when she arrived at the sidewalk, in front of the facility, Resident 6 was lying on the ground on his right side. CNA 7 called the charge nurse for help, then went to the resident's room to get his wheelchair and returned the resident to his room. CNA 7 stated Resident 6 had difficulty walking and used his wheelchair to get around. She stated she was not assigned to the resident that day and could not explain why the resident was walking outside the facility by himself and was not using his wheelchair. Resident 6 was then transported to the acute hospital. The Licensed Nurse, who was on duty at the time of the incident and who filled out the incident report, was no longer employed by the facility and was not available for interview. The acute hospital's history and physical, dated August 10, 2010, indicated Resident 6 had a right hip fracture, right wrist fracture, a subdural hematoma, Dilantin toxicity (an anti-seizure medication). Toxicity can cause confusion, abnormal gait, decreased blood pressure that could further lead to dizziness, seizures. The resident's Dilantin blood level was 50.8 microgram per milliliter (Mcg/ml), the therapeutic range being 10.0 - 20.0 Mcg/ml. Other [DIAGNOSES REDACTED]. The resident was transferred to the Intensive Care Unit to await surgery. The Operative Report, dated August 13, 2010, indicated a preoperative [DIAGNOSES REDACTED]. The resident was sent to the recovery room in stable condition. There was no documentation in the clinical record regarding treatment for [REDACTED]. Resident 6 was readmitted to the facility on [DATE]. Review of the MARs from September 2010 to March 2011 indicated the resident continued to complain of right leg pain, severity of 6-7 on a pain scale of 1-10 and was medicated with Vicodin ES (extra strength), a highly addictive opioid pain reliever, 7.5 mg/750 mg, one tablet, on a near daily basis. A Joint Mobility Assessment, dated August 24, 2010, indicated the resident's limitation to his right hip was minimal (75-100%) and was causing the resident pain. The facility policy and procedure titled "Fall Prevention and Reduction", undated, indicated it was the policy of the facility to prevent falls to the extent possible and within the control of the facility. If and when falls occur, the facility shall implement corrective measures to reduce the incidence of falls. The policy indicated plans of care shall include interventions for provision of monitoring and supervision of resident to prevent fall incidents. Plans of care shall be revised and updated whenever a resident experiences an actual fall. Licensed Nurse shall immediately complete an incident report and incident investigative report relating to the fall incident. The policy indicated care plans for residents identified to be at high risk for falls should identify impaired cognition, impaired physical functioning, certain medications and diagnoses. In addition, the policy indicated staff should develop short term plans of care for each actual incident of falls, addressing identified problems leading to the fall. Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrences of falls. The facility failed to ensure this policy and procedure was implemented. The facility policy and procedure titled "Care Plan", undated, indicated care plans are to be reviewed, at a minimum, once every 90 days and whenever necessary, either as a result of significant change in resident's status and condition, or if discontinued. This was not followed.