Every finding on record at Madera Rehabilitation & Nursing Center

Based on observation, interview, and record review the facility failed to maintain essential equipment in a safe operating condition when one of two boiler systems (a device that heats the facility's water) was not monitored, maintained and failed to operate from 2/21/26 to 2/24/26.This failure resulted in a non-functioning boiler system, unable to heat water throughout the facility's resident rooms, nurses' stations and shower rooms and placed the residents at risk for poor hygiene, infectious disease and discomfort. The facility's residents were unable to shower for three days, and nursing staff were unable to wash their hands in hot water for infection prevention. During an interview on 2/24/26 at 1:32 p.m. with the Administrator (ADM), the ADM stated he received a phone call from the Maintenance Supervisor (MS) on the morning of 2/21/26 because the boiler to the facility's water supply was not working. The ADM stated the MS had told him the issue was limited to stations 1 and 2. The ADM stated the vendor (VDR) used to repair the boiler system came out that morning and did not have the part to fix the boiler while onsite. The ADM stated the facility did not have hot water in stations 1 and 2 for three days from the morning of 2/21/26 until 2/24/26. The ADM stated the VDR returned to the facility in the morning of 2/24/26 and fixed the boiler.During a concurrent observation and interview on 2/24/26 at 1:43 p.m. with Resident 1, Resident 1 was lying in bed and stated the facility did not have hot water since Saturday. Resident 1 stated she did not get a shower on 2/23/26 as scheduled because there was no hot water.During a concurrent observation and interview on 2/24/26 at 1:53 p.m. with Resident 2, Resident 2 was lying in bed and stated he was told there was no hot water since Saturday. Resident 2 stated the Certified Nursing Assistant (CNA) used cool water to clean him up during rounds over the weekend.During an interview on 2/24/26 at 1:57 p.m. with CNA 1, CNA 1 stated she worked on Station 4 through the weekend and the facility's hot water had not been working since Saturday 2/21/26. CNA 1 stated she offered the residents scheduled for showers to either have a cold shower or a bed bath with cold water.During an interview on 2/24/26 at 2:28 p.m. with CNA 2, CNA 2 stated she worked on Station 3 on Saturday 2/21/26. CNA 2 stated there was no hot water in the resident showers, rooms or nurses station sinks. During an interview on 2/24/26 at 2:35 p.m. with CNA 3, CNA 3 stated she worked on Station 1 on Monday 2/23/26 and there was no hot water in any of the resident rooms, nurses' station or shower rooms.During an interview on 2/24/26 at 2:39 p.m. with CNA 4, CNA 4 stated she went to shower a resident on Saturday (2/21/26) and when she turned on the hot water in the station 2 shower room, the water did not heat up. CNA 4 stated she reported there was no hot water and the MS was notified.During an interview on 2/24/26 at 2:45 p.m. with CNA 5, CNA 5 stated she worked the weekend and there was no hot water available in the resident rooms or shower rooms.During an interview on 2/24/26 at 2:50 p.m. with CNA 6, CNA 6 stated she worked on station 5 over the weekend and there had been no hot water since Saturday 2/21/26.During an interview on 2/24/26 at 2:59 p.m. with Registered Nurse (RN) 1, RN 1 stated she worked on station 6 over the weekend and there had been no hot water since Saturday 2/21/26.During a concurrent observation and interview on 2/24/26 at 3:27 p.m. with the MS, the MS stated he received a phone call from a staff member on 2/21/26 around 10:00 a.m. and was notified there was no hot water in stations 1 and 2. The MS stated he came into the facility and checked the boiler and found the fan to the boiler igniter was not working because the motor was frozen. The MS stated he called the VDR repairman and they came to the facility around 12:00 p.m. The MS stated he was informed the motor would have to be replaced and was told it was the weekend so the part to repair the boiler would not be available until Monday or Tuesday. The MS stated on Saturday 2/21/26 he had checked the sink water temperatures at Stations 1 and 2 by running hot water and putting his hand under it. The MS stated he did not use a thermometer to check the temperatures, but the water was cold to touch. The MS stated the main areas affected were stations 1 and 2 nurses' station, shower rooms and resident rooms. The MS stated he checked the other stations (stations 3, 4, 5 and 6) and there was no hot water in their shower rooms, resident rooms or nurses station sinks. The MS stated the laundry room had hot water because it was on a separate boiler. The MS stated he notified the ADM that stations 1 and 2's hot water was not working but did not report the other stations because the other sinks weren't as cold as stations 1 and 2, but the water was not getting hot. The MS stated the boiler does not receive routine service from an outside vendor and they are called only when there is an issue. The boiler to the main section of the facility was observed in an outside closet near the kitchen. There were two boilers in the closet, the MS stated they worked as one to heat the facility's water. The MS pointed to a large cover on the side of the main boiler and stated the motor that was replaced was under the cover, it was not visible. The second boiler was a tankless water heater in a closet outside the laundry room. The MS stated the boiler only heats the water for the laundry room and was not affected.During an interview on 2/24/26 at 4:04 p.m. with the Director of Nursing (DON), the DON stated she received a text on Saturday 2/21/26 that stations 1 and 2 did not have hot water. The DON stated she was told the laundry room was on a separate boiler and had hot water that the staff could use to provide bed baths. The DON stated her expectation to test water temperatures was to use a thermometer to get an accurate reading. The DON stated it was important for the facility to have hot water to shower the residents to prevent skin issues, infection control and for proper hand hygiene when hand sanitizers were not appropriate to use.During an interview on 2/24/26 at 4:30 p.m. with the ADM, the ADM stated when the MS called on Saturday 2/21/26, he was not informed there was no hot water to stations 3, 4, 5, and 6, so he did not realize how widespread the issue was. The ADM stated his expectations for accurate water temperature readings was for a thermometer to be used. During a review of the Service Work Order, dated 2/24/26, from the VDR, the work order indicated, . Returned and arrived at 11:30 AM and installed the new motor and had hot water running by 11:45 AM. 2/24/26. Tested system and system is operating properly at this time. Replace . Combustion Motor.During a review of the facility's P&P titled Maintenance Service, dated 12/2009, the P&P indicated, . maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include. maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. maintaining the heat/cooling system, plumbing fixtures. in good working order. Maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . During a review of the facility's policy and procedure (P&P) titled Water Temperatures, Safety of, dated 12/2009, the P&P indicated, . Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record water tempers in a safety log. If at any time water temperatures feel excessive to the touch. staff will report this finding.

Based on observation, interview, and record review, the facility failed to implement an effective infection control program when 12 of 65 hand sanitizer dispensers tested were not dispensing alcohol-based hand rub (ABHR-an alcohol-containing preparation [liquid, gel or foam] designed for application to the hands to inactivate germs) when used. These failures had the potential for staff not performing hand hygiene and could have caused cross contamination (accidental transfer of harmful bacteria, viruses or allergens from one surface or person to another) spreading infections to residents and staff.During a concurrent observation and interview on 2/11/26 at 10:49 a.m. with the Infection Preventionist (IP), 65 hand sanitizer dispersers in the hallways and nurses' stations were tested for function. The dispensers in the following areas did not dispense ABHR: Rooms 2, 6, 17, 20, 30, 39, 52, 54, 56, 61, next to the Station 3 shower room and next to the maintenance office. The IP stated housekeeping was responsible for refilling or replacing the ABHR dispensers. The IP stated it was important for the dispensers to work properly to prevent spread of germs and infections to the residents and staff. The IP stated staff were expected to perform hand hygiene going in and coming out of resident rooms, before and after wearing gloves, using the restroom, eating and if the hands were soiled.During an interview on 2/11/26 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was aware there were hand sanitizer dispensers in the facility that did not work, so she kept ABHR gel on her medication cart to clean her hands. During an interview on 2/11/26 at 1:07 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated there were some ABHR dispensers that did not work in the hallways. CNA 1 stated it was important to have access to ABHR going in and out of the resident rooms to prevent spreading infection. CNA 1 stated when an ABHR dispenser not working as she came out of the room she would have to go down the hall and find another one to clean her hands.During an interview on 2/11/26 at 2:00 p.m. with CNA 2, CNA 2 stated ABHR stops the spread of germs and illness. CNA 2 stated ABHR needed to be used going in and coming out of the resident rooms, before and after resident care, before and after passing meal trays.During a concurrent interview on 2/11/26 at 3:55 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated it was very important for the hand sanitizer dispensers to work properly to prevent the spread of infection and for personal hygiene. The DON stated staff should perform hand hygiene when they come on duty, before going home, in and out of resident rooms, between residents' care, after using the bathroom and before and after meals. The ADON stated the facility was aware there were issues with the sanitizer dispenser not working well and they would address the issue with the company who provides them.During a review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, dated 10/2023, the P&P indicated, . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene products and supplies. are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility. Hand hygiene is indicated. immediately before touching a resident. after touching a resident . after touching a resident's environment. immediately after glove removal.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for four of 15 sampled residents when the Infection Preventionist (IP) performed influenza (a highly contagious respiratory illness) tests and did not document the tests in Residents 5, 8, 12, and 14's electronic medical record (EMR).This failure resulted in an inaccurate and incomplete medical record for Residents 5, 8, 12, and 14.During a review of Resident 3's admission Record (AR), undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental ability such as memory, thinking, reasoning and communication) and anxiety (feeling or fear, dread and uneasiness).During a review of Resident 3's Change in Condition (CIC), dated 1/30/26, the CIC indicated, . Positive for influenza A [acute viral respiratory infection], nasal congestion, nonproductive cough.During a review of Resident 5's AR, undated, the admission record indicated, Resident 5 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor-uncontrolled growth of abnormal cells in the body) of the lung and secondary neoplasm (cancer that has spread from the place where it first started) of the brain.During a review of resident 5's CIC, dated 1/30/26, the CIC indicated, . resident was noted to be shaking and weak, with altered level of responsiveness. O2 [oxygen level-amount of oxygen in the blood with a normal reading is 95-100% and anything below 92% is considered low requiring medical attention] 82% on room air.During a review of Resident 9's AR, undated, the admission record indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of the arm, leg and trunk on the same side of the body) and hemiparesis (weakness or reduced motor function on one side of the body) following cerebral infarction (type of stroke where blood flow to part of the brain is blocked) and chronic kidney disease (progressive damage and loss of function in the kidneys).During a review of Resident 9's CIC, dated 1/30/26, the CIC indicated, . Resident tested positive for influenza A.During a review of Resident 10's AR, undated, the admission record indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys have lost nearly all function) and hemiplegia and hemiparesis following cerebrovascular disease (group of condition that disrupt blood flow to the brain).During a review of Resident 10's CIC, dated 1/30/26, the CIC indicated, . started on 01/30/26. Resident observed to have an occasional non-productive cough. Resident tested + [positive] for influenza A.During a concurrent interview and record review on 2/11/26 at 3:02 p.m. with the IP, the IP stated Residents 3, 5, 9 and 10 tested positive for influenza on 1/30/26. The IP stated Resident 10's roommate (Resident 12) started showing respiratory symptoms with a nonproductive cough on 2/4/26. The IP stated she tested Resident 12 for influenza. The IP reviewed Resident 12's EMR and stated she did not document the test. The IP stated Resident 5 had shortness of breath and a low oxygen level on 1/30/26, so she tested him for influenza before he was transferred to the acute care hospital (ACH). The IP reviewed Resident 5's CIC dated 1/30/26 and stated, I thought the nurse would put it [the flu test] in the change in condition. The IP stated she performed Resident 5's influenza test but did not document it. The IP stated she had tested Resident 5's roommate (Resident 8) but was unable to find documentation of the influenza test in his EMR. The IP stated she should have documented it in the EMR. The IP stated Resident 14 started to have a nonproductive cough on 2/4/26 and remembered testing him. The IP reviewed Resident 14's EMR and stated she did not document the test or results. The IP stated she should have documented the influenza tests she performed for an accurate medical record. During a review of Resident 12's AR, undated, the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism (progressive disease of the nervous system marked by tremor, muscle rigidity and slow imprecise movements), Type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and anxiety.During a review of 8's AR, undated, the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus, hypertension (high blood pressure) and muscle weakness.During a review of Resident 14's AR, undated, the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following intracerebral hemorrhage (type of stroke with sudden bleeding into the tissues of the brain), respiratory failure (when lungs cannot get enough oxygen or fail to remove carbon dioxide) and hypoxia (low blood oxygen level). During a concurrent interview on 2/11/26 at 3:55 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated she was present when the IP had tested the residents for influenza. The DON stated if the tests were not documented they were considered not done. The DON stated that the medical record was not complete without documentation of the influenza tests. The DON stated the IP performed the tests and the expectation was for her to document them accurately. The DON stated it was not the charge nurse's responsibility to document the influenza tests if they did not perform them. The DON stated Residents 12 and 14 had developed coughs and the IP had tested the residents, but because the tests were not documented there was no way to show they were done.During a review of the facility's job description titled Infection Preventionist, undated, the job description indicated, . Infection Preventionist is accountable for decreasing the incident and transmission of infectious diseases between patients, staff, visitors and the community. Accountable for surveillance of healthcare acquired and community acquired infections.During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, dated 7/2017, the P&P indicated, . All services provided to the resident. shall be documented in the resident's medical record. The following information is to be documented in the resident medical record. Treatments or services performed. Documentation in the medical record will be objective. complete, and accurate. Documentation of procedures and treatments will include care-specific details . date and time the procedure/treatment was provided. name and title of the individual(s) who provided the care. how the resident tolerated the procedure/treatment. signature and title of the individual documenting.

Based on interview, and record review, the facility failed to ensure two of sixteen sampled residents (Resident 2 and Resident 4) maintained acceptable parameters of nutritional status when:1. Resident 2 was at risk of unplanned weight loss, and did not receive adequate nutritional interventions to maintain acceptable parameters of nutritional status. This failure resulted in a severe weight loss of 7.95% in less than 2 months from 6/2/25 to 7/28/25 without timely assessment, monitoring, or physician notification. 2. Resident 4 was admitted on [DATE] with a diagnosis of protein-calorie malnutrition (inadequate intake of protein and calories) and sustained a 9.58% unintentional weight loss from 5/30/25-6/27/25 with no nutritional therapeutic diet type or nutritional supplemental diet interventions (a targeted, evidence-based strategy to improve a person's nutritional status by adding dietary supplements to their regular diet. These interventions are customized to meet an individual's specific needs, often in conjunction with dietary counseling and other therapeutic approaches). This failure resulted in Resident 4 sustaining a 14.37 % unintentional weight loss from 5/30/25-7/17/25 before nutritional therapeutic diet type or nutritional supplemental diet interventions were added to Resident 4's plan of care which lead to an overall unintentional weight loss of 11.98% from 5/30/25-7/31/25 due to delayed identification of nutritional therapeutic diet type and nutritional supplemental intervention requirements. 1.During a record review of Resident 2's Medical Record (documents related to person's health information), the Medical Record indicated Res 2 had a weight loss of 8.4 pounds (lbs). Resident 2 weighed 105.4 pounds (lbs- unit of measurement) on 6/2/2025 and weighed 97 lbs on 7/28/2025. The Percentage of weight loss of 7.95% loss occurred in 56 days. The Care Plan (a written guide for how the nursing home staff will take care of a resident every day), did not reflect updated interventions to address this unplanned weight loss. There were no Interdisciplinary Team (IDT) notes to address Resident 2's weight loss. There were no Registered Dietitian (RD) notes to address Resident 2's weight loss or interventions. The weights for Resident 2 were documented as follows; 5/2/25 weight of 106 lbs, 6/2/25 weight of 105.4 lbs and 7/28/25 weight of 97 lbs. Diet (weight loss) Notes DATE WEIGHT May 2, 2025 106.0 lbs June 2, 2025 105.4 lbs July 28, 2025 97.0 lbs During an interview on 8/12/25 at 3:10 p.m., with Resident 2 and her daughter (RP 4) RP 4 stated Resident 2 spoke mostly Spanish. RP 4 stated Resident 2 has been on a soft, mushy diet which Resident 2 did not like. Resident 2's daughter stated that her mom did not eat more than half her food in a day as she does not like how soft and mushy the food was and how the texture was hard for Resident 2. During a concurrent interview and record review on 8/13/25 at 1:36 p.m., with Licensed Vocational Nurse (LVN 4), LVN 4 stated that a resident with a weight loss of over 5% in that short amount of time should have had some type of intervention. LVN 4 stated she was unable to find an intervention, an updated care plan, a change of condition or a Situation, Background, Assessment and Recommendation (SBAR) communication forms documented regarding weight loss in Resident 2's medical record. LVN 4 stated it was very important to address weight loss in residents because they could become weaker. LVN 4 stated residents need to be on appropriate diet to get the best compliance of meal intake and the best nutrition. During a concurrent interview and record review with the Speech Language Pathologist (SLP) on 8/13/25 at 11:31 a.m., regarding Resident 2. The SLP stated that according to the medical record, Resident 2 was on a mechanical soft diet. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment) MDS Section K (swallowing/Nutritional Status) and section L (Oral/Dental Status) indicated there were no issues found that would require extra care or special treatment in these areas. The SLP stated Resident 2 was not on his patient load. The SLP stated he was aware Resident 2 was unhappy with her diet and had not received a referral. The SLP reviewed Resident 2's medical record and could not find any type of intervention to address Resident 2's weight loss. The SLP stated it was important to address any resident with unplanned weight loss so that they can maintain their optimum health. The SLP stated a fortified/high protein diet should have been started immediately as soon as the weight loss was identified. The SLP stated Resident 2's severe weight loss was not identified. The SLP stated it was important to start residents on a fortified/high protein diet early on to prevent or slow down weight loss. During an interview via phone on 8/13/25 at 4:30 p.m., with the Registered Dietitian (RD), the RD stated she does not currently have access to the chart but was very well aware of Resident 2. The RD stated she was unaware of Resident 2's weight loss of 7.95% from 6/2/25 to 7/28/25. The RD stated Resident 2 must have come back from the hospital, dialysis or a family visit and that is why it did not get caught or triggered. The RD stated that weights should be done anytime residents return from the acute care hospital. The RD stated that she only looks at weights from week to week and does not do a look-back. The RD stated this weight loss should have been brought up by nursing in the IDT meeting but stated that it might have been overlooked for a number of reasons. The RD stated she was part-time and is 100% remote and does not see the residents. The RD stated there were two other RDs that help cover. The RD stated the RDs were responsible for ordering and overseeing residents' diets. The RD stated it was normal for residents to not be triggered, and weight issues not addressed in IDT meetings. The RD stated during the IDT meetings she is provided with too much information. The RD stated the staff goes over a lot of the weights and she only needs the current weight. During a concurrent interview and record review with the Director of Nursing (DON) on 08/14/25 at 2:00 p.m., the DON stated it was the RD's job to identify signs and symptoms of weight loss, and it was not the nurse's job. The DON stated that multiple interventions should be used such as supplements, addressing current diets, and preferences to help combat weight loss not just adding snacks as a first line defense. The DON stated the RD should be doing lookbacks not just focusing on week-to-week weights. The DON stated that Nursing is not responsible for looking for interventions. This should come from the RD. DON stated she was unable to find any record of RD notes for weight loss in the chart and there were no IDT notes regarding weight loss. The DON stated it was important for the right diet to be ordered for the residents so that the residents have the opportunity to enjoy the correct diet. The DON stated the texture was important to achieve compliance and increased intake which may prevent weight loss. The DON stated not doing so can cause the residents emotional and physical harm. During a concurrent interview and record review with the DON on 08/14/25 at 3:12 p.m., the facility policy titled Nutrition (impaired)/Unplanned Weight Loss - Clinical Protocol was reviewed. The policy indicated, . the staff and physician will define the individual's current nutritional status (weight, food/fluid intake and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain and significant risk for impaired nutrition .the staff will report to the physician significant weight gain or losses . The DON stated this did not occur. During a record review of the job description titled, Registered Dietician, the job description indicated, . assess the nutritional needs, nutrition diagnosis, intervention and evaluation of patient and document in the medical record . and . consults with physicians, IDT, healthcare professionals to determine nutritional needs of patients . During a record review of the document titled, Position Summary for Registered Dietitian on 08/13/2025 at 4:15 PM which states, . assess the nutritional needs, nutrition diagnosis, intervention and evaluation of patient and document in the medical record . and . consults with physicians, IDT, healthcare professionals to determine nutritional needs of patients . During a review of the Registered Dietician's signed job contract, titled, Healthcare Services Group, INC. Job Description, dated 06/15/2023, the job contract indicated, .completes comprehensive nutrition assessments. and completes comprehensive assessments in accordance with current standards of practice. During a review of the article/professional reference titled, Academy of Nutrition and Dietetics dated x/xx/xx, retrieved from https://www.eatrightpro.org/practice/nutrition-care-process/ncp-overview. The document stated that the Nutrition Care process is a systematic method that dietetics and nutrition professionals use to provide nutrition care for residents. The four steps include: Nutrition Assessment and Reassessment, Nutrition Diagnosis, Nutrition Intervention and Nutrition Monitoring and Evaluation. The Nutrition Assessment is the first step in the process and includes multiple domains including food and nutrition related history. Physical examination findings and tools that assess health or disease risk status, and progress evaluation. The second step, Nutrition Diagnosis is used to identify existing nutrition problems that the Registered Dietitian Nutritionist, RDN, is responsible for treating. The third step in the process is Nutrition Intervention and is customized to meet the individual's needs. Nutrition intervention requires goal planning and action (implementation) to meet those goals. The fourth and last step in the Nutrition Care Process is Nutrition Monitoring and Evaluation. This step measures the progress of the interventions and whether the plan needs to be revised. Academy of Nutrition and Dietetics. (2024). NCP [NAME]: Nutrition Care Process quality evaluation and standardization tool. Chicago, IL: Academy of Nutrition and Dietetics. 2. During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes (T2DM-high blood sugar), protein-calorie malnutrition (PEM-inadequate intake of protein and calories), iron deficiency (body lacks sufficient iron), chronic kidney disease (CKD-progressive damage to kidneys and cannot filter blood adequately), dementia (progressive decline in memory and cognition), and altered mental status. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/2/25, the MDS indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 7 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 4 was severely cognitively impaired. During a review of Resident 4's MDS, dated 6/6/25, the MDS indicated Resident 4 had a Swallowing and Nutritional Status (a resident assessment tool used to identify resident's ability to maintain adequate nutrition and hydration, covering aspects like swallowing disorders, height, weight, weight loss, and nutritional approaches) assessment completed on admission with no identified swallowing or nutritional issues. During a review of Resident 4's Weights and Vitals Summary, dated 8/12/25, the document indicated, Resident 4's weights were .5/30/2025 167 lbs (pounds- a unit of weight measurement).6/6/2025 167 lbs.6/12/2025 164 lbs.6/19/2025 161 lbs.6/27/25 151 lbs.7/3/2025 149 lbs.7/10/2025 149 lbs.7/17/2025 143 lbs.7/24/2025 146 lbs.7/31/25 147 lbs. The document indicated Resident 4 had a 9.58 % weight loss in one month, from 5/30/25-6/27/25. The document indicated Resident 4 had a 14.37% weight loss in one and a half months, from 5/30/25-7/17/25. The document indicated Resident 4 had a 11.98% total weight loss from admission on [DATE] to the most recent weight on 7/31/25. The document indicated the facility did not predict, anticipate or implement timely or appropriate diet type interventions or identify potential nourishment factors that could lead to unintentional weight loss on admission or on the first signs of weight loss. During a review of Resident 4's Order Summary Report, dated 8/13/25, the document indicated, from 5/30/25-6/2/25 Resident 4 had a a regular diet pureed texture thin consistency, from 6/2/25-6/9/25 Resident 4 had a regular diet minced and moist thin consistency, from 6/9/25-7/18/25 Resident had a regular diet mechanical soft texture thin consistency, from 7/18/25-8/7/25 Resident 4 had a fortified/high protein diet mechanical soft texture consistency to promote weight maintenance, and from 8/7/25- 8/13/25 Resident 4 had a fortified/high protein diet mechanical soft texture thin consistency. The document indicated Resident 4 had a 9.58% weight loss from 5/30/25-6/27/25 and on 7/1/25 diabetic snacks (healthy snacks that are low in added sugar) were added three times a day, in between meals related to significant weight loss and variable oral intake. The document indicated Resident 4 had a 14.37% weight loss from 5/30/25-7/17/25 and on 7/18/25 a fortified/high protein diet to promote weight maintenance and high protein nourishment two times a day were added for increased protein needs, on 7/21/25 additional snacks were added three times a day in between meals to promote increased oral intake. During a review of Resident 4's Nutrition Assessment, dated 6/16/25, the document indicated, .current food and fluid intake 51-75% .nutritional risk related to (proceed to care plan) variable PO [oral] intakes and at risk for malnutrition, CKD, metabolic encephalopathy[metabolic or chemical imbalances in body], hypotension [low blood pressure], T2DM, PEM, dysphagia [difficulty swallowing], UTI [urinary tract infection-infection in urinary system], iron deficiency anemia, HTN [hypertension-high blood pressure], GERD [gastroesophageal reflux disorder- stomach acid flows back into esophagus]. During a review of Resident 4's IDT (interdisciplinary team) Weight Management Assessment, dated 6/27/25, the document indicated, Resident 4 had a significant weight loss in one week. The document indicated, .weight change likely r/t [related to] variable PO [oral] intakes.resident would benefit from weight maintenance/no further weight loss at this time. Dietary recommendations included adding diabetic snacks three times a day and to continue weekly weights. The document was signed by the Registered Dietician (RD). The document did not indicate the provider was in attendance. During a review of Resident 4's IDT Weight Management Update, dated 7/3/25, the document indicated, .weight update.weights: 07/03/2025: 149 lbs 06/27/2025: 151 lbs 06/19/2025 161 lbs weight change:18 lb (-10.7%) x1/mo [one month].meal consumption: 25-50% .Resident's current weight on 07/03/2025 in 149 lbs, reflecting a continued downward trend from 151 lbs on 06/27/2025 and 161 lbs on 06/19/2025.meal consumption remains variable, ranging between 25-50%. Resident is receiving 2 pm snack due to risk for malnutrition. Due to recent significant weight loss and inconsistent PO intake, dietary plan has been updated to included diabetic (DM-diabetic) snacks three times daily between meals. The document was signed by the RD. The document did not indicate an order for a 2 p.m. snack was placed. The document did not indicate the provider was in attendance. During a review of Resident 4's IDT Weight Management Update, dated 7/18/25, the document indicated, .weight update.weight variance.143lb.weight change 6 lb (-4%) x1/wk [one week].weight change likely [related to] variable PO intake. Resident with continued care presenting with significant weight loss x >3 month [greater than 3 months].resident would benefit from no further weight loss at this time.add fortified/high protein diet.add HPN [high protein] BID [twice a day]. The document was signed by the RD. The document did not indicate the provider was in attendance. During a review of Resident 4's IDT Weight Management Update, dated 7/24/25, the document indicated, .most recent weight on 07/24/2025 is 146 lbs, up from 143 lbs on 07/17/2025, and down from 149 lbs on 07/10/2025.resident has exhibited a pattern of gradual weight loss for over three months.continue to monitor trends. The document was signed by the RD. The document indicated Resident 4 had lost twenty-one pounds since admission on [DATE]. The document indicated once a high protein fortified diet and high protein nourishment shake were added on 7/18/25 Resident 4's weight improved. The document indicated Resident 4 was admitted with a protein calorie malnourishment and poor variable intake. The document indicated dietary inappropriately added snacks as a first intervention for a resident with decreased and variable intake. The document indicated Resident 4 was not appropriate assessed for nutritional needs. The document did not indicate the provider was in attendance. During a review of Resident 4's IDT Weight Management Update, dated 7/31/25, the document indicated, .weight update.weights: 07/30/2025: 147 lbs 07/24/2025: 146 lbs 07/17/2025: 143 lbs 07/10/2025: 149 lbs.will changed resident from weekly weights to monthly weights. The document was signed by the RD. The document did not indicate the provider was in attendance. The document did not trend the weight to the admission weight. During an interview on 8/8/25 at 11:10 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 4 did not have swallowing or chewing difficulties. CNA 2 stated she was not aware of any swallowing or nutritional concerns for Resident 4. CNA 2 stated Resident 4 needed minimal assistance and ate meals in her room independently. During an interview on 8/8/25 at 11:15 a.m. with the Responsible Party (RP) 2, RP 2 stated he was Resident 4's husband. RP 2 stated he visited Resident 4 every day. RP 2 stated some days Resident 4 did not eat a lot. RP 2 stated facility staff weighed her frequently throughout the month. RP 2 stated he was not aware of her current weights or weight trend. During a concurrent interview and record review on 8/12/25 at 10:57 a.m. with the Speech Language Pathologist (SLP), Resident 4's Electronic Medical Record, dated 8/12/25 was reviewed. The SLP stated Resident 4 had been placed on his service since admission related to dysphagia and memory care. The SLP stated he had been working with Resident 4 to develop strategies and recall techniques to determine her least restrictive diet texture and encourage oral intake. The SLP stated Resident 4 did not currently have any swallowing or chewing issues. The SLP stated Resident 4 required encouragement with meal intake. The SLP stated he spoke with staff and had recommended meal encouragement when eating and distant supervision by eating in the vintage dining hall. The SLP stated there was no specific documentation of the recommendation or order for meal encouragement and dining in the vintage dining hall for distant supervision . The SLP stated he had changed Resident 4's diet texture throughout admission to determine the least restrictive diet texture and the Registered Dietician (RD) was responsible to determine the most appropriate diet type. The SLP stated dietary and clinical staff would refer residents to him for weight loss if there was a concern for swallowing or chewing. The SLP stated he had not received a weight loss referral for Resident 4. The SLP stated Resident 4 had a diet type order change on 7/18/25 to a fortified/high protein diet. The SLP stated from 5/30/25-6/27/25 Resident 4 had lost over 10 lbs, which was considered a significant weight loss. The SLP stated he had been aware of Resident 4's weight loss. The SLP stated a fortified/high protein diet should have been started immediately on admission or with noted significant weight loss. The SLP stated it was important to prevent weight loss and implement interventions before weight loss occurred or as soon as it was noted to have occurred. The SLP stated not initiating a fortified/high protein diet on admission or when first noting weight loss impacted Resident 4. During a concurrent interview and record review on 8/13/25 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 4's Electronic Medical Record, dated 8/13/25 was reviewed. LVN 3 stated Resident 4 weights had been down trending since admission with limited nutritional interventions. LVN 3 stated Resident 4 lost 20 lbs from 5/30/25 – 7/31/25 which was a significant weight loss. LVN 3 stated Resident 4 had poor and variable intake with an admitting diagnosis of protein-calorie malnourishment. LVN 3 stated it was not appropriate to add snacks as a nutritional intervention for a resident with poor or variable intake and significant weight loss. LVN 3 stated Resident 4 required fortified high protein nutritional supplements and diet types to ensure she received as many nutrients as possible when she did eat. LVN 3 stated Restorative Nursing Aides (RNA) were responsible to obtain weekly weights, report variances to licensed nursing staff and document weights. LVN 3 stated licensed nursing staff were responsible to trend weights once documented and notify nurse management to initiate interventions within the interdisciplinary team. LVN 3 stated licensed nursing staff were responsible for identifying weight variances and reporting weight changes to the provider. LVN 3 stated licensed nursing staff were responsible for reporting inappropriate dietary interventions to the unit manager and provider. LVN 3 stated Resident 4 was not an appropriate candidate to add dietary snacks with a documented poor oral intake. LVN 3 stated it was not appropriate for Resident 4 to be moved from weekly weights to monthly weights as she still had weight loss from admission. LVN 3 stated the RD was responsible to trend weekly weights. During an interview on 8/13/25 at 11:13 a.m. with Restorative Nursing Aide (RNA) 1, RNA 1 stated RNA's obtained weekly weights, reported variances to licensed nursing staff , and documented weights. RNA 1 stated weekly weights were obtained to monitor for variance and initiate timely interventions before significant weight loss occurred. RNA 1 stated it was important to initiate person centered interventions to prevent and reverse weight loss. RNA 1 stated it was not appropriate to add snacks only as an intervention with noted poor intake and significant weight loss. RNA 1 stated protein and calories were needed to prevent weight loss such as shakes, supplements and protein. During an interview on 8/13/25 at 4:12 p.m. with the Registered Dietician (RD), the RD stated she was remote and had never been to the facility. The RD stated she shared the RD role with two other RD's. The RD stated she was responsible for managing residents with severe weight loss and attending weight loss interdisciplinary (IDT) meetings. The RD stated she could not view recorded weights within the electronic charting system. The RD stated she relied on the electronic charting system to alert her to significant weight changes at the intervals of one month, six months and one year. The RD stated that at three months she manually calculated weight changes. The RD stated she viewed weights at one-week intervals, but did not compare weekly weights to previous weeks' weights. The RD stated she would not compare trending weights until the one month, three-month, six months, and one year interval. The RD stated in IDT weight variance meetings, IDT members shared every residents trending weights since admission, but it was .overkill they tell me every weight trend and don't need to know. The RD stated, .I just look at weekly weights.wouldn't compare to the previous weeks weight or other recorded weights, at one month interval would trigger me if weight loss. The RD stated her first intervention was to always add snacks, unless the resident had poor intake then would suggest a nutritional supplemental diet intervention, such as a shake. The RD stated, .I wouldn't add all my interventions at once because then I wouldn't have anything else to try if they continued to lose weight. The RD stated Resident 4 was admitted with a protein-calorie malnutrition diagnosis with noted poor and variable intake. The RD stated she would not have initiated a fortified/high protein diet type on admission or with noted initial weight loss because .everyone comes in with a protein calorie malnourishment deficiency, why would I add everyone on that right away, everyone would be on a high protein fortified diet and high protein shakes then with that logic. The RD stated by adding snacks as an initial intervention with noted weight loss it increased Resident 4's opportunities to consume calories in between meals. The RD stated it was possible Resident 4 preferred to snack instead of eating meals. The RD could not state if Resident 4 preferred to snack instead of eating meals. The RD stated it was better to add snacks then to not have any interventions at all. The RD stated she completed nutritional assessments, remotely, and relied on licensed nursing staff to obtain information which she would then interpret and complete nutritional assessments. The RD stated there was a potential gap with the risk of delayed intervention by not comparing weekly weights to previous weeks and waiting for the one month, three-month, six months, and one year interval alert on the electronic charting system to trigger a weight change. The RD indicated by waiting for the one month, three month, six month and one year interval significant weight loss could occur without notice. During a concurrent interview and record review on 8/14/25 at 1:49 p.m. with the Director of Nursing (DON), Resident 4's Electronic Medical Record, dated 8/14/25 was reviewed. The DON stated resident weights were obtained on admission and then weekly for those at risk for weight changes. The DON stated weights were obtained weekly to identify potential weight variances. The DON stated it was important to trend all weights to identify weight changes before they became significant weight variances at one month, three-month, six month or one-year intervals. The DON stated it was important to trend weights so the IDT could conduct a weight variance meeting as soon as weight variances were identified. The DON stated the RD, licensed nursing staff, dietary staff, and herself were present for IDT meetings. The DON did not state the provider attended IDT weight meetings. The DON stated the IDT meetings discussed trending weights as a team and then the RD provided recommendations and would consult with the provider for orders. The DON stated it was the responsibility of the RD to trend all weights since admission when performing weekly weight reviews and when participating in IDT meetings. The DON stated 180 days' worth of weights were discussed in weight IDT meetings to identify weight trends. The DON stated it would not be possible to identify a weight loss trend if all the weights were not compared. The DON stated Resident 4 had an admitting diagnosis of protein-calorie malnutrition and weight loss should have been anticipated. The DON stated Resident 4 should have been admitted on high protein shakes and a fortified high protein diet type to prevent weight loss based on her admitting diagnosis. The DON stated Resident 4 sustained a significant weight loss of 9.58% from 5/30/25-6/27/25. The DON stated it was not appropriate to solely add snacks as an intervention with significant weight loss and noted poor variable intake. The DON stated it was an expectation to add appetite stimulants, high protein shakes, and or fortified high protein diet types when significant weight loss was identified to prevent further weight loss. The DON stated it was expected and a standard of practice to add as many interventions as required to predict, prevent and reverse weight loss. The DON stated it was not appropriate to save interventions in anticipation of needing to add them for ongoing weight loss. The DON stated Resident 4 had delayed dietary interventions which led to further significant weight loss. The DON stated when weight loss is expected and identified dietary interventions should not be implemented one at a time. The DON stated by only viewing weekly weights and not trending weights there was a gap in the system. The DON stated the RD was expected, per policy and job duty description, to trend and monitor weights as to identify weight variances. The DON stated she was aware the RD relied on licensed nursing staff to obtain clinical assessment information for the RD to complete remote resident nutritional assessments. The DON stated it was unlikely the RD could complete effective and accurate nutritional assessments as she was not observing or collecting resident information herself. The DON stated ineffective and inaccurate nutritional assessments could contribute to weight loss. The DON stated it was not appropriate to allow Resident 4 to suffer weight loss before providing appropriate and timely nutritional interventions. The DON stated the RD withheld dietary interventions and delayed timely appropriate dietary interventions for Resident 4. The DON stated Resident 4 suffered unintentional weight loss which caused suffering and was determinantal to her well-being. The DON stated facility policy and procedures regarding weight loss and weight management had not been followed for Resident 4. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2017, the P&P indicated, .the dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of,[TRUNCATED]

Based on observations, interviews and record review, the facility failed to ensure residents' environment remained free of accident hazards as possible when: 1. In the memory care unit, facility staff were aware an exit door was secured by a slide barrel lock (a type of lock that requires the user to slide the barrel of the lock in order to unlock the device) and placed on the door in a position that was out of reach for most individuals. An environmental hazard risk assessment was not done for the lock on the door. Some staff were unaware of the placement of the slide-barrel lock and residents were not trained to unlock the device.These failures resulted in the possibility of 26 of 26 residents ((Residents 8, 16, 18, 20, 23, 24, 31, 43, 45, 51, 56, 58, 60, 64, 75, 76, 88, 99, 104, 117, 136, 149, 156, 168, 172 and 187) and staff being unable to exit the door in an emergency and could lead to entrapment. These failures could affect all 26 memory care residents, representing widespread scope and severity and substandard quality of care.2. Facility staff was aware of the path of travel to the smoking area from the entrance of the facility crossed the parking area and did not safely and effectively address the hazard posed to residents who smoke and travel the path in order to reach the smoking area. These failures resulted in one of 15 sampled residents (Resident 81) traveling the path on 7/15/25 at time and was struck by a vehicle while in his wheelchair. Resident 81 sustained an unavoidable fracture (break in bone) to his left distal fibula (lower, outer portion of the two long bones in the lower leg) and medial malleolus (bony prominence located on the inner side of the ankle joint) fracture and was admitted to general acute care hospital (GACH) from 7/15/25 through 7/21/25, an open reduction internal fixation (ORIF-surgical opening the fracture site to realign the bone fragments and then using internal hardware like screws, plates, or rods to hold pieces together) to repair the fracture was performed on 7/18/25. These injuries resulted in Resident 81's decreased independence in mobility and to experience pain which led to increased dependence on staff to meet all his activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily care for themselves) needs1. During an observation on 08/05/25 at 1:06 p.m. a slide barrel lock was installed at the top right corner of an exit door located in the dining room located within the memory care unit leading out to a patio. During a concurrent observation and interview on 8/8/25 at 9:23 AM with the Director of Nurses (DON), DON observed the lock on the door and stated that she was not aware that this type of lock had been installed on the door. DON stated, “That lock can’t be there”. DON stated that she thinks this is very unsafe and needs to be replaced. DON stated that it is a, “huge safety issue”. DON stated she never knew that the door had this type of lock installed. DON stated that in the event of an emergency the residents could not get out safely and the fire department could not get in easily. DON further stated that this could be considered a restraint. DON demonstrated that she was not able to reach the lock because the lock was installed high up on the door. During a concurrent observation and interview on 08/08/25 at 9:42 AM with Maintenance Director (MAINT DIR) the door leading from the dining room to an outside patio was equipped with a lock. According to MAINT DIR the lock’s design was a slide barrel lock and stated the lock was installed several months before. The MAINT DIR stated the position of the lock on the door, near the very top right corner of the door, prevented most individuals, including staff and residents to reach the lock and could result in the possibility of residents and staff unable to exit the door in an emergency and could lead to entrapment. MAINT Dir stated that the slide barrel lock requires some fine motor skills and cognitive understanding to operate. Residents in the memory care unit, many of whom may have dementia or Alzheimer's, may not be able to unlock them in an emergency, posing a serious risk during fire or evacuation situations. Locks like these can trap residents or staff inside or outside the building, especially if staff are unaware the lock has been engaged. MAINT DIR stated that there had been no facility risk or hazard assessment done on this door and lock. MAINT DIR removed the lock from the door. During a review of the facility’s policy and procedure titled, “Exits or Means of Egress” revised date January 2024, indicated “… primary and secondary exit doors will remain unlocked at all times…” During a review of professional reference from the Life Safety Code (NFPA 101) Published by the National Fire Protection Association (NFPA) in which it requires, “…“doors must be readily operable from the egress side when a building is occupied. Locks and latches should not require special knowledge or effort to operate from the egress side” and “that all occupancies, including health care facilities, have unobstructed and readily accessible means of egress to allow for safe evacuation during emergencies” (NFPA 101: Life safety Code, Means of Egress Requirements (NFPA, latest edition). 2. During a review of Resident 81’s GACH document titled, “Physician History and Physical Note” dated 7/16/25, the note indicated, “…presented to the emergency department [ED] after reportedly being struck by a pickup truck while seated in his wheelchair in a parking lot… ED Imaging and Findings: CT [computed tomography scan or CAT scan-medical imaging procedures that uses X-rays[type of electromagnetic radiation used to create images of the inside of the body particularly bones] to create detailed cross-sectional images of the body) Bilateral Lower Extremities (7/15/25 21:09): Left leg: Comminuted, displaced acute traumatic fracture of the distal fibular shaft. Comminuted medial malleolus fracture. Moderate soft tissue swelling. Right Leg: No acute fracture or dislocation… Discharge Summary… Hospital course: …successful ORIF on 7/18/2025…” During a review of Resident 81’s “admission Record,” (AR-a document containing resident profile information) dated 7/16/25, the AR indicated, Resident 81 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (group of conditions that affect the blood vessels in the brain) dysarthria (speech disorder characterized by difficulty in articulating words and producing clear speech) and anarthria (complete loss of the ability to produce speech) history of alcohol abuse, muscle weakness, unspecified dementia (a progressive state of decline in mental abilities) and diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Residents 81’s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 81’s Brief Interview of Mental status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 81 was cognitively intact. During a review of Resident 81’s MDS Assessment, “Section GG-Functional Abilities,” dated 7/15/25, was reviewed. The MDS “Section GG” indicated, “…R. Wheel 50 feet with two turns… code 05 [Setup or clean-up assistance (helper sets up or cleans up; resident competes activity. Helper assist only prior to or following activity) …S. Wheel 150 feet: Once seated in a wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space…code 05…” During a concurrent observation and interview on 8/5/25 at 3:15 p.m. in Resident 81’s room, Resident 81 was sitting up at the edge of his bed appropriately dressed and observed All Cotton Elastic bandage (ACE- used to provide support and compression to injured or weak body parts) covering his left foot up to below the knee. Resident 81 stated he had an accident in the facility parking lot when he went out for a smoke and was coming back to the facility. Resident 81 stated he was struck by a vehicle backing out of the parking stall. Resident 81 stated he tried to get out of the way, but his wheelchair was hit on the side and went down on his right side with his wheelchair. Resident 81 stated the vehicle went forward and the driver got out of the vehicle and saw him on the ground with his wheelchair on top of him. Resident 81 stated the driver asked if he was injured and picked up the wheelchair off him and set the wheelchair on the ground. Resident 81 stated the driver then picked him up and placed him on the wheelchair and pushed the wheelchair inside to the nursing station. Resident 81 stated the driver informed the nursing staff what happened. Resident 81 stated he told the nurse he had pain in his feet and requested to be sent out to the hospital. Resident 81 stated he did not remember other residents were outside smoking or any staff member supervising smokers. Resident 81 stated the only way to the smoking area was to go through the parking area behind rows of parked cars. Resident 81 stated the facility decided on the smoking area location and thought it was safe. Resident 81 stated, “I just had to be careful passing behind parked cars to avoid getting hit.” During an interview on 8/7/25 at 2:10 p.m. with Registered Nurse (RN) 2, RN 2 stated she was Resident 81’s nurse when Resident 81 was hit by a vehicle in the parking lot. RN 2 stated Resident 81 was alert and oriented and an independent smoker, Resident 81 was able to safely smoke on his own. RN 2 stated she last saw Resident 81 sitting up in his wheelchair requesting a cigarette. RN 2 stated she reminded Resident 81 it was not time to go out for smoke but Resident 81 insisted. RN 2 stated she was not sure if Resident 81 went out by himself to the smoking area and was not assisted by a staff member. RN 2 stated smokers had to go out the double door through the parking area to reach the smoking area. RN 2 stated she was not sure if it was safe for Resident 81 or any residents who smoked to go in the smoking area by themselves. RN 2 stated she did not remember any other accidents that occurred in the parking area before. RN 2 stated she remembered one of the CNA notified her of Resident 81 had an accident outside in the parking area. RN 2 stated she saw CDM/D wheeled Resident 81 to the nursing station and CDM/D stated he hit Resident 81 with his vehicle while he was backing out of parking area. RN 2 stated Resident 81 complained of pain in his feet and requested to be sent out to GACH. RN 2 attempted to assess Resident 81’s feet but refused. RN 2 stated she offered pain medication which Resident 81 agreed to take. During an interview on 8/7/25 at 2:38 p.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated she was familiar with Resident 81’s care. CNA 9 stated she last saw Resident 81 in his room sitting in his wheelchair and did not mention about wanting to go out to smoke. CNA 9 stated she walked outside to the parking lot and saw people in the parking lot standing around Resident 81 sitting in his wheelchair behind a car. CNA 9 stated she notified RN right away and stated, “I think he [Resident 81] was hit by a car.” CNA 9 stated Resident 81 was wheeled back in his wheelchair back inside the facility and was complaining of pain. CNA 9 stated licensed nurses took care of Resident 81 and was sent out to the hospital. During a concurrent observation and interview on 8/7/25 at 3 p.m. with the Certified Dietary Manager/Driver (CDM/D) and DON outside in the parking lot where the incident occurred. The CDM/D showed the location where his vehicle was parked and the location of Resident 81 in his wheelchair when hit with his vehicle while he was backing out of the parking stall. The CDM/D stated his vehicle was parked in the second row on the 14th parking stall from the street near the kitchen back door exit. The CDM/D stated he did not remember seeing Resident 81 or any staff in the parking area when he walked toward his vehicle. The CDM/D stated he drives a truck and is higher than the regular vehicle and he did not see anyone around his vehicle when he was backing his vehicle out of the parking stall then he heard a “Steady honk”, so he parked his vehicle and got out of the vehicle. The CDM/D stated he walked to the back of his vehicle and saw Resident 81 in his wheelchair tilted on its side behind his vehicle and the vehicle parked next to his in number 13 parking stall. The CDM/D stated Resident 81 was laying on his right side on the ground with the wheelchair and Resident 81’s legs were straight out. The CDM/D stated he immediately moved the wheelchair and asked Resident 81 if he was alright. The CDM/D stated Resident 81 gave him permission to move and sit him in the wheelchair to bring him inside the facility due to the extreme heat (100 degrees Fahrenheit) condition at the time. The CDM/D stated he pushed Resident 81 inside the facility to the nursing station and notified the licensed nurse and the administrator. The CDM/D stated he remembered Resident 81 telling the licensed nurse he had pain in his feet and wanted to be sent out to the hospital. The CDM/D stated from the double door to the site of the incident was six parking stalls including the two handicapped spaces in the first row of parking spaces and directly opposite are eight parking spaces before his vehicle. The CDM/D stated from the smoking area to the site of the incident, Resident 81 had to pass the enclosed large trash bin area, four parking spaces and through the end of driveway where car turns to go to the next rows of parking stalls. The CDM/D stated there was no other safe pathway for residents except to go through the parking area behind parked cars going from the facility to the smoking area. During a phone interview on 8/7/25 at 3:30 p.m. with Compassionate Care Driver (CCD), the CCD stated he was sitting inside his vehicle when the accident occurred. The CCD stated his car was parked across from where the DSM/D’ vehicle was parked. The CCD stated he saw the CDM/D walking towards his vehicle and started his vehicle, he saw Resident 81 in his wheelchair wheeling himself from the smoking area and as Resident 81 approached behind the CDM/D vehicle and tried to move his wheelchair faster to avoid the vehicle. The CCD them saw the CDM/D vehicle backed out and was about to hit Resident 81 in his wheelchair “I pressed my vehicle’s horn steadily, but the vehicle already hit the wheelchair.” The CCD stated Resident 81’s wheelchair was struck and Resident 81 flipped to the side with his wheelchair. The CCD stated Resident 81 was not run over by the vehicle. The CCD stated he saw CDM/D moved his vehicle forward, got out of his vehicle and walked around behind his vehicle. The CCD stated he got out of his vehicle and helped the CDM/D with Resident 81. The CCD stated the driver straightened the wheelchair and picked up the resident and sat him on the wheelchair and pushed the wheelchair inside the facility and let the licensed nurse know of what happened. The CCD stated he did not remember seeing other residents or staff outside in the smoking area at the time of the accident. During an interview on 8/12/25 at 8:26 a.m. with the Director of Staff Development (DSD), the DSD stated she started working in the facility as DSD since 5/22/25. The DSD stated the smoking area was moved after the accident in the parking area. The DSD stated the smoking area was under the tree at the back of the parking area. The DSD stated residents who smoked had to go through the parking area behind parked cars to go to the smoking area. The DSD stated it was not safe for residents to go through the parking area behind parked cars without any staff assistance. The DSD stated Resident 81 was assessed as an independent smoker, he was alert and oriented and was able to smoke independently. During a concurrent observation and interview on 8/12/25 at 9:38 a.m. with Resident 120 in the smoking area, Resident 120 stated he had been in the facility for a year and had always smoked. Resident 120 stated he was an independent smoker and could go out to smoke anytime he wanted. Resident 120 stated the smoking area was moved after the accident in the parking area. Resident 120 stated there was no sidewalk to use from the double door to the smoking area. Resident 120 stated they had to go through the parking lot, and it was not safe. Resident 120 stated Resident 81 was slower to wheel himself and sometimes refused help from the staff. Resident 120 stated he was outside smoking before the accident and did remember seeing Resident 81 outside smoking with the group. During an interview on 8/12/25 at 10 a.m. with CNA 8, CNA 8 stated residents who smokes have schedule to follow and had to be assisted when they go outside. CNA 8 stated it was not safe for them to go through the parking lot to the smoking area. CNA 8 stated the parking lot was always busy and there was no sidewalk from the facility to the smoking area. During an interview on 8/12/25 at 1:45 p.m. with LVN 9, LVN 9 stated the smoking area was moved after Resident 81’s accident in the parking lot. LVN 9 stated the residents are to be assisted to the smoking area by the activity staff and or any staff member then assisted back in the facility after they are done smoking. LVN 9 stated he did not think it was safe for residents to go out alone to smoke because they must go through the parking area behind parked cars. LVN 9 stated he always made sure residents who smoke were assisted when they go out to smoke because of the lack of safe pathway to the smoking area. During an interview on 8/12/25 at 4:20 p.m. with Activity Assistant (AA), AA stated she was working the day the incident happened in the parking lot. AA stated she was outside in the smoking area at 4 p.m. supervising smokers before the incident and Resident 81was not outside with the group. The AA stated she helped smokers when they go outside to smoke because it is quite a distance from the double door to the smoking area. The AA stated residents had to go through the parking lot behind parked cars to get to the smoking area and there were always cars coming in and out. The AA stated, “There was a high risk of accident happening, there was no sidewalk for residents and staff to use.” During a concurrent interview and record review on 8/12/25 at 4:45 p.m. with Assistant Director of Nursing (ADON), the ADON reviewed Resident 81’s medical record titled “Smoking Assessment” dated 3/4/25, the ADON stated Resident 81 was assessed as independent smoker before the accident. The ADON stated she was working the day the incident happened and was on her way out when she saw Resident 81sitting up in his wheelchair surrounded by staff by the nursing station. The ADON stated she assisted the licensed nurse and attempted to perform a head-to-toe assessment but Resident 81 refused. The ADON stated she notified the administrator of the incident and assisted sending Resident 81 out to hospital. The ADON stated the smoking assessment did not cover how residents go from the facility to the smoking area. The ADON stated there was no sidewalk or safe pathway from the facility to the smoking area. The ADON stated smokers had to be assisted when they go out to smoke because they had to go through the parking area to reach the smoking area. The ADON stated it was not safe for residents to be by themselves when they go out to smoke, there are a lot of cars all the time. During a concurrent observation and interview on 8/13/25 at 3:05 p.m. with MAINT DIR and DON outside in the parking lot, the MAINT DIR stated he was unable to measure the distance from the double door where residents exited the facility to go to the smoking area. The MAINT DIR stated in the first row of the parking area are four handicapped parking spaces and six regular parking spaces, 16 parking spaces on the opposite side. The MAINT DIR stated four parking spaces next to the trash bins area before the smoking area and an additional four rows of 16 parking spaces. The MAINT DIR stated the parking lot was always busy, cars were constantly going in and out, staff and visitors used the parking area and entered the facility through the double door. The MAINT DIR stated it was not a safe area for residents to be on their own, navigating behind parked cars and cars trying to find parking spaces and cars leaving the parking area. The MAINT DIR stated it was also a long distance from the double door to the smoking area, the MAINT DIR stated, “It was an accident waiting to happen.” During an interview on 8/14/25 at 10:06 a.m. with the DON, the DON stated she had only been in the facility for eight weeks. The DON stated she was not in the facility when the incident happened and was notified by phone. The DON stated she was notified Resident 81 was run over by a vehicle in the parking lot. The DON stated, “The distance from the double door to the old smoking area was quite long and the parking lot is busy all the time.” The DON stated the double door was where ambulance and transportation vans picked up and dropped off residents. The DON stated there should have been staff assisting residents in the parking lot when they go out to smoke because they had to go through the parking area behind several parked cars and it was not safe. The DON stated her expectation was for the facility to ensure there was a safe pathway/walkway for residents when they went out to the smoking area to smoke. The DON stated it was the responsibility of the facility to ensure resident’s safety. During an interview on 8/14/25 at 11:05 a.m. with the Administrator (ADM), the ADM stated he was notified by phone by the ADON of the incident on the day it happened. The ADM stated he interviewed staff including the activities assistant who was with the smokers at 4 p.m. and Resident 81 was not with the group smoking. The ADM stated about the accident, “It was unfortunate, it could have happened to anybody, not just residents, it could have happened to staff or visitors.” The ADM stated it was a risk for anybody. The ADM stated the old smoking area was safe, it was an unfortunate event that occurred. The ADM stated the incident was not preventable, “There was nothing that could have been done to prevent the accident from happening.” The ADM stated they moved the smoking area to a new location after the incident and residents did not have to go through the parking lot. During a review of the facility’s policy and procedure (P&P) titled “Smoking Policy-Residents,” dated 1/2024, the P&P indicated, “…Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which facility can accommodate their smoking or non-smoking preferences… Smoking is only permitted in designated resident smoking areas… Any resident with smoking privileges requiring monitoring shall have the supervision of a staff member, family member… Residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents…” During a review of the facility’s P&P titled. “Safety and Supervision of Residents,” dated 1/24, the P&P indicated, “…2. Safety risks and environment hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI [Quality Assurance and Performance Improvement-systematic, data-driven, and proactive approach to improving the quality of care and quality of life in healthcare settings] reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the facility staff shall review the events in an attempt to identify the root-cause and possible associated hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. When safety risks can not be completely eliminated, such as the risk for falls and related injuries, the facility staff shall develop strategies to mitigate the risk for injuries that could result from these events. 5. The facility staff and QAPI committee shall review interventions to mitigate hazards or risk for injuries and modify as deemed necessary…” During a review of facility’s policy and procedure (P&P) titled, “Accidents and Incidents-Investigating and Reporting,” dated 7/19, the P&P indicated, “…The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident… Incident/accident reports will be reviewed… for trends related to accident or safety hazards in the facility and to analyze any individual vulnerabilities.” During a review of facility’s P&P titled, “Unusual Occurrence Reporting,” dated 12/23, the P&P indicated, “… 1. Our facility will report the following events to appropriate agencies… or other calamities that damage the facility or threaten the welfare, safety or health of residents… “ During a review of the facility’s P&P titled, “Resident Rights,” dated 2/23, the P&P indicated, “… Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident’s rights to: a dignified existence; be treated with respect, kindness and dignity… be informed of safety…”

Based on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when:The facility did not include an evaluation of the physical environment in its facility assessment to ensure the needs of the resident population were met for 26 of 26 residents in the memory care unit and 15 of 15 smokers in the facility.These failures placed residents in the memory care unit unable to exit the door in an emergency and could lead to entrapment and placed smoking residents safety at risk.During a concurrent interview on 08/14/2025 at 3:25 p.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON stated they did not identify any issues with how the Resident smoking area was set up in the past. The ADM stated they implemented changes after a resident was hit by a vehicle, but nothing was documented in the facility assessment. The ADM stated they felt no need to assess issues with the smoking area because they had not had an accident before. The ADM stated the facility assessment was not updated for the lock placed on the door in the memory care unit. The DON stated she had toured the unit before with another health facilities evaluator nurse and no issues with the lock were identified. The ADM stated the last time the Facility Assessment was updated was on may 2nd 2025 but it was not updated to reflect the smoking area or the locked door in the memory care unit.During a review of the facility's Facility Assessment, undated, the Facility assessment did not include any assessments regarding safety in resident smoking areas or environmental assessments regarding locks on doors in the memory care unit.

Based on observation, interview and record review, the facility failed to meet professional standards of practice for nine out of 15 sampled residents (Residents' 95, 96, 14, 68, 86, 87, 129, 144 and 164) when:1.Resident 95's tramadol (opioid pain medication used to treat moderate to severe pain) medication lacked an appropriate indication and an associated pain scale to guide administration.This failure resulted in Resident 95's tramadol medication order not having complete and appropriate administration instructions which could lead to inappropriate administration, overmedication, or overdose. 2.Resident 96's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order. This failure resulted in Resident 32 not receiving his oxygen therapy as ordered which had the potential to result in nasal dryness, shortness of breath, oxygen toxicity (lung damage that happens from breathing in too much extra oxygen therapy), and serious medical condition.3. Licensed Vocational Nurse (LVN) 10 did not follow their facility protocol of responding to wander guard (a system designed to prevent residents in a healthcare facilities, particularly with dementia [a progressive state of decline in mental abilities] and Alzheimer's [a disease characterized by a progressive decline in mental abilities] from wandering off and potentially endangering themselves) alarm system when activated and turned off the alarm without checking outside of the facility for residents who could have possibly left the facility without staff knowledge.This failure placed Residents' 14, 68, 86, 87, 129 and 164 with wander guard at risk to have left the facility which could result in accidents and potential for serious injury.4. Resident 144's 8:00 a.m. scheduled 81 mg (milligram-a very small unit of weight) aspirin (medication used to help prevent heart problems because it keeps blood from clotting too easily), 100 mg extended-release (a type of medicine that released slowly into the body over time) metoprolol succinate (medication used to treat high blood pressure) and 10mg amlodipine (medication to treat high blood pressure) were administered at 9:12 a.m. These failures to follow proper medication administration practices had the potential to result in reduced effectiveness of treatment or harm to Resident 144.1.During a review of Resident 95's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (condition in which brain tissue dies due to lack of blood flow), epilepsy (seizures due to abnormal brain activity), stiff-man syndrome (disorder which includes fluctuating muscle rigidity and spasms triggered by noise, touch, or distress), and major depressive disorder (persistent sadness). During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/22/25, the MDS indicated Resident 95 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 95 was cognitively intact. During a review of Resident 95's Order Summary Report, dated 8/12/25, the Order Summary Report indicated, .tramadol HCI oral tablet 50 MG (milligrams- unit of measurement for medication dosage) give 1 tablet by mouth every 8 hours for pain management.active.order date 5/23/24.start date 5/23/24. During an interview on 8/7/25 at 1:54 p.m. with Resident 95 in Resident 95's room, Resident 95 stated, licensed nursing staff administered tramadol every day. Resident 95 stated licensed nursing staff did not assess her pain prior to administration of tramadol. Resident 95 stated her pain was well controlled with her other medications and had acetaminophen (pain medication used to treat mild to moderate pain) available as needed if she had breakthrough pain, which worked to manage her pain. Resident 95 stated she had received tramadol every day since admission. Resident 95 stated she did not need pain medication everyday and would prefer not to take pain medication if she was not in pain. Resident95 stated tramadol made her feel sleepy after administration. During an interview on 8/7/25 at 2:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 95 was able to make her needs known. CNA 1 stated Resident 95 did not often verbalize pain or show signs of being in pain. CNA 1 stated if Resident 95 was in pain she would notify the CNA or licensed nursing staff, and pain medication would be administered. During a concurrent interview and record review on 8/7/25 at 3:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 95's Order Summary and Medication Administration Record (MAR), dated 8/7/25 was reviewed. LVN 1 stated Resident 95 had an active order for tramadol to be given .every 8 hours for pain management. LVN 1 stated Resident 95's tramadol medication order did not have an appropriate indication for use or associated pain scale within the administration instructions. LVN 1 stated it was important to ensure pain medication administration instructions had specific indications for use and associated pain scales to ensure the lowest most effective medication could be administered for pain management. LVN 1 stated routine, scheduled and as needed pain medication required pain scales associated within the order. LVN 1 stated tramadol was an opioid (a controlled substance that can become highly addictive) and would not be appropriate to be administered if Resident 95 had no pain. LVN 1 stated complete and appropriate administration instructions ensured medication was administered safely within parameters and could be monitored. LVN 1 stated without knowing what the pain medication was targeting to treat or what pain level to give it for it could not be assessed for effectiveness or tapered. LVN 1 stated Resident 95 was at risk for overmedication without complete and appropriate tramadol administration instructions. During an interview on 8/7/25 at 3:54 p.m. with Responsible Person (RP) 1, RP 1 stated she was Resident 95's medical and financial decision maker. RP 1 stated Resident 95 did not express or portray pain every day. RP 1 stated Resident 95 required pain medication to manage her diagnosis of stiff-man syndrome, but did not require pain medication every day. RP 1 stated some days Resident 95 had no pain. RP 1 stated Resident 95 was able to make her needs known and should be included in making her own medical decisions. During an interview on 8/12/25 at 3:45 p.m. with the Pharmacist Consultant (PC), the PC stated Resident 95's tramadol order administration instructions were not specific and required a review of her medical chart to determine appropriateness. The PC stated all pain medication orders required a pain scale within the administration instructions to ensure pain medication was administered appropriately. During a concurrent interview and record review on 8/14/25 at 1:49 p.m. with the Director of Nursing (DON) Resident 95's Order Summary Report, dated 8/14/25 was reviewed. The DON stated Resident 95's order for, .tramadol HCI oral tablet 50 MG give 1 tablet by mouth every 8 hours for pain management. did not contain appropriate administration instructions. The DON stated pain medication needed to indicate what pain was being targeted to treat and an associated pain scale for administration. The DON stated pain can not be monitored if it is not known what the medication is being administered to treat or if it is not administered for an appropriate pain level. The DON stated tramadol was an opioid that was intended to treat moderate to severe pain levels and would not be appropriate to administer for mild pain. The DON stated every pain medication is expected, per policy, to have an indication and reason as to why the medication was to be given. The DON stated it was important to understand what condition or pain symptom was being targeted for treatment to ensure monitoring and effective pain relief. The DON stated every pain medication was expected, per policy, to have an associated pain scale in the administration instructions to ensure it was appropriate to administer the medication for the targeted pain level. The DON said if pain medication was not administered appropriately it could lead to tolerance or dependency on the medication. The DON stated licensed nursing staff, and pharmacy was responsible to ensure all medications administration instructions were complete and accurate before administration. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medication, dated 10/2022, the P&P indicated, .facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.pain management is a multidisciplinary care process that includes.assessing the presence of pain.monitoring the effectiveness of interventions.when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. During a review of the facility's in-service meeting minutes titled, Pain Level Monitoring and Documentation, dated 4/15/2025, the in-service meeting minutes indicated, if pain medication is ineffective or out of scale for pain medication notify MD immediately.example MAR.Norco 10/325 mg give 1 tablet by mouth every 4 hours as needed for severe pain level 7-10.entering (0) zero would be incorrect. 2.During a review of Resident 96's AR, dated 8/12/25, the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD-progressive lung disease that restricts breathing), acute and chronic respiratory failure (condition when lungs cannot oxygenate the blood), Alzheimer's disease (progressive disease that leads to cognitive decline and memory loss), and dementia (decline in mental ability). During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96 had a BIMS score of 15, which suggested Resident 96 was cognitively intact. During a review of Resident 96's Order Summary Report, dated 8/12/25, the Order Summary Report indicated, .oxygen at 2 liter/min [LPM- liter per minute- a unit of measurement for the flow rate of oxygen] via nasal cannula [a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen] as needed for shortness of breath.active.order start date 11/12/22.start date 11/12/22. and .oxygen at 2 liter/min via nasal cannula continuously at bedtime.active . order start date 11/12/22.start date 11/12/22 During an observation on 8/5/25 at 9:55 a.m. in Resident 96's room, Resident 96 was observed lying in bed, eyes closed with his nasal cannula in his nose. Resident 96's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents breathe). The oxygen concentrator was observed on the left side of the bed turned on at 4 LPM. During a concurrent observation, interview and record review on 8/6/25 at 8:11 a.m. with LVN 2 in Resident 96's room, Resident 96 was observed lying in bed with his nasal cannula in his nose. Resident 96's nasal cannula was observed connected to the oxygen concentrator. LVN 2 stated Resident 96's oxygen concentrator was on at 4 LPM. LVN 2 stated Resident 96 had an active oxygen order for 2 LPM as needed and at bedtime. LVN 2 stated Resident 96's oxygen concentrator should not be on 4 LPM. LVN 2 stated Resident 96's oxygen had not been administered correctly per physician order. LVN 2 stated licensed nursing staff were responsible for ensuring oxygen therapy was administered as prescribed. LVN 2 stated there was no documentation or order to reflect a rationale for the oxygen administration increase. LVN 2 stated oxygen was a medication and needed to be administered as prescribed. LVN 2 stated Resident 96 had COPD and was at risk for excessive oxygen administration which could result in serious medical conditions. During a concurrent interview and record review on 8/14/25 at 1:49 p.m. with the DON, a photo of Resident 96's oxygen concentrator, dated 8/5/25 and 8/6/25 and Resident 96's Order Summary Report, dated 8/14/25 was reviewed. The DON stated Resident 96 had an active order for oxygen therapy at 2 LPM via nasal cannula as needed for shortness of breath and oxygen therapy at 2 LPM via nasal cannula at bedtime. The DON stated Resident 96 received 4 LPM oxygen via nasal cannula on 8/5/25 and 8/6/25. The DON stated provider orders were not followed. The DON stated oxygen was a medication and she expected all licensed staff to administer medication per the provider order. The DON stated it was important to administer oxygen as ordered to ensure Resident 96's diagnoses were treated and maintained. The DON stated a new order and progress note would be required if oxygen was increased for any reason. The DON stated Resident 96 was at risk for oxygen toxicity and serious medical condition which could be detrimental to his care when the incorrect amount of oxygen was administered. The DON stated professional standards of practice, facility policy and procedure, and expectations were not followed when Resident 96 received the incorrect administration of 4 LPM oxygen therapy on 8/5/25 and 8/6/25. During a review of the facility's policy and procedure P&P titled, Administering Medications, dated 4/2023, the P&P indicated, medications are administered in accordance with prescriber orders.the individual administering the medication.verify.right dosage. if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. During a review of the facility's P&P titled, Oxygen Administration, dated 2/2024, the P&P indicated, .verify that there is a physician's order for this procedure. Review the physicians orders or facility protocol for oxygen administration.adjust the oxygen delivery device so that is comfortable for the resident and the proper flow of oxygen is being administered. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 3. During a concurrent observation and interview on 8/8/25 at 2:53 p.m. with LVN 10 in nursing station 1 and 2. LVN 7stated the alarm was set off by a resident with a wander guard. LVN 10 stated wander guard was also placed on residents trying to get out of bed without calling for assistance. LVN 10 stated all the facility doors are equipped with sensors and triggered when a resident with a wander guard gets too close to the door. LVN 10 stated the alarm in nursing station 1 & 2 was triggered by the double door that goes out to the parking lot. LVN 10 stated she turned off the alarm and did not check outside for any residents who may have left the facility. LVN 10 stated she was not sure about the facility protocol on turning off the alarm when triggered by a wander guard. LVN 10 stated she was not sure how many residents in her station had wander guard. During an interview on 8/12/25 at 8:26 a.m. with the Director of Staff Development (DSD), the DSD stated she started working in the facility on 5/22/25 and did not remember providing in-services training on elopement. The DSD stated the facility had six residents with a wander guard system. The DSD stated the facility practice was to check and look at the surrounding area, including outside of the facility and then turn off the alarm once cleared. The DSD stated once the alarm was triggered, staff should respond immediately. The DSD stated, Ensuring safety of residents is the priority. During a review of Resident 14's admission Record, dated 8/14/25, the admission record indicated Resident 14 was admitted to facility on 2/3/21 with diagnoses which included unspecified dementia and major depressive disorder (mental health condition characterized by feelings of sadness, loss of interest or pleasure. During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 14's Brief Interview of Mental status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 7 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 14 had severe cognitive impairment. During a review of Resident 64's admission Record dated 8/14/25, the admission record indicated, Resident 64 was re-admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 64's MDS assessment dated [DATE], the MDS assessment indicated Resident 64's BIMS score of 6 of 15 which indicated Resident 64 had severe cognitive impairment. During a review of Resident 86's admission Record, dated 8/14/25, the admission record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), altered mental status (behaving or thinking differently than they usually do) and anxiety (feelings of worry, fear, nervousness, and unease). During a review of Resident 86's MDS assessment dated [DATE], the MDS assessment indicated Resident 86's BIMS score of 3 of 15 which indicated Resident 86 had severe cognitive impairment. During a Review of Resident 87's admission Record, dated 8/14/25, the admission record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses which indicated unspecified dementia, depression and anxiety. During a review of Resident 87's MDS assessment dated [DATE], the MDS assessment indicated Resident 87's BIMS score of 12 out of 15 which indicated Resident 87 had moderate cognitive impairment. During a review of Resident 129's admission Record, dated 8/14/25, the admission record indicated, Resident 129 was admitted to the facility on [DATE] with diagnoses which included Parkinsonism (a progressive disorder of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), dementia and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality. During a review of Resident 129's MDS assessment dated [DATE], the MDS assessment indicated Resident 129's BIMS score of 3 of 15 which indicated Resident 129 had severe cognitive impairment. During a review of Resident 164's admission Assessment, dated 8/14/25, the admission assessment indicated, resident 164 was admitted to the facility on [DATE] with diagnoses which included dementia, muscle weakness and dysphagia oral phase (difficulty with the actions that happen in the mouth before the act of swallowing). During a review of Resident 164's MDS assessment dated [DATE], the MDS assessment indicated Resident 164\s BIMS score of 3 of 15 which indicated Resident 164 had severe cognitive impairment. During an interview on 8/12/25 at 10:15 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated wander guard are used for residents who are at risk for elopement. CNA 8 stated when the door alarm was triggered by a wander guard, staff should immediately check outside the doors for any residents who may have left the facility without letting the staff know. CNA 8 stated the alarm stays on until all residents with wander guard are accounted for. During an interview on 8/12/25 at 2:05 p.m. with LVN 9, LVN 9 stated wander guard devices are placed on residents who are at risk for elopement. LVN 9 stated all the door leading to the outside have sensors and is triggered when a resident with a wander guard gets too close to the door. LVN 9 stated when an alarm goes off, the resident with a wander guard moved away from the door, check outside for any resident who may have left without staff knowing then turn off the alarm. LVN 9 stated, I do not just turn off the alarm asked staff to check the surroundings and check the locations of all residents with wander guard then turn off the alarm. During an interview on 8/13/25 at 10:59 a.m. with Registered Nurse (RN) 3, RN 3 stated the practice for when the wander guard alarm was triggered was to have staff check outside to make sure there were no residents trying to leave the facility. RN 3 stated some staff to check for residents with wander guard are all inside then turn off the alarm. During an interview with the Assistant Director of Nursing (ADON) the ADON stated wander are placed on residents are not alert and oriented and had history of wandering and tried to leave facility. The ADON stated the protocol for when the alarm was triggered was to assign staff to check outside of the facility and inside the facility to make sure residents did not try to leave facility without staff knowledge. The ADON stated once cleared and all residents accounted for then the alarm can be turned off. During an interview on 8/14/25 at 10:30 a.m. with the Director of Nursing (DON) the DON stated the expectation when a wander guard alarm was triggered was for staff to check outside the facility, resident rooms including toilet. The DON stated once cleared, the alarm can then be turned off. The DON stated, Accidents could happen if they are left outside. During an interview on 8/14/25 at 11:30 a.m. with the Administrator (ADM), the ADM stated, The practice was to get up and check to see if anyone get out. The ADM stated his expectation was for staff to make rounds and check resident rooms to make sure no residents are missing. During a review of facility policy and procedure (P&P) titled, Resident Monitoring System, dated 3/23, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The Nurse, Social Services, or designee determines if resident needs to be placed on monitoring devise. Resident monitoring device are issued after obtaining physician's order and the resident or resident's authorized representative. Nursing will use the testing device provided by the manufacturer to ensure proper working order and document result. The Maintenance Department or designee tests the monitoring system at exit points at least weekly. document testing on the Monitoring Device testing log. During a review of facility policy and procedure (P&P) titled, Wandering and Elopement, dated 3/23, the P&P indicated, . If an employee observes a resident leaving the premises, he/she should: . get help from other staff members . instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave facility or has left the premises. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement. 4. During a medication administration observation on 8/6/25 at 8:50 a.m. with LVN 6, LVN 6 entered a room, which was a three-resident room. LVN 6 administered the scheduled 9:00 a.m. medications to the residents in Bed A and Bed B. LVN 6 documented the medication administration as completed on the residents Medication Administration Record (MAR); the MAR screen at the time of administration were yellow. At 9:12 a.m., LVN 6 completed passing medications to Bed A and Bed B and proceeded to Resident 144 in Bed C. Resident 144's medications were scheduled for 8:00a.m. LVN 6 administered Resident 144 his scheduled 81 mg aspirin, 100 mg extended-release metoprolol succinate and 10 mg amlodipine. When LVN 6 documented the medications as administered in the MAR, the screen on the MAR was red/pink in color. The time of administration recorded in the medication administration task was 9:12 a.m. During an interview on 8/13/25 at 2:37 p.m. with the Pharmacy Consultant (PC), the PC stated staff have one hour before or one hour after the scheduled time to administer medications. The PC stated the nurse was outside of the allowed administration window by giving medications after 9:00a.m. The PC stated it was important for medications to be given within the scheduled time frame because delays could reduce their effectiveness and potentially cause complications in managing the residents' medical conditions. During an interview on 8/14/25 at 10:13 a.m. with LVN 4, LVN 4 stated medications were allowed to be administered one hour before or one hour after the scheduled time. LVN 4 stated if medications were given outside of that time frame, they were considered late. LVN 4 stated if the MAR screen was red the medication was considered late, and if the MAR screen was yellow, the medication was considered on time. LVN 4 stated a risk to the residents that medications might not be as effective if they were administered late. During an interview on 8/14/25 at 10:20 a.m. with LVN 6, LVN 6 stated there was a one-hour window to administer medications. LVN 6 stated if a medication was scheduled for 8:00 a.m. and was administered at 9:12 a.m. then the medication was administered late. LVN 6 stated it was important that medications were given on time because they managed chronic conditions and delays in administration could cause complications. During an interview on 8/14/25 at 10:59 a.m. with the DON, the DON stated nursing staff could administer medications either one hour before or one hour after the scheduled time. The DON stated if medications were given outside of that time frame, they were considered late, and that it was considered a medication error. During a review of the facilities P&P titled, Administering Medications, revised April 2023, staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.medications are administered in accordance with prescriber orders, including any required time frame.medication administration time are determined by resident need and benefit.medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review the facility failed to ensure food reached an appetizing temperature when temperatures for gravy sauce, french fries, grounded burger patty, food in cups and diced pears did not reach desired temperatures during tray line on 8/6/25.This failure placed all residents receiving food from the kitchen not eating their meal and placed their nutritional status at risk which could potentially lead to weight loss. FacilityDuring on observation on 8/6/25 between 11:30 a.m. through 12:45 p.m. in the kitchen during tray line, observed dietary cook (DC) and DC 2 checked temperatures of the food on the steam table. Temperature of french fries, gravy sauce, grounded burger patty, food in cups and diced pears were not checked.During an interview on 8/8/25 at 9:24 a.m. with DC 1, DC 1 stated the practice was to make sure temperatures of food on the steam table including desserts were checked to ensure the was safe to serve residents. DC 1 stated food temperatures are checked prior to serving and document in the logbook every meal. DC 2 stated it was the responsibility of the cook to ensure the temperature of food reached a safe temperature to serve to residents. DC 1 stated there was a risk of residents getting sick if the temperature of food was not safe. DC 1 stated residents could get sick.During an interview on 8/8/25 at 10:20 a.m. with Certified Dietary Manager/Driver (CDM/D), he stated it was important to check temperatures of all the food making sure it reached a safe temperature prior to serving to residents. The CDM/D stated his expectation was to make sure temperatures of food were checked and recorded in the logbook. The CDM/D stated not checking temperature could result in undercooked food which could place residents to develop gastrointestinal illness (illness that affects the digestive system [GI tract] which runs from mouth to anus) which could result in serious health condition.During an interview on 8/12/25 at 9:27 a.m. with Certified Dietary Manager Assistant (CDMA), she stated all temperatures of food to be served to residents should be checked and that included dessert. The CDMA stated the cook usually are responsible for ensuring the temperatures are checked and documented.During a phone interview on 8/12/25 at 4:21 p.m. with the Registered Dietitian (RD), the RD stated her expectation was, All food in the hot table needs temperature to be checked. The RD stated checking the temperature to ensure food was safe to serve to residents. The RD stated unsafe temperatures could cause serious illnesses for residents.During a review of facility's policy and procedure (P&P), titled, Food Preparation and Service, dated 10/17, the P&P indicated, .The danger zone for food temperatures is between 41 degrees Fahrenheit [unit of measurement] and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms [tiny living organism that can cause disease or illness] that cause foodborne illness [disease of discomfort caused by consuming contaminated food or beverage] . The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens.

Based on observation, interview and record review, the facility failed to ensure the planned menus were followed when residents on fortified diet (foods that have extra nutrients, like vitamins and minerals to improve the food's nutritional value to prevent nutrient deficiencies) were not served fortified food as prescribed by their Medical Doctor (MD) on 8/6/25.This failure had the potential for all residents on fortified diets to receive inadequate amounts of nutrients, potentially leading to weight loss and malnutrition. During review of facility's document titled, WEEK 2 WEDNESDAY Cambridge [NAME] CYCLE 2 2025 Spring, undated, the document indicated, . Lunch. FORTIFIED HIGH PROTEIN. SUPER SOUP 6 oz [ounces-unit of measurement]. During observation on 8/6/25 between 11:48 a.m. to 12:45 p.m. during the tray line, dietary staff scooped food in plates for residents, different diet types were observed, fortified diet were prepared like other diets. Dietary staff did not add fortified soup to the food trays for residents ordered a fortified diet. During an interview on 8/8/25 at 9:45 a.m. with Dietary [NAME] (DC) 1, she stated it was important to make sure residents on fortified diet received their diet as ordered by MD. DK 1 stated fortified diet are ordered for residents who are at risk for losing weight. DK 1 stated dietary staff serving the food should make sure to give residents the fortified diet to prevent additional weight loss. During a concurrent interview and record review on 8/8/25 at 10:35 a.m. with Certified Dietary Manager/Driver (CDM/D), CDM/D reviewed the menu spread sheet for 8/6/25 and stated residents on fortified diet should have received six ounces super soup for lunch. The CDM/D stated residents on fortified diet needed the extra calories on their meal to prevent them from losing more weight. The CDM/D stated dietary staff should have made sure residents received their fortified diet as ordered by MD.During an interview on 8/12/25 at 9:40 a.m. with Certified Dietary Manager Assistant (CDMA), the CDMA stated residents on fortified diet did not receive fortified food on 8/6/25 for lunch. The CDMA stated it was important to follow diet ordered by MD because residents needed extra calorie and protein.During a phone interview on 8/12/25 at 4:15 p.m. with Registered Dietitian (RD), the RD stated it was important to ensure residents on fortified diet received the diet ordered by the MD. The RD stated her first recommendation for residents who are losing weight was to give fortified food to stop the weight loss and gain weight back. The RD stated it was important to follow a fortified diet as ordered by MD.During a review of facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated 10/17, the P&P indicated, .Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each resident, the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food can be issued.During a review of the facility's policy and procedures (P&P) titled, Therapeutic Diets, dated 10/17, the P&P indicated, .1. Diet will be determined in accordance with the residents' informed choices, preferences, treatment goals and wishes. 2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The physician may delegate this task to a registered dietitian as permitted by state law. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian.

Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food services safety when:1.One of two ice machines and food preparation sink was not equipped with an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water).This failure had the potential for contaminated water to flow back into the sink and ice machine and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 173 residents in the facility, causing foodborne illness.2.Two opened bags of parmesan cheese and one and one-half loaves of bread did not have an opened or used by date.3. One dietary staff member did not cover all her hair on the sides with her hair net while working inside the kitchen.4. Food scoops used for puree diet were laid on top of the steam table during tray line. These failures had the potential for residents to develop gastrointestinal illness (illness that affects the digestive system [GI tract] which runs from mouth to anus) which could result in serious health conditions.1. During a concurrent observation and interview on 8/6/25 at 8:50 a.m. in the kitchen with Certified Dietary Manager/Driver (CDM/D) and Certified Dietary Manager Assistant (CDMA), checked the ice machine in the kitchen and the food preparation sink did not have an air gap. The CDMA stated they need an air gap to prevent backflow of contaminated water to the machine and the food preparation sink and preventing bacteria from going into the food to be served to residents. The CDM/D stated he will let the administrator know to work on the air gap.During an interview on 8/8/25 at 10:07 a.m. with CDM/D, the CDM/D stated he contacted a company to inspect and install an air gap. The CDM/D stated air gap prevents the overflow of contaminated water back in the food preparation sink. CDM/D stated residents served contaminated food and ice water could make them sick, especially our vulnerable residents. The CDM/D stated the ice machine in the kitchen did not have an air gap and he tried to put one after the service guy completed the service on the machine. During an interview on 8/12/25 at 9:20 a.m. with the CDMA, the CDMS stated the air gap was important to prevent overflow back to the ice machine and the food prep sink preventing contaminated water and bacteria from getting in the water and food served to residents. The CDMA stated they serve a vulnerable population and serving them contaminated water and food could easily make them sick which could lead to serious health condition.During a review of the professional reference titled, FDA Food Code 2022, Chapter 5. Water, Plumbing, and Waste, section 5-203.14 indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT . backflow prevention is required by LAW, by: . providing an air gap as specified under S 5-202.13 . During a review of professional reference titled, FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, section 5-202.13 indicated, . During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 2. During the initial tour in the kitchen on 8/5/25 at 9:15 a.m. with CDM/D, two opened bags of parmesan cheese found with no opened date and used by date. One and one-half loaves of bread were found under the food preparation sink and had no opened or used by date.During an interview on 8/8/25 at 9L24 a.m. with Dietary [NAME] (DC) 1, DC 1 stated the bread should not have been moved from the rack and stored under the sink and should have been labeled with the date it was opened and used by date. DC 1 stated the parmesan cheese should have been dated also with the opened and used by date. DC 1 stated it was important to have the dates to make sure food was not served to residents past its used by date. During an interview on 8/8/25 at 10:15 a.m. with the CDM/D, he stated her expectation was for all opened food to be labeled with the date opened and used by date. The CDM/D stated dietary staff should have made sure they labeled everything they opened to prevent serving expired food to residents, which could make them sick.During a review of the facility policy and procedure (P&P) titled, Refrigerators and Freezers, dated 12/14, the P&P indicated, . All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in the refrigerator. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.3. During an interview on 8/8/25 at 9:30 a.m. with DC 1, she stated everyone working in the kitchen should be wearing hair nets appropriately and to make sure there are no loose hair outside of the hair net. DC 1 stated hairnet prevents hair from falling in the plate served to residents. DC 1 stated it was a contamination issue; we do not want residents to get sick when we can prevent it.During an interview on 8/8/25 at 10:15 a.m. with CDM/D, he stated the expectation was for anyone entering the kitchen to the food preparation area to wear a hairnet and to ensure all hair was covered. The CDM/D stated men who have beard and worked in the kitchen are also expected to cover their beard. The CDM/D stated this was to prevent cross contamination of food served to residents which could make them sick.During an interview on 8/12/25 at 9:30 a.m. with CDMA, she stated she started working for the company 4/25. CDMA stated the expectation was to make sure all dietary staff wear hairnet as soon as they enter the kitchen and to ensure all the hair was covered, no loose hair. The CDMA stated covering hair was to prevent hair from falling into the food which could cause contamination.During a review of facility policy and procedure (P&P) titled, Food Service Distribution, dated 10/17, the P&P indicated, .7. Food and nutrition services shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. During a review of the facility policy and procedure (P&P) titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated 12/21, the P&P indicated, . Food Service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. 4. During tray line observation on 8/6/25 at 11:30 a.m. observed DK 2 by pureed food with scoops laid out on top of the steam table next to the pureed food trays. Observed DK 2 placed the food scoops on top of the steam table after each used. The scoops had food left over and left food particles on top of the steam table.During an interview on 8/8/25 at 9:35 a.m. with DC 1, she stated the food scoops for the pureed food should have been left inside the food tray. DK 1 stated placing the scoops on top of the steam table after each used was not acceptable and unsanitary. DC 1 stated it could cause cross contamination which could cause residents to get sick. During an interview on 8/8/25 at 10:35 a.m. with CDM/D, he stated it was not acceptable to place the scoops on top of the steam table. The scoop had left over food on it and leaving food on top of the steam table every time the scoop was used. CDM/D stated it was a contamination issue which could cause illness to residents.During an interview on 8/8/25 at 10:55 a.m. with the DC 2, DC 2 stated she served the puree food during the tray line. DC 2 stated she placed the food scoops on top of the steam table after each use. DC 2 stated she should have left the scoops inside the food tray and not placed them on top of the steam table next to the pureed food. DC 2 stated it was unsanitary; there could have been bacteria which could have made residents sick. During a phone interview on 8/12/25 at 4:03 p.m. with the Registered Dietitian (RD), the RD stated she had not been in the facility, she lives five hours away from the facility and her contract was for her to work remotely. The RD stated there are other RD's contracted with the facility who does the on-site visit. The RD stated she had never seen or heard of the word airgap before, the RD stated, It is a new terminology to me. The RD stated the expectation was for all food in the steam/hot table temperature checked to ensure food reached the proper temperature and safe to serve to residents. The RD stated her expectation as an RD was to ensure fortified diet was followed. The RD stated her first recommendation for residents who are losing weight was to fortify the diet. The RD stated staff working in the kitchen should be putting on the hairnet and beard for men as soon as they enter the kitchen and to ensure all the hair was covered and no loose hair. The RD stated the hairnet and beard cover was to prevent any loose hair falling on the food served to residents which is an infection control issue. During a review of the facility policy and procedure (P&P) titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated 12/21, the P&P indicated, . Food Service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on observation, interview and record review, the facility failed to ensure all prescribed medications were available and administered to residents as scheduled for three of seven sampled residents (Resident 53, 82 and 144) when the facility did not have the medications available for administration. This failure placed Residents 53, 82 and 144 at risk for not receiving the physician ordered medical treatment, placing residents at risk for ineffective management of their medical conditions.Findings:1. During an observation of the medication administration task on 8/6/25 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she did not administer Resident 53's [Polyethylene glycol] (medication that helps people have bowel movements), because it was not available in her medication cart.During a review of Resident 53's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 53 has a history of constipation (when a person had a hard time going to the bathroom because their stools were too hard, dry or did not come out easily).During a review of Resident 53's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 5/16/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 53 had no cognitive impairment.During a review of Resident 53's Medication Administration Record (MAR), dated month of August 2025, the MAR indicated Resident 53's [Polyethylene glycol] was not administered on 8/6/25 at 8:00 a.m.2. During an observation of the medication administration task on 8/6/25 at 9:00 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she did not administer Resident 82's 10 mg (milligram-a small unit to measure weight) Oxybutynin (medication that helped relax the bladder [a hollow organ that held pee until a person was ready to use the restroom] tablet and Vitamin E, because it was not available in the medication cart.During a review of Resident 82's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 82 had a history of overactive bladder (a condition where a person's bladder muscles worked too often)During a review of Resident 82's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 7/7/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 82 had severe cognitive impairment.During a review of Resident 82's Medication Administration Record (MAR), dated month of August 2025, the MAR indicated Resident 82's Oxybutynin 10 mg tablet and Vitamin E 200 mg tablet was not administered on 8/6/25 at 9:00 a.m.3. During an observation of the medication administration task on 8/6/25 at 9:12 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated she did not administer Resident 144's isosorbide mononitrate extended release (medication the helps relax and widen blood vessels so the heart can get more blood and oxygen) 24 Hour 60 mg tablet because it was not available in her medication cart. Resident's blood pressure obtained prior to medication administration was 122/68.During a review of Resident 144's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/7/25, the AR indicated Resident 144 had a history of heart failure (a condition in which the heart was not able to pump blood was well as it should), and hypertension (when blood pushes too hard against the walls of the blood vessels).During a review of Resident 144's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), dated 6/24/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 144 had moderate cognitive impairment.During a review of Resident 144's Medication Administration Record (MAR), dated month of August 2025, the MAR indicated Resident 144's Isosorbide Mononitrate extended release 24-hour 60 mg tablet was not administered.During an interview on 8/14/25 at 10:13 a.m. with LVN 4, LVN 4 stated all nurses were responsible for checking that resident's medications were available.During an interview on 8/14/25 at 10:20 a.m. with LVN 6, LVN 6 stated nurses were to check the residents' supply of medications, and if it appeared the supply was getting low, they were to reorder the medication or notify the charge nurse.During an interview on 8/14/25 at 10:59 a.m. with the Director of Nursing (DON), the [NAME] stated it was the responsibility of the nurse to reorder medications that were running low. The DON stated nurses needed to ensure residents did not run out of their regularly scheduled medications, as this placed the residents at risk.During a review of facilities Charge Nurse Job Description, date unknown, the Charge Nurse Job Description indicated, order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies.ensure that an adequate stock level of medications, medical supplies, equipment etc., is maintained on your unit/shift at all times to meet the needs of the residents.During a review of the facilities policy and procedure (P&P) titled, Pharmacy Services Overview, revised April 2024, the P&P indicated, residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for four of 22 sampled residents (Resident 6, 49, 68 and 185), when1. Resident 6's care plan interventions to minimize fall related injuries were not implemented. Resident 6 did not have a bilateral floor mat and reacher at bedside. This failure had the potential to place Resident 6 at risk for an avoidable fall and obtaining fall-related injuries. 2. Resident 49's care plan interventions to address communication problem related to diagnosis of Expressive Aphasia (a disorder that makes it difficult to speak) and Resident 49's primary language was Persian were not implemented. Resident 49 had no communication book and/or translator/interpreter service. This failure resulted in Resident 49 getting frustrated about not being able to communicate with the staff and being understood by staff. 3. Resident 68's care plan interventions to provide his prescribed diet and a scoop plate (an assistive plate which helps people place food on their utensils) were not followed.This failure had the potential to cause resident 68 to not be able to adequately scoop up his own food and also cause Resident 68 to choke on food not prepared in accordance with his diet order 4. Resident 185's care plan interventions indicated the bed was to remain in the lowest position to reduce the risk for falls. The bed was observed not in the lowest position. This failure had the potential to place Resident 185 at an increased risk for fall and injury.1.During a concurrent observation and interview on 8/7/2025 at 10:12 a.m. with Resident 6, in Resident 6's room, Resident 6 was sitting in wheelchair awake, clean and well groomed. Resident 6 had a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) against the wall. Resident 6's wife and daughter were at bedside. Resident 6 was alert and oriented to familiar names and faces including his name and the names of his wife and daughter. Resident 6 stated he had fallen from bed. During an interview on 8/7/2025 at 10:14 a.m. with Responsible Person (RP) 3, in Resident's 6's room, RP 3 stated Resident 6 had been falling from bed at the facility and was witnessed by his roommate. RP 3 stated Resident 6 had a Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) and had confusion (inability to think clearly or quickly, often resulting in disorientation). RP 3 stated Resident 6 attempted to get out of bed and stand from his wheelchair. RP 3 stated she visits every day to closely monitor Resident 6. RP 3 stated Resident 6 had one floor mat in the room and should have two floor mats for each side of bed. She stated Resident 6 was receiving therapy. During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/8/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with primary admitting diagnosis of Sepsis (a life-threatening blood infection). Resident 6 had other diagnosis of Peripheral Vascular Disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), Encephalopathy (a condition that alters brain function or structure, leading to change in mental status), Essential Hypertension (HTN-high blood pressure), Anemia (a condition where the body does not have enough healthy red blood cells), and muscle weakness. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/22/24, the MDS section C indicated Resident 6 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 8 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 6 was moderately impaired. During an interview on 8/07/2025 at 3:19 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 6 was a high risk for falls due to multiple attempts of getting out of bed and getting up from his wheelchair. CNA 4 stated Resident 6's confusion had increased. CNA 4 stated she saw one floor mat in Resident 6's room and she had not seen a Reacher (a daily living aid designed to assist people with limited range of motion to grab out of reach items with ease) at bedside. CNA 4 stated Resident 6 should have a falling star at his name by the door. CNA 4 stated Resident 6 requires assistance with activities of daily living (ADLs - routine tasks/activities such as transferring from bed to wheelchair/wheelchair to bed, bathing, dressing and toileting a person performs daily to care for themselves). CNA 4 stated Resident 6's care plan should be followed by staff to prevent Resident 6 from falling. CNA 4 stated the care plan should be reviewed by staff at the beginning of the shift for staff to follow to ensure proper care is being provided to the residents. During a concurrent interview and record review on 8/08/2025 at 2:15 p.m. with the Director of Nursing (DON), Resident 6's electronic medical record (EMR- a digital version of a patient's paper chart) titled, Care Plan Report, undated was reviewed. The Care Plan Report indicated, .The resident is at risk for falls with injury related to limited mobility, use of antihypertensive medication (a type of drug used to treat high blood pressure), altered metal status.Interventions: Floor mat to right side and left side of bed to minimize the risk of injury from falls. Provide Reacher to the resident. The DON stated Resident 6 should have two floor mats for right and left side of bed and reacher should be placed within easy reach. The DON stated fall care plan interventions should be implemented and followed to achieve the goal of preventing more falls and minimizing fall related injuries. During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, revised March 2023, the P&P indicated, . 3. The care plan intervention is derived from analysis of the information gathered as part of the comprehensive assessment.7. the comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; c. includes the resident's stated goals upon admission and desired outcomes.reflects currently recognized standards of practice for problem areas and conditions. 2. During a concurrent observation and interview on 8/5/2025 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. Resident 49 was awake with slurred (indistinct and difficult to hear or understand) speech and was able to respond during conversation by nodding his head using yes and no questions. Resident stated dadada.tatatata. continuously. Resident 49 was unable to move his right upper extremity and right lower extremity. During a review of Resident 49's AR, dated 8/7/25, the AR indicated Resident 49 was admitted to the facility on [DATE] with diagnosis of Hemiplegia (paralysis on one side of the body)and hemiparesis (muscle weakness on side of the body) following Cerebral Infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, Aphasia following Cerebral Infarction, Dysphagia (difficulty swallowing) following Cerebral Infarction, and Dysarthria (difficulty speaking due to weak speech muscles) following Unspecified Cerebrovascular Disease (loss of blood flow to a part of the brain). During a review of Resident 49's MDS, dated [DATE], the MDS section C indicated Resident 49's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 49's BIMS Summary Score was blank. During an interview on 8/6/2025 at 12:16 p.m. with CNA 5, in Resident 49's room, CNA 5 stated she communicated with Resident 49 by pointing out the items and using gestures. CNA 5 stated she was not aware of a communication book or communication board (a visual aid that uses pictures, symbols, or text to help people with communication difficulties express their needs, wants, and ideas). CNA stated she never saw a communication board at Resident 49's bedside. CNA 5 stated Resident 49 used a different language and was difficult to understand. CNA 5 stated she was not sure what language it was. During a concurrent observation on 8/6/2025 at 12:20 p.m. with CNA 7, in Resident 49's room, CNA 7 was serving the lunch tray at the bedside table in front of Resident 49. CNA 7 stated she did not see a communication board at bedside. CNA 7 stated Resident 49 should have a communication board at bedside to be able to communicate with him. During a concurrent observation and interview on 8/6/2025 at 4:30 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 49's room, LVN 2 was looking for the communication book at Resident 49's bedside. LVN 2 opened the first drawer of Resident 49's bedside dresser, the communication board was located underneath the fruits and stated, .looks like it has never been used. LVN 2 stated the communication board was dirty and sticky with bread crumbles and sticky paste all over the communication board. LVN 2 stated there was no communication book at bedside and stated, not that I know of. LVN 2 was holding the communication board and stated, this is not a communication book. LVN 2 stated she needs to clean the communication board and should be placed within easy access. Resident 49 was continuously making sound with words of dadadada. Resident 49 looks frustrated, and his face turned red. LVN 2 stated she was unable to tell what the language the resident was speaking and stated, I will find out. LVN 2 called the family and brought the phone to Resident 49 to interpret what Resident 49 was trying to say. LVN 2 stated the family translated in English and per family it was random words. During a concurrent interview and record review on 8/08/2025 at 11:50 a.m. with LVN 3, Resident 49's EMR titled, Care Plan Report, undated was reviewed. The Care Plan Report indicated, .The resident has a communication problem/t Expressive Aphasia, stroke primary language is Persian. Date initiated 4/17/24, interventions: Monitor effectiveness of communication strategies and assistive device (Communication Book) . Date initiated 4/17/24, . Monitor effectiveness of communication strategies and assistive device (Communication Poster) . Revision on:8/7/25. LVN 3 stated she was not aware of the communication book or the communication poster. LVN 3 stated she hadn't seen a communication book nor the communication poster at Resident 49's bedside. LVN 3 stated she never used a communication poster when communicating with Resident 49. LVN 3 stated staff communicate with Resident 49 by pointing on objects and use of facial expression. LVN 3 stated Resident 49 can respond to yes and no questions by nodding and left-hand movements. LVN 3 stated Resident 49 had slurred speech and mumbled. LVN 3 stated Resident 49 can understand basic English, and his primary language was Persian Language. LVN 3 stated Resident 49 should utilize a translator service for Persian language. LVN 3 stated the care plan should be specific to the needs of the residents. LVN 3 stated care plan should be implemented and followed to communicate effectively with Resident 49. During an interview on 8/13/2025 at 4:20 p.m. with the DON, the DON stated Resident 49's care plan intervention for the communication book should be implemented and followed by staff to properly and effectively communicate with the resident. The DON stated all residents who speaks non-English language and had difficulty speaking should have a communication board at bedside to express their needs. The DON stated resident's care plan should be person-centered. During an interview on 8/14/2025 at 2:15 p.m. with the Social Services Director (SSD), the SSD stated she had not encountered a Persian speaking language resident. The SSD stated the facility do not a have a staff who can understand and speak a Persian language. The SSD stated she will find a translator or interpreter services for residents that cannot speak and understand English. The SSD stated Resident 49 was provided with a communication poster. The SSD stated the facility does not have a communication book. During a review of the facilities P&P titled, Care Plans, Comprehensive Person Centered, revised March 2023, the P&P indicated, . 3. The care plan intervention is derived from analysis of the information gathered as part of the comprehensive assessment.7. the comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; c. includes the resident's stated goals upon admission and desired outcomes.reflects currently recognized standards of practice for problem areas and conditions. 3. During a review of Resident 68's AR, dated 6/25/25, the AR indicated, Resident 68 was admitted to the facility on [DATE] with the following diagnoses: unspecified sequel of cerebral infarction (the long-term effects or consequences of a stroke), muscle weakness (a reduced ability of one or more muscles to generate force), contracture of the left shoulder (a condition characterized by pain and stiffness in the shoulder), and dysphagia (medical condition characterized by difficulty swallowing). During a review of Resident 68's, Meal Ticket (document which outlines resident meal preferences, ordered diet, and allergies, undated, the Meal Ticket, indicated, .mechanical soft texture . Assist Instructions: scoop plate . During a review of Resident 68's, Order Summary Report, dated 8/13/25, the Order Summary Report indicated, . Order Summary . Fortified/high protein diet Mechanical soft texture . use of scoop plate for all meals . During an observation on 8/5/25 at 12:05 p.m. in the assisted feeding dining room, Resident 68's meal tray had a regular plate instead of a scoop plate and he was served a hard piece of toast. During a concurrent observation and interview on 8/5/25 at 12:16 p.m. with CNA 6, CNA 6 stated Resident 68 was not provided with a scoop plate. CNA 6 stated Resident 68 needed to have a scoop plate because he had muscle weakness, and a scoop plate allowed him to eat his meals better. During a concurrent observation and interview on 8/5/25 at 12:16 p.m. with CNA 6, CNA 6 stated Resident 68 received burnt toast as part of his meal. CNA 6 stated Resident 68 should not have been given the piece of hard toast because he was on a mechanical soft diet, and he may have trouble eating it which could cause him to choke. During concurrent observation and interview on 8/5/25 at 12:16 p.m. with the Speech Language Pathologist (SLP), Resident 68 received hard toast for lunch. The SLP stated Resident 68 was on a prescribed mechanical soft diet and the piece of hard toast on his plate should not have been provided. The SLP stated Resident 68 needed to receive softer slices of bread to be able to eat it comfortably, he had not progressed enough to be able to adequately eat and swallow the toast. During an interview on 8/12/25 at 4:27 p.m. with the Infection Preventionist (IP), the IP stated she was checking meal trays before they were sent to the residents on Monday 8/5/25. The IP stated she checks the meal trays and compares them with the Meal Ticket in order to ensure the residents receive the correct meal in regards to meal preferences, special equipment, ordered diet, and food allergies. The IP stated she did not notice if the toast provided to Resident 68 was too hard, the kitchen staff should have noticed as well when they placed the food on the plates. The IP stated providing Resident 68 with a scoop plate helped the resident be able to better feed himself and help promote independence since he did suffer from deficits related to a past stroke. The IP stated providing Resident 68 with the correct meal consistency would ensure he did not aspirate (inhaling a substance other than air into the lungs) or choke on his food if he tried to eat something he could not handle. During an interview with CNA 5, CNA 5 stated scoop plates were provided to residents with weaknesses in order to provide more independence to the residents. These residents have weaknesses that make eating their meals difficult, providing a scoop plate helps residents feel more dignified if they can help feed themselves. CNA 5 stated a mechanical soft diet is determined by the SLP, it is an evaluation to see what a resident can and ca not swallow, if a resident gets an inappropriate diet they may have a hard time swallowing their food which would then put the resident at risk for choking. CNA 5 stated residents should never get the wrong diet. During a concurrent interview and record review on 8/13/25 at 9:35 a.m. with the Certified Dietary Manager (CDM), Resident 68's Meal Ticket, undated, was reviewed. The Meal Ticket, indicated Resident 68 was on a mechanical soft diet and was to be provided a scoop plate. The CDM stated a person on a mechanical soft diet should not have received hard toast during their lunch, kitchen staff should have caught it during the tray line (food assembly system in a facility where food trays are prepared). The CDM stated Resident 68 had dysphagia and may have trouble eating the food if it was not the right consistency. The CDM stated Resident 68 was also supposed to have a scoop plate because it would help him be able to scoop the food on his own, it also could have helped him feel more independent if he was able to do it on his own. During a concurrent interview and record review on 8/13/25 at 10:26 a.m. with LVN 4, Resident 68's Clinical Record (CR), dated 8/13/25, was reviewed. The CR indicated Resident 68 had a diagnosis of dysphagia and cerebral infarction and Resident 68 was prescribed a mechanical soft diet with instructions to use a scoop plate for all meals. LVN 4 stated Resident 68 should not have received hard toast since he had dysphagia which made it difficult to swallow food. LVN 4 reviewed Resident 68's Comprehensive Care Plan, dated 8/13/25, the Comprehensive Care Plan indicated Resident 68 was at risk for altered nutrition due to his dysphagia and he was to be provided with his ordered diet and a scoop plate for all meals. LVN 4 stated the care plan was not followed and Resident 68 could have choked as a result. During an interview on 8/13/25 at 10:48 a.m. with the Director of Staff Development (DSD), the DSD stated staff needed to ensure meal trays were accurate before a resident ate their food because inaccurate diets may lead to a resident choking on their food During an interview on 8/14/25 at 1:53p.m. with the Assistant Director of Nursing (ADON) Resident 68's Comprehensive Care Plan, dated 8/14/25, was reviewed. The Comprehensive Care Plan indicated Resident 68 was to be given a mechanical soft diet with a scoop plate. The ADON stated Resident 68's care plan indicated to provide his diet as ordered throughout various sections of the plan. The ADON stated Resident68's Comprehensive Care Plan interventions were not followed. The ADON stated the Comprehensive Care Plans purpose was too easily inform staff of the care and interventions a resident required. Nurses and CNAs can both see what interventions to follow and what was supposed to be implemented for all the residents. The ADON stated providing Resident 68's prescribed diet was important because otherwise he could aspirate and experience weight loss if he did not eat. The ADON stated the scoop plate helps encourage him to eat and it also helps promote independence which may raise his self-esteem. During a review of the facility's policy and procedure (P&P) titled, Meals, dated 3/23, the P&P indicted, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . 4. Residents who may Benefit from Assistive Devices: 1. Adaptive devices (Special eating equipment and utensils) will be provided for residents who need or request them .2. Assistance will be provided to ensure than residents can use and benefit from special eating equipment and utensils . During a review of the facility's P&P titled, Food and Nutrition Services, dated 10/17, the P&P indicated, .6. Nursing staff will ensure that assistive devices are available to residents as needed. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 3/23, the P&P indicated, .7. The comprehensive, person centered care plan: a. includes measurable objectives and timeframes b. describes the services that are to be furnished to attain or maintain highest practicable physical, mental, and psychosocial well-being. 4. During a review of Resident 185's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 8/13/25, the AR indicated Resident 185 had a history of left femur fracture (Thigh bone had been broken. This bone goes from the hip down to the knee), osteoporosis (a disease that made a person's bones weak, thin and break more easily), and abnormalities of gait and mobility (the way a person walked or moved was not normal. This could include walking with a limp, dragging a foot, moving slowly, or having trouble keeping balance). During a review of Resident 185's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 185 had no cognitive impairment. During an observation on 8/6/25 at 8:21 a.m. in Resident 185's room, Resident 185's bed was observed not to be in the lowest position. The bed height was approximately two feet from the floor and matched the height of the roommate's bed, who was not identified as a fall risk. Resident 185 was lying in bed at the time of the observation. During a concurrent observation and interview on 8/6/25 at 2:24 p.m. with Certified Nursing Assistant (CNA) 3, Resident 185's bed was observed to not be in the lowest position. CNA 3 stated Resident 185's bed could go lower and confirmed that it was not currently in the lowest position. CNA 3 then lowered Resident 185's bed approximately one foot. During an interview on 8/12/25 at 2:08 p.m. with CNA 4, CNA 4 stated fall precautions included ensuring the residents had their call light, the bed was in the lowest position, and personal items were within reach. CNA 4 stated the care plan contained all necessary information about the residents and provided daily guidance regarding their care. CNA 4 stated if the care plan specified the bed was to be in the lowest position, it should consistently be maintained that way. During an interview on 8/12/25 at 2:30p.m. with Registered Nurse (RN) 1, RN 1 stated care plans were important as they provided the care plan to be followed. RN 1 stated care plans were based on the residents' condition and guided staff in providing appropriate care. RN 1 stated care plans informed staff on how to assist the residents and that care planned interventions should be carried out. RN 1 identified common fall risk interventions, including keeping the bed in the lowest position, ensuring items were within reach, providing reminders to use call light, performing frequent checks and keeping breaks locked. During an interview on 8/14/25 at 10:59a.m. with the Director of Nursing (DON), the DON stated it was expected that the bed be placed in the lowest position if specified in the care plan, as this intervention was intended to help prevent resident falls. It was further expected that all care planned interventions be consistently carried out. During a review of Resident 185's MDS Section GG-Functional Abilities-admission (MDS- GG), dated 7/15/25, the MDS- GG indicated Resident 185 required assistance with eating, substantial assistance with oral hygiene, was dependent in toileting, required substantial assistance with upper body dressing, was dependent in lower body dressing, and was dependent in putting on and removing footwear. During a review of Resident 185's Fall Risk Assessment, dated 7/30/25, the Fall Risk Assessment indicated Resident 185 had experienced a fall within the past 6 months and was determined to be a risk for falls. During a review of Resident 185's Care Plan Report, dated 7/14/25, the Care Plan Report indicated Resident 185 was a risk for falls related to limited mobility, muscle weakness and abnormalities of gait and mobility. The goal of the care plan was for Resident 185 to remain free from minor injury. A listed intervention included keeping Resident 185's bed in the lowest position. During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, revised March 2023, the P&P indicated, 3. The care plan intervention is derived from analysis of the information gathered as part of the comprehensive assessment.7. the comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; c. includes the resident's stated goals upon admission and desired outcomes.reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review the facility failed to provide assistive devices during meals for three of 12 residents (Resident 44, 68, and 67) when: 1.Resident 44 was not provided with a right-hand built-up spoon (an adaptive dining aid [a device used to assist with feeding] designed for people who have limited grasp or face difficulties in supination) during his lunch on 8/5/25. This failure resulted in for Resident 44 not being able to feed himself and had the potential risk of losing his independence when eating. 2. Resident 68 was not provided a scoop plate (an assistive plate which helps people scoop up food onto a utensil) during his lunch on 8/5/25 This failure had had the potential to result in Resident 68 to not be able to eat his meal 3. Resident 67's food was not served in bowls on her meal tray during lunch on 8/5/25. This failure had the potential to limit Resident 67's ability to feed herself independently and safely.1.During a concurrent observation and interview on 8/5/25 at 12:20 p.m. with Resident 44, in the dining room, Resident 44 was sitting up in a wheelchair eating lunch meal with the assistance of Speech Language Pathologist (SLP). Resident 44 had a scoop plate. Resident 44 smiled when asked how are you? During a concurrent interview and record review on 8/5/25 at 12:23 p.m. with the Speech Language Pathologist (SLP), in the dining room, Resident 44's Meal Ticket (document which outlines resident meal preferences, ordered diet, and allergies), undated was reviewed. The Meal Ticket indicated, .Puree/Level 4 Texture. Assist instruction: scoop plate, RIGHT-HANDED BUILT-UP SPOON. The SLP stated Resident 44's right-handed built-up spoon was not provided by the kitchen in Resident 44's tray. The SLP stated Resident 44 should have a right-handed built-up spoon in his meal tray and stated, the kitchen forgot to put it in the tray. The SLP stated Resident 44's right-handed built-up spoon helped him with self-feeding. During a review of Resident 44's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/14/25, the AR indicated, Resident 44 was admitted to the facility on [DATE]with the following diagnoses: Fracture of Ramus of Right Mandible (a rare break of the vertical part of the lower jaw on the right side), Dysphagia (medical condition characterized by difficulty swallowing)., Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Essential Hypertension (HTN-high blood pressure). During a review of Resident 44's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 7/22/25, the MDS section C indicated Resident 44 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 6 was severely impaired. During a review of Resident 44's, Order Summary Report, dated 8/14/25, the Order Summary Report indicated, . Order Summary . built up straight spoon . During an interview on 8/8/25 at 11:16 a.m. with the Director of Rehabilitation (DOR), the DOR stated residents that requires adaptive equipment (devices designed to assist people with physical limitations to be able to feed themselves) like scoop plates, built-up utensils should be provided when eating to be able to feed themselves and to prevent food and drink spillage. During an interview on 8/8/25 at 2:15 p. with the Director of Nursing (DON), the DON stated using adaptive equipment like scoop plates and built-up utensils is important to help residents when eating and increase their independence during meals. The DON stated residents' adaptive equipment should be provided in their meal tray and should be available for every meal. During a review of the facility's policy and procedure (P&P) titled. Assistance with Meals, dated 7/17, the P&P indicated, . Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who may Benefit from Assistive Devices: 1. Adaptive devices (Special eating equipment and utensils) will be provided for residents who need or request them .2. Assistance will be provided to ensure than residents can use and benefit from special eating equipment and utensils . 2. During a review of Resident 68's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/25/25, the AR indicated, Resident 68 was admitted to the facility on [DATE] with the following diagnoses: unspecified sequel of cerebral infarction (the long-term effects or consequences of a stroke), muscle weakness (a reduced ability of one or more muscles to generate force), contracture of the left shoulder (a condition characterized by pain and stiffness in the shoulder), and dysphagia. During a review of Resident 68's, Meal Ticket, undated, the Meal Ticket, indicated, .mechanical soft texture . Assist Instructions: scoop plate . During a review of Resident 68's, Order Summary Report, dated 8/13/25, the Order Summary Report indicated, . Order Summary . use of scoop plate for all meals . During an observation on 8/5/25 at 12:05 p.m. in the assisted feeding dining room, Resident 68's meal tray had a regular plate instead of a scoop plate. During a concurrent observation and interview on 8/5/25 at 12:16 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 68 was not provided with a scoop plate. CNA 6 stated Resident 68 needed to have a scoop plate because he has muscle weakness, and a scoop plate allowed him to eat his meals better. During an interview on 8/12/25 at 4:27 p.m. with the Infection Preventionist (IP), the IP stated she was checking meal trays before they were sent to the residents on Monday 8/5/25. The IP stated she checks the meal trays and compares them with the Meal Ticket in order to ensure the residents receive the correct meal in regard to meal preferences, special equipment, ordered diet, and food allergies. The IP stated she did not notice Resident 68 was not provided a scoop plate. The Ip stated providing Resident 68 with a scoop plate helped the resident be able to better feed himself and help promote independence since he did suffer from deficits related to a past stroke. During an interview with CNA 5, CNA 5 stated scoop plates were provided to residents with weaknesses in order to provide more independence to the residents. These residents have weaknesses that make eating their meals difficult, providing a scoop plate helps residents feel more dignified if they can help feed themselves. During a concurrent interview and record review on 8/13/25 at 9:35 a.m. with the Certified Dietary Manager (CDM), Resident 68's Meal Ticket, undated, was reviewed. The Meal Ticket, indicated Resident 68 was to be provided a scoop plate. The CDM stated Resident 68 was supposed to have a scoop plate because it would help him be able to scoop the food on his own, it also could have helped him feel more independent if he was able to do it on his own. During an interview on 8/13/25 at 11:07 a.m. with the DON, the DON stated Resident 68 should have been provided with his scoop plate during lunch. The DON stated a scoop plate would have helped Resident 68 scoop the food onto his spoon and actually attempt to eat it on his own. During a review of the facility's P&P titled, Food and Nutrition Services, dated 10/17, the P&P indicated, .6. Nursing staff will ensure that assistive devices are available to residents as needed. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . During a review of the facility's P&P titled, Meals, dated 3/23, the P&P indicted, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . 4. Residents who may Benefit from Assistive Devices: 1. Adaptive devices (Special eating equipment and utensils) will be provided for residents who need or request them .2. Assistance will be provided to ensure than residents can use and benefit from special eating equipment and utensils . 3. During an observation on 8/5/25 at 12:14 p.m. in the dining room, Resident 67's meal tray had her food served on a plate. During a review of Resident 67's meal ticket, the meal ticket indicated, Assist Instructions: Food in Bowls During a review of Resident 67's admission Record, dated 8/8/25, the admission Record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses which included Generalized Osteoarthritis (joint disease that causes the breakdown of cartilage, the smooth tissues that cushions and protects joints.), glaucoma (group of eye diseases that damage the optic nerve which sends visual information to the brain) and hearing loss. During a review of Resident 67's Order Summary Report (OSR) dated 8/8/25, the OSR indicated, . Regular diet Regular texture, Thin consistency, food in bowls. During a concurrent observation and interview on 8/5/25 at 12:20 p.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated Resident 67's food is placed on regular plate, the ticket was to put food in bowls. CNA 10 stated Resident 67's food should have been in bowls for Resident 67 to pick up her food easier and feed self safely. CNA 10 stated the licensed nurse inspecting the food trays should have been checking the trays for the proper equipment and could have been corrected before the food was served to Resident 67. During an interview on 8/8/25 at 9:24 a.m. with Dietary [NAME] (DC) 1, she stated the instructions on the meal ticket should be followed. DC 1 stated the order for food to be placed in bowls should be followed on all meals, we have bowls in the kitchen to use and there was reasons why residents had orders for special equipments. DC 1 stated the last person in the tray line should have checked the tray making sure everything was followed including food in bowls. During an interview on 8/8/25 at 10:25 a.m. with the Certified Dietary Manager/Driver (CDM/D), he stated the responsibility should have started in the kitchen. The CDM/D stated it was the responsibility of the dietary staff during the tray line to ensure orders were followed and once the food tray leaves the kitchen, it then becomes the responsibility of the nursing staff. The CDM/D stated it was important to follow the instructions in the meal ticket to ensure residents' safety during meals. During a phone interview on 8/12/25 at 4:10 p.m. with Registered Dietitian (RD), the RD stated the expectation was for dietary staff to follow order on how food should be served. The RD stated the order for food to be placed in bowls should have been followed, it was more convenient for residents to eat. During a review of facility's policy and procedure (P&P) titled, Assistance with Meals, dated 7/17, the P&P indicated, . 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged /padded handles, plate guards, and/or specialized cups.

Based on observation, interview and record review, the facility failed to protect and promote the rights of the residents for 13 of 28 sampled residents (Residents' 2, 14, 30, 148, 38 50, 4, 9, 28, 59, 67, 68 and 130) when: 1a.Staff did not use an alternate communication method with Spanish speaking residents (Residents 2 and 14) such as language assistance, interpreters or translated materials. 1b. Staff was speaking in a foreign language during resident care for Residents 30, 148, 38 and 50. These failures violated Residents 2, 14, 30, 148, 38 and 50's rights to understand the care provided to them in a language they understood. 2. Three female residents in room [ROOM NUMBER] shared a bathroom with three male residents in room [ROOM NUMBER]. 3. Resident 4 watched other residents on her table eating while she waited for over five minutes for her food to be delivered on 8/5/25.These failures resulted in violation of Resident's 4, 9, 28, 59, 67, 68 and 130's right to privacy and dignity. 1.During an interview on 8/6/25 at 9:30 a.m. with Resident 2 and her daughter, Responsible Party (RP) 4, RP 4 stated Resident 2 speaks Spanish and understood very limited English. RP 4 stated Resident 2 relied on pointing a lot. Resident 2 demonstrated that she can say, I need a pain pill in English. There were no alternate communication method observed in Resident 2's room. RP 4 stated it was a challenge and difficulty when there are no Spanish speaking staff assigned to care for Resident 2. During an interview on 8/6/25 at 3:47 p.m., with Resident 14, Resident 14 stated in Spanish he could not speak English. There were no alternate communication methods observed in Resident 14's room. Resident 14 stated to Certified Nursing Assistant (CNA) 2 who came into the room that it would be helpful with his care needs being met if there was a board with pictures on it so he could point out to staff if he needs something. CNA 2 stated she was not proficient in speaking and interpreting medical terminology in Spanish and would not understand Resident 14 if he verbalized a medical need. During an interview on 8/5/25 at 10:20 a.m., with Resident 30, Resident 30 stated he has difficulty verbalizing his needs and understanding some staff because they were talking in a foreign language while providing care to him. During an interview on 8/5/25 at 10:43 a.m., with Resident 148 stated staff were speaking in a foreign language during care. During an interview on 8/5/25 at 11 a.m., with Resident 38, Resident 38 stated staff were speaking in a foreign language while providing care to her and her roommate During an interview on 8/5/25, at 12:15 p.m., with Resident 50, Resident 50 stated she had the same complaints with her roommate as some staff were speaking in a foreign language while providing care to them. Resident 50 stated it was frustrating to not understand what the staff were saying while providing care to her. During a concurrent interview on 8/5/25 at 2:17 p.m., with the Director of Nursing (DON), the DON reviewed the staffing schedules the week of 7/21/25 to 7/27/25. The DON stated the expectation was for staff not to speak in a foreign language while providing care to the resident. The DON stated staff should be speaking in a language understood by the residents in order to have the residents needs met. During an interview on 8/6/25 at 10:19 AM with Registered Nurse 2 (RN 2), RN 2 was unable to articulate interventions she would put in place for Spanish speaking residents. During an interview on 8/13/25, at 1:36 p.m., with Licensed Vocational (LVN) 4, LVN 4 stated she would ask Spanish speaking staff to translate for her when communicating with Spanish speaking residents. LVN 4 stated she was not aware of translator services available in the facility. During an interview on 8/13/25, at 11:14 a.m., with LVN 3, LVN 3 stated she was not proficient in speaking Spanish to Spanish speaking resident and would need a translator. LVN 3 stated residents would have difficulty if staff spoke in a foreign language during care and it was important for staff to speak in a language residents could understand to provide their care needs. During an interview on 8/13/25 at 1:58 p.m., with the DON, the DON stated Spanish speaking staff were not available 24/7 and the expectation was to have a communication board, or a language line staff can use. The DON stated she has been in the facility for two a half months and she has not seen any communication board or language line being utilized by the staff. During a review of the facility's policy and procedure titled, Communication Barriers, Reduction of, with a revised date of 11/8/17, indicated, .the facility will make arrangements for interpreters or alternate means of communication such as pictures, sign language, Braille, etc., to enhance communication between residents and staff During a review of job description for Certified Nurse Assistant (undated) indicated as a requirement that the staff member, .must be able to speak, read, write and comprehend the English language . During a review of job description for Charge Nurse (undated) indicated as a requirement that the staff member, .must be able to speak, read, write and comprehend the English language . During a review of job description for Registered Nurse Supervisor (undated) indicated as a requirement that the staff member, .must be able to speak, read, write and comprehend the English language . During a review of the facility's policy and procedure titled Resident Rights, with a revised date of February 2023, indicated that the, .residents have the right to be treated with respect, kindness, and dignity. 2. During an observation on 8/7/25 at 2:20 p.m. in hallway outside of room [ROOM NUMBER] and 17. room [ROOM NUMBER] had three female residents and room [ROOM NUMBER] had three male residents. room [ROOM NUMBER] and room [ROOM NUMBER] had one bathroom located between rooms towards the end of the room, one door leading to room [ROOM NUMBER] and one room leading to room [ROOM NUMBER]. During a review of Resident 9's admission Record, dated 8/8/25, the admission record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 59's admission Record, dated 8/13/25, the admission record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses which included dementia and multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves). During a review of Resident 67's admission Record, dated 8/8/25, the admission record indicated Resident 67 was admitted to the facility on [DATE] with diagnoses which included depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable) and hallucination (experiencing something, such as a sound, sight, smell, taste, or touch, that is not actually there yet it feels real). During a review of Resident 28's admission Record, dated 8/13/25, the admission record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD- irreversible kidney failure) and pain. During a review of Resident 68's admission Record, dated 8/13/25, the admission record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included dementia and muscle weakness. During a review of Resident 130's admission Record, dated 8/13/25, the admission record indicated Resident 130 was admitted to the facility on [DATE] with diagnoses which included heart failure (heart muscle cannot pump enough blood to meet the body's need) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) During a concurrent interview and record review on 8/12/25 at 11:45 a.m. with the Director of Staff Development (DSD), the DSD reviewed resident room assignments and stated room [ROOM NUMBER] are all female residents and room [ROOM NUMBER] are all male residents and stated, They should not have shared bathroom. The DSD stated room with male residents only should not be sharing bathroom with a room with female residents. The DSD stated, Privacy is one of the patient rights. During a concurrent observation and interview on 8/12/25 at 10:15 a.m. with CNA 8, CNA 8 walked to room [ROOM NUMBER] and room [ROOM NUMBER]' bathroom and stated, both resident rooms shared one bathroom, the facility should not be doing it CNA 8 stated she was familiar with residents in room [ROOM NUMBER] and room [ROOM NUMBER]. CNA 8 stated Resident 28 was ambulatory and was the only resident using the bathroom. During an interview on 8/12/25 at 10:51 a.m. with CNA 7, CNA 7 stated social service department are responsible in making the decision of moving residents, they decide what room they are moved to. CNA 7 stated not sure how long residents had been in room [ROOM NUMBER] and room [ROOM NUMBER], they had been in their room for a while. During an interview on 8/13/25 at 9;15 a.m. with the Social Service Director (SSD), the SSD stated the social service department handles moving residents to different rooms and ensures compatibility of residents. The SSD stated she barely started in the facility as the SSD, and she was not aware of the situation in room [ROOM NUMBER] and room [ROOM NUMBER] sharing bathroom. The SSD stated the practice was to notify family members of residents before moving to a different room. The SSD stated she was not sure whether families of residents in room [ROOM NUMBER] and 17 were notified of the situation. The SSD stated it was resident rights to not share a bathroom with the opposite sex. During a phone interview on 8/13/25 at 10:17 a.m. with RP 5, RP 5 stated it was her first time to hear about her family member (Resident 59 in room [ROOM NUMBER]) room sharing a bathroom with male residents. RP 5 stated she was concerned because Resident 59 would tell her things and she was not sure of the facts. RP 5 stated she hopes the facility will do something about the situation. During a phone interview on 8/13/25 at 10:29 a.m. with RP 6, RP 6 stated he was not aware her family member's (Resident 67 in room [ROOM NUMBER]) room was sharing a bathroom with a room with male residents. During a phone interview on 8/13/25 at 11:39 a.m. with RP 7, RP 7 stated he was not aware of his family member (Resident 68 in room [ROOM NUMBER]) sharing a bathroom with a room with female residents. RP 7 stated it was not acceptable for both rooms to share one bathroom even if none of the residents in room [ROOM NUMBER] did not use the bathroom. RP 7 stated the facility did not inform him of the situation. During an interview on 8/14/25 at 10:29 a.m. with the DON, the DON stated, There should be separation of male and female residents. The DON stated female and male residents can not share a bathroom, it is one of their resident rights to have privacy. During an interview on 8/14/25 at 11:25 a.m. with the Administrator (ADM), the ADM stated room [ROOM NUMBER] and room [ROOM NUMBER] sharing a bathroom is a nursing issue. The ADM stated he needed to investigate the situation and who are the residents in the room who can use the bathroom. The ADM stated, I do not have to answer to that, I have to find who can answer, when asked if families of affected residents were made aware of the situation. During a review of facility policy and procedure (P&P) titled, Resident Rights, dated 2/23, the P&P indicated, .Federal and Stated laws guarantee certain basic rights to all residents of this facility. These rights include .a dignified existence, be treated with respect, kindness and dignity, be free from abuse, neglect.be informed of safety or clinical restrictions. During a review of facility's policy and procedure (P&P) titled, Transfer, Room to Room, dated 12/16, the P&P indicated, .The facility reserve the right to make room transfers when necessary and as may be requested by the resident, an/or his or her representative (sponsor). Orient the resident to the new transfer. his or her family and visitors will be informed of the room change. 3. During observation on 8/5/25 at 12:05 p.m. in the dining room between 12:05 p.m. to 12:25 p.m. Resident 4 was observed sitting on one table with three other residents. Facility staff started distributing food to residents in the dining room. Staff served food to other residents at Resident 4's table at 12:15 p.m. and they started eating while Resident 4 watched while waiting for her food. Resident 4's food was served at 12:25 p.m. During an interview on 8/5/25 at 12:20 p.m. with CNA 10 in the dining room assisting a resident at Resident 4's table. CNA 10 stated one of the staff went in the kitchen to follow up on Resident 4's food. CNA 10 stated she was not sure why the kitchen did not send Resident 4's food tray in the cart with the other resident's food tray. CNA 10 stated it was not right for Resident 4 watching other residents eat while she was waiting for her food. During an interview on 8/12/25 at 11:45 a.m. with the Director of Staff Development (DSD), the DSD stated the during meals, staff should be making sure to let the kitchen know where residents will be eating to avoid residents watching other residents eat while waiting for their food. The DSD stated it was a dignity issue and resident rights. During an interview on 8/12/25 at 10:46 a.m. with CNA 7, she stated during mealtimes, licensed nurse checked the food in the cart before it was distributed to residents. CNA 7 stated food is served at one table at a time to avoid having residents watching other residents on their table eat while they wait for their food. CNA 7 stated she was not sure why Resident 4's tray was late; she usually eats in the dining room. CAN 7 stated Resident 4 should not have to watch other residents at her table while she waited for her food. During an interview on 8/14/25 at 10:25 a.m. with the DON, the DON stated the staff should have made sure to notify kitchen of residents eating in the dining room to avoid having residents watched other residents eat while they wait for their food. The DON stated the practice was to serve one table at a time. During a review of facility policy and procedure (P&P) titled, Assistance with Meals, dated 7/17, the P&P indicated, . All residents will be encouraged to eat in the dining room. Facility staff will help resident who require assistance with eating. The Food Services Department will deliver food carts to appropriate areas. During a review of facility policy and procedure (P&P) titled, Resident Rights, dated 2/23, the P&P indicated, .Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include .a dignified existence, be treated with respect, kindness and dignity, be free from abuse, neglect.be informed of safety or clinical restrictions.

Based on observation, interview and record review, the facility failed to ensure nail care was provided for one of nine sampled residents (Resident 49) when Resident 49's fingernails were long, jagged (sharp, uneven edges) and dirty with brownish to blackish dirt built up underneath the nails.This failure had potential for Resident 49 in obtaining avoidable skin related injuries and infection (the invasion and growth of germs in the body).During a concurrent observation and interview on 8/5/25 at 11:02 a.m. with Resident 49, in Resident 49's room, Resident 49 was lying in bed. Resident 49 was awake with slurred (indistinct and difficult to hear or understand) speech and was able to respond during conversation by nodding his head using yes and no questions. Resident 49 was unable to move his right upper extremity and right lower extremity. Resident 49 moved his left hand towards the left side of the bed. Resident 49's right hand was elevated with pillow; right hand was closed in a fist (a hand with a finger s clenched in the palm) position with minimal swelling. Resident 49 was unable to open his right hand. Resident 49 had no washcloth or palm protector on right hand.During a review of Resident 49's MDS, dated [DATE], the MDS section C indicated Resident 49's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 49's BIMS Summary Score was blank.During a review Resident 49's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/14/25, the AR indicated Resident 49 was admitted to the facility on [DATE] with diagnosis of Hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on side of the body) following Cerebral Infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, Aphasia following Cerebral Infarction, Dysphagia(difficulty swallowing) following Cerebral Infarction, Dysarthria (difficulty speaking due to weak speech muscles) following Unspecified Cerebrovascular Disease (loss of blood flow to a part of the brain), Contracture (is tightening and shortening of the surrounding soft tissues which then restrict joint [a connection of two bones in the skeletal system] movement). of Muscle Right Hand, and Contracture, Unspecified Joint.During a concurrent observation and interview on 8/6/25 at 12:16 p.m. with Certified Nursing Assistant (CNA) 11, in Resident 49's room, CNA 11 checked Resident 49's right and left hand. CNA 2 stated Resident 49's right hand was contracted and stated, .like a fist. CNA 11 attempted to open Resident 49's right hand and stated CNA fingernails are long with brownish to blackish dirt built-up underneath the nails. CNA 11 stated there was no washcloth or palm protector applied to Resident 49's right hand. CNA 11 stated Resident 49 had not been wearing a splint (is a device designed to prevent contractures by gently stretching and maintaining the position of affected joints, such as the hand, wrist, or foot) to the right hand. CNA 11 Resident 49's left hand fingers were long, jagged and dirty with brownish to blackish dirt underneath the nails and the left thumb finger with brownish stained. CNA 11 stated Resident 49's fingernails should be trimmed and cleaned because Resident 49 uses his left hand when eating. CNA 11 stated she will provide nail care to Resident 49 and will clean his hands. CNA 11 stated CNAs were responsible in doing nail clipping and nail care.During an interview on 8/12/25 at 2:32 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Licensed Nurses conduct weekly checks of resident's fingernails every Sunday to ensure fingernails are trimmed and cleaned to prevent infection and self-inflicting scratches and injury. The ADON stated Resident 49 had a right-hand contracture, a washcloth should be applied and kept his fingernails trimmed to prevent self-inflicting scratch and injury to the palm of the hand. During a concurrent observation and interview on 8/8/25 at 1:45 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 49's room, LVN 3 checked Resident 49's right and left hand. LVN 3 stated Resident 49's right left fingernails were long and dirty with brownish to blackish built-up dirt underneath the nails. LVN 3 stated CNAs do nail clipping every Sunday. LVN 3 stated Resident 49's fingernails should be cleaned and trimmed to prevent infection. LVN 3 stated Resident 49 uses his left hand for holding the food during meals. LVN 3 stated having long and dirty fingernails is an infection control issue. LVN 3 stated she will inform the CNA to do nail care for Resident 49 as soon as possible.During an interview on 8/8/25 at 11:16 a.m. with the Director of Rehabilitation (DOR), the DOR stated she provided training to nursing staff regarding right hand hygiene and applying washcloth/palm protector to protect resident's palm for any injury. During a review of Resident 49's clinical record titled, Occupational Therapy: Weekly TEN Details, dated 6/3/25, Occupational Therapy: Weekly TEN Details indicated, .CNA trained in hand hygiene for skin integrity and use of washcloth or palm protector.During an interview on 8/13/25 at 4:20 p.m. with the Director of Nursing (DON), the DON stated her expectation for nursing staff to keep residents' fingernails cleaned and trimmed to prevent infection and skin injury. The DON stated nursing staff should follow and implement OT training about Resident 49's hand hygiene for skin integrity and use of washcloth or palm protector.During a review of facility's policy and procedure titled, Fingernails/Toenails, Care of, dated, 2/18, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching his or her skin.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when:1. A box of Nicotine Transdermal Patches (a patch that released nicotine [a chemical found in tobacco] through the skin to help people stop smoking) were found in the Station 5 Medication Cart without a resident identifier on the box.This failure had the potential to cause a medication error and place residents at risk for receiving the wrong medication.2. An opened foil envelope packet of Budesonide inhalation suspension (a medicine that helped reduce swelling and irritation in the lungs) was found in the Station 5 Medication Cart without the date of opening written on the packet.This failure had the potential to compromise the integrity, potency and safety of the medication and placed residents at risk for receiving ineffective or unsafe treatment.3. An open bottle of iodine (a chemical used to clean and disinfect cuts, scrapes or skin to prevent infection) was found in the Station 5/6 Treatment Cart without the date of opening written on the container.This failure had the potential to affect the integrity and effectiveness of the solution and placed residents at risk for compromised infection control and unsafe treatment.4. Two opened tubes of 20% Zinc Oxide (an ointment used to protect the skin and prevent irritation and help treat rashes) were found in the Station 3 Treatment Cart without an open date.This failure had the potential to affect the integrity and effectiveness of the product and placed residents at risk of receiving compromised treatment.5. An opened tube of Phenylephrine Hemorrhoidal Ointment (a medicine used to relieve pain, itching and swelling in and around the anus) was found in the Station 3 Treatment Cart without a resident identifier on the tube itself.This failure had the potential to result in a medication error and placed residents at risk of receiving medication that was not prescribed for them.6. An opened tube of Hydrocortisone Acetate 1% (a cream used to reduce swelling, redness and itching of the skin) was found in the Station 3 Treatment Cart without an open date.This failure had the potential to affect the integrity and effectiveness of the medication and placed residents at risk for receiving compromised treatment.7. An opened tube of Muscle Rub Cream 10% menthol and 15% methyl salicylate topical analgesic (a topical medicine applied to sore muscles to help relieve pain and discomfort) was found in the Station 3 Treatment Cart without an open date.This failure had the potential to affect the integrity and effectiveness of the medication and placed residents at risk for receiving compromised treatment.8. An open tube of Diphenhydramine topical cream (topical medicine to relieve itching, redness or irritation caused by insect bites rashes or allergic reactions) was found in the Station 3 Treatment Cart without an open date.This failure had the potential to affect the integrity and effectiveness of the medication and placed residents at risk for receiving compromised treatment.9.Two opened tubes of 100% Medical Grade Manuka Honey (a special honey used on wounds and burns to help kill bacteria [germs] and promote healing) were found in the Station 3 Treatment Cart without open dates.This failure had the potential to affect the integrity and effectiveness of the medication and placed residents at risk for receiving compromised treatment.10. An unopened bottle of Lispro insulin (a fast-acting insulin to help control blood sugar levels) was found in the Station 1 Medication Cart, despite the packaging indicating it should be refrigerated until opened.This failure had the potential to compromise the effectiveness of the medication and placed residents at risk for receiving ineffective treatment.11. An opened bottle of carbamide peroxide 6.5% ear drops (a medicine used in the ears to help soften and remove ear wax safely) was found in the Station 2 Medication Cart without a resident identifier.This failure had the potential to result in a medication error and placed residents at risk of receiving medication that was not prescribed for them.Findings:1. During an observation on [DATE] at 9:29 a.m. a box of Nicotine Transdermal Patches was found in the Station 5 Medication Cart without a resident identifier on the box.During an interview on [DATE] at 10:35 a.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated resident medications needed to be labeled with a resident identifier to ensure staff knew which resident they belonged to.During an interview on [DATE] at 4:23 p.m. with the Pharmacist Consultant (PC), the PC stated all resident medications were required to have a resident identifier to properly identify which resident the medication belonged to.During an interview on [DATE] at 10:59 a.m. with the Director of Nurses (DON), the DON stated medications should be labeled with a resident identifier to prevent them from being confused with another resident's medications.2. During an observation on [DATE] at 10:19 a.m. an opened foil envelope packet of Budesonide inhalation suspension was found in the Station 5 Medication Cart without the date of opening written on the packet. The label indicated the medication was good for 14 days after opening.During an interview on [DATE] at 10:35 a.m. with LVN 7, LVN 7 stated medications needed to be labeled with an open date on the package to track how long they remained effective, noting that different medications had different expiration periods after opening.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated the medication remained effective for two weeks after opening and emphasized the importance of labeling it with the open date to ensure staff could accurately track its expiration.During an interview on [DATE] at 10:59 with the DON, the DON stated the expectation was for staff to record the date an item was opened to ensure its expiration date was accurately tracked.3. During a concurrent observation and interview on [DATE] at 10:43 a.m. with LVN 7 at the Station 5 Nurses' Station, an opened bottle of iodine in the 5/6 Treatment Cart was not labeled with an open date. LVN 7 stated that bottles and other over-the-counter products (OTC) were required to be labeled with an open date so staff would know how long the item had been in use.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.4. During an observation on [DATE] at 8:55 a.m., two tubes of 20% Zinc Oxide were found in the Station 3 Treatment Cart without an open date.During an interview on [DATE] at 9:07 a.m. with LVN 5, LVN 5 stated the process was to date items when they were opened. LVN 5 stated it was important to know this information to ensure the product did not expire. LVN 5 further stated that all medications and OTCs in the treatment carts should be labeled with an open date.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.5. During an observation on [DATE] at 8:55 a.m., an opened tube of Phenylephrine Hemorrhoidal ointment was found in the Station 3 Treatment Cart without a resident identifier labeled on it.During an interview on [DATE] at 9:07 with LVN 5, LVN 5 stated the Hemorrhoidal ointment should have a resident identifier on it. LVN 5 explained it was important to ensure the product was labeled with a resident identifier because, when multiple residents had the same medication, it was necessary to know which tube belonged to each resident to prevent mix-ups.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated all medications should be labeled with a resident identifier to ensure the medication was assigned to the correct resident. The PC stated a risk to the residents would be medication mix-ups and potential cross contamination.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated medications should be labeled with a resident identifier. The DON explained that the tube is a separate item and should not be mixed up with another resident's medication, emphasizing that labeling the original box alone was not sufficient.6. During an observation on [DATE] at 8:55 a.m., an opened tube of Hydrocortisone Acetate 1% cream found in Station 3 Treatment Cart without an open date.During an interview on [DATE] at 9:07 a.m. with LVN 5, LVN 5 stated the process was to date items when they were opened. LVN 5 stated it was important to know this information to ensure the product did not expire. LVN 5 further stated all medications and OTCs in the treatment carts should be labeled with an open date.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.7. During an observation on [DATE] at 8:55 a.m., an opened tube of Muscle Rub Cream 10% menthol and 15% methyl salicylate topical analgesic was found in the Station 3 Treatment Cart without an open date.During an interview on [DATE] at 9:07 a.m. with LVN 5, LVN 5 stated the process was to date items when they were opened. LVN 5 stated it was important to know this information to ensure the product did not expire. LVN 5 further stated that all medications and OTCs in the treatment carts should be labeled with an open date.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.8. During an observation on [DATE] at 8:55 a.m., an opened tube of Diphenhydramine topical cream was found in the Station 3 Treatment Cart without an open date.During an interview on [DATE] at 9:07 a.m. with LVN 5, LVN 5 stated the process was to date items when they were opened. LVN 5 stated it was important to know this information to ensure the product did not expire. LVN 5 further stated all medications and OTCs in the treatment carts should be labeled with an open date.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.9. Two opened tubes of 100% Medical Grade Manuka Honey were found in the Station 3 Treatment Cart without opened dates.During an interview on [DATE] at 9:07 a.m. with LVN 5, LVN 5 stated the process was to date items when they were opened. LVN 5 stated it was important to know this information to ensure the product did not expire. LVN 5 further stated all medications and OTC's in the treatment carts should be labeled with an open date.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated that all products, both OTC and prescription, were to be labeled with an open date. The PC stated this was important because every product has an expiration date, and it was necessary to know when that date would be.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated the expectation of staff was to place the date on items when they were opened. The DON explained that some medications were seldom used, and labeling helped ensure the medication was not expired.10. During a concurrent observation and interview on [DATE] at 9:14 a.m. with Registered Nurse (RN) 3, an unopened bottle of Lispro insulin was found in the Station 1 Medication Cart. The label indicated that the insulin was to be refrigerated until used. RN 3 stated that because the cap was still on the bottle, the insulin had not been used and should have been stored in the refrigerator rather than in the medication cart.During an interview on [DATE] at 9:30 with Registered Nurse Supervisor (RNS), the RNS stated if medication was not stored properly, its effectiveness could be altered and that would be a risk to the resident.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated all insulins should be refrigerated until used. Once used, they can be stored at room temperature. This is important because it helped maintain its potency and effectiveness and improper storage could reduce its ability to control blood glucose (the amount of sugar in the blood that gave the body energy to function).During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated unused insulin should be stored in the refrigerator and that the unopened bottle should not have been in the medication cart.11. During a concurrent observation and interview on [DATE] at 9:56 a.m. with RNS, a opened bottle of carbamide peroxide 6.5% ear drops was found in the Station 2 Medication Cart without a resident identifier on the bottle. RNS stated it was important to ensure the product itself had a resident identifier to confirm it was used only for that specific resident. RNS stated receiving the wrong medication or product would cause cross-contamination or ineffective treatment.During an interview on [DATE] at 4:23 p.m. with the PC, the PC stated all medications should be labeled with a resident identifier to ensure the medication was assigned to the correct resident. The PC stated a risk to the residents would be medication mix-ups and potential cross contamination.During an interview on [DATE] at 10:59 a.m. with the DON, the DON stated medications should be labeled with a resident identifier. The DON explained that the tube is a separate item and should not be mixed up with another resident's medication, emphasizing that labeling the original box alone was not sufficient.During a review of facilities policy and procedure (P&P) titled, Administering Medications, revised 4/2023, the P&P indicated, the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.the individual administering the medication checks the label to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication.During a review of facilities policy and procedure (P&P) titled Medication/Treatment/Labeling and Storage, revised 2/2023, the P&P indicated, medications /treatments requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location.labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.the medication labels includes at a minimum a. medication name, b. prescribed dose, c. strength, d. expiration date, e. residents name.OTC medications in containers the label contains f. expiration date .

Based on observation, interview, and record review, the facility failed to ensure one of nine sampled residents (Resident 95) drug regimen was free from unnecessary drugs when Resident 95 received tramadol (opioid pain medication- a controlled substance used to treat moderate to severe pain) prescribed for pain management, despite reporting no pain. This failure resulted in over-medication and inadequate pain management practices of Resident 95 which had the potential to result in adverse consequences and complications which could lead to serious medical conditions.Findings: During a review of Resident 95's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (condition in which brain tissue dies due to lack of blood flow), epilepsy (seizures due to abnormal brain activity), stiff-man syndrome (disorder which includes fluctuating muscle rigidity and spasms triggered by noise, touch, or distress), and major depressive disorder (persistent sadness). During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/22/25, the MDS indicated Resident 95 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 95 was cognitively intact. During a review of Resident 95's Order Summary Report, dated 8/12/25, the Order Summary Report indicated, .tramadol HCI oral tablet 50 MG (milligrams- unit of measurement for medication dosage) give 1 tablet by mouth every 8 hours for pain management.active.order date 5/23/24.start date 5/23/24. During a review of Resident 95's Medication Administration Record, dated 8/12/25, the document indicated from 6/1/25-6/30/25 tramadol was administered 74 times for a pain rating of 0 out of 10. The document indicated from 7/1/25-7/31/25 tramadol was administered 85 times for a pain rating of 0 out of 10. The document indicated from 8/1/25-8/11/25 tramadol was administered 29 times for a pain rating of 0 out of 10. During an interview on 8/7/25 at 1:54 p.m. with Resident 95 in Resident 95's room, Resident 95 stated, licensed nursing staff administered tramadol every day to her. Resident 95 stated her pain was well controlled with her other medications and had acetaminophen (pain medication used to treat mild to moderate pain) available as needed if she had breakthrough pain, which worked to manage her pain. Resident 95 stated she had received tramadol every day since admission. Resident 95 stated she did not need pain medication every day and would prefer not to take pain medication if she was not in pain. Resident 95 stated tramadol made her feel sleepy after administration. During a concurrent interview and record review on 8/7/25 at 3:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 95's Order Summary and Medication Administration Record (MAR), dated 8/7/25 was reviewed. LVN 1 stated Resident 95 had an active order for tramadol to be given .every 8 hours for pain management. LVN 1 stated tramadol was an opioid (a controlled substance that can become highly addictive) used to treat severe pain and would not be appropriate to be administered if Resident 95 had no pain. LVN 1 stated it was a professional standard to assess for pain prior to administration of routine, scheduled and as needed pain medication. LVN 1 stated the purpose of a pain assessment was to determine if pain medication was needed and which pain medication was most appropriate to administer. LVN 1 stated Resident 95 had been administered tramadol inappropriately when it was given for a recorded pain level of 0 out of 10 in 6/2025, 7/2025 and 8/2025. LVN 1 stated it was important to accurately assess and document pain levels to ensure the lowest most effective dose of pain medication was administered. LVN 1 stated Resident 95 was at risk for overmedication with the administration of tramadol with no reported pain. During an interview on 8/12/25 at 3:45 p.m. with the Pharmacist Consultant (PC), the PC stated he was responsible for reviewing medication orders for appropriateness to ensure it was administered per the indication. The PC stated licensed nursing staff was responsible to complete pain assessments and administer the most appropriate pain medication based on the assessment. The PC stated all pain medication orders required a pain scale within the administration instructions to ensure pain medication was administered appropriately. The PC stated the administration of tramadol was not appropriate to be administered for a pain rating of 0 out of 10. During a concurrent interview and record review on 8/14/25 at 1:49 p.m. with the Director of Nursing (DON), Resident 95's Order Summary, and Medication Administration Record, dated 8/14/25 was reviewed. The DON stated tramadol was an opioid pain medication used to treat moderate to severe pain. The DON stated moderate to severe pain was considered 4 and above out of 10 on the pain scale. The DON stated according to facility policy and standard of practice a pain assessment was to be completed prior to all scheduled, routine, and as needed pain medication. The DON stated it was important to conduct a pain assessment to determine the most effective pain medication to administer or withhold and to monitor its effectiveness. The DON stated Resident 95 was at risk for overmedication or building up a pain medication tolerance to tramadol for inappropriate administration for a pain rating of less than 4 out of 10. The DON stated it was not appropriate to administer opioids when there was no reported pain. The DON stated it was not appropriate to administer tramadol 74 times between 6/1/25-6/30/25, 85 times between 7/1/25-7/31/25, and 29 times between 8/1/25- 8/11/25 for pain reports of 0 out of 10. The DON stated facility policy and pain management in-services had not been followed by licensed nursing staff when tramadol was administered for a pain rating of 0 out of 10. The DON stated Resident 95 was overmedicated and at risk for side effects such as, opioid dependency, increased pain tolerance threshold and constipation. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2023, the P&P indicated, .if a dosage if believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber , the resident's attending physician or the facility's medical director to discuss the concerns.During a review of the facility's P&P titled, Administering Pain Medications, dated 10/2022, the P&P indicated, .the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive car plan, and the resident's choices related to pain management.pain management is a multidisciplinary care process that includes the following.identifying and using specific strategies for different levels and sources of pain.modifying approaches as necessary.when opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. During a review of the facility's P&P titled, Pain Assessment and Management, dated 10/2023, the P&P indicated, .identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs.During a review of the facility's in -service meeting minutes document titled, Pain Level Monitoring and Documentation, dated 4/15/25, the in-service indicated, .if pain medication is ineffective or out of scale for pain medication, notify MD [medical doctor] immediately.entering (0) zero would be incorrect.

Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of six sampled residents (Resident 13) when Resident 13's antidepressant medication (used to treat depression and mental health conditions), and anticoagulant medication (used to prevent blood clots from forming) use were inaccurately coded on the MDS assessment. These failures had the potential to result in Resident 13's care needs not met. During a review of Resident 13's admission Record, dated 8/8/25, the admission record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one sided weakness or partial paralysis), depression (feeling of persistently sad and hopeless, impacting ability to enjoy life and carry out daily activities), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing and unspecified atrial fibrillation (heart upper chambers beat irregularly and often rapidly). During a review of Resident 13's Order Summary Report, dated 8/8/25, the Order Summary Report, indicated, .Apixaban Oral Tablet 5 MG [milligram-unit of measurement], Give 5 mg by mouth two times a day.Start Date: 4/18/25. Sertraline HCL [hydrochloride] Oral Tablet 25 MG (Sertraline HCl) Hive 25 mg by mouth one time a day. Start Date: 4/22/25. [brand name] Oral tablet 10 MG (empagliflozin) Give 1 [one] tablet by mouth one time a day. During a concurrent interview and record review on 8/13/25 at 11:22 a.m. with Minimum Data Set Nurse (MDS) 1 and MDSN 2, Resident 13's MDS assessment Section N (medications) dated 7/15/25 was reviewed. MDSN 1 and MDSN 2 stated Resident 13 received antidepressant medication and anticoagulant medication. MDSN 1 and MDSN 2 stated Resident 13's use of antidepressant medication and anticoagulant medication were not coded in the MDS assessment dated [DATE]. MDSN 1 and MDSN 2 stated Resident 13 should have been coded as receiving antidepressant medication and anticoagulant medications. During an interview on 8/14/25 at 10:15 a.m. with the Director of Nursing (DON), the DON stated her expectation when it comes to the MDS assessment was for everyone completing the assessment to be accurate and completed on time. The DON stated both MDSN 1 and MDCN 2 are new and are LVNs and she submits or transmits the assessments, but she was not responsible in checking for accurateness. During a review of facility's policy and procedure (P&P) titled, Resident Assessments, dated 10/23, the P&P indicated, .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas. All persons who have completed any potion of the MDS resident assessment form must sign the document attesting to the accuracy of the information.

Based on interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for two of nine sampled residents (Resident 95 and Resident 108) when:Resident 95 had an active order for sertraline (psychotropic medication used to treat conditions such as depression) oral tablet, ordered on 7/5/25, with no electronic provider signature prior to administration.Resident 108 had an active order for aripiprazole (psychotropic medication used to treat conditions such as schizophrenia), ordered on 3/19/25, with no name of the licensed nursing staff that prepared and verified the consent form.These failures resulted in the violation of Resident 95's and Resident 108's right to be informed of, in advance, of their anti-psychotic medication treatment risks and benefits by a physician or alternative treatment options which could lead to negative side effects. 1. During a review of Resident 95's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (condition in which brain tissue dies due to lack of blood flow), epilepsy (seizures due to abnormal brain activity), stiff-man syndrome (disorder which includes fluctuating muscle rigidity and spasms triggered by noise, touch, or distress), major depressive disorder (persistent sadness), and anxiety disorder (persistent worry and fear). During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/22/25, the MDS indicated Resident 95 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 95 was cognitively intact. During a review of Resident 95's Order Summary Report (OSR), dated 8/12/25, the OSR indicated Resident 95 had an order for, .sertraline HCI oral tablet 50 MG [milligrams- unit of measurement for medication dosage].give 0.5 tablet by mouth one time a day for major depressive disorder.active.order date 7/5/25.start date 7/6/25. During a review of Resident 95's Informed Consent-Psychoactive Medication- V 2 (ICPM), dated 7/5/25, the ICPM did not indicate the provider electronically signed the consent. During a review of Resident 95's Medication Administration Record (MAR), dated 8/12/25 and 8/13/25, the MAR indicated, .sertraline HCI oral tablet 50 MG.give 0.5 tablet by mouth one time a day for major depressive disorder. had been administered daily, per the order, since 7/5/25. 2. During a review of Resident 108's AR, dated 8/12/25, the AR indicated Resident 108 was admitted to the facility on [DATE] with diagnoses of heart failure (heart does not pump blood properly), atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), repeated falls, and schizophrenia (mental illness which affects ability to think, feel and behave clearly). During a review of Resident 108's MDS, dated 6/13/25, the MDS indicated Resident 108 had a BIMS score of 15, which suggested Resident 108 was cognitively intact. During a review of Resident 108's OSR, dated 8/12/25, the OSR indicated Resident 108 had an order for, .aripiprazole oral tablet 15 MG.give 1 tablet by mouth one time a day for schizophrenia.active.order date 3/19/25.start date 3/20/25. During a review of Resident 108's Informed Consent-Psychoactive Medication- V 2 (ICPM), dated 3/19/25, the ICPM did not indicate the name of the licensed nurse that verified informed consent and prepared the consent. During a concurrent interview and record review on 8/8/25 at 11:19 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 95's and Resident 108's ICPM's, dated 7/5/25 and 3/19/25 were reviewed. LVN 3 stated all consents were completed and obtained electronically. LVN 3 stated the provider was responsible for contacting the resident or resident responsible party (RP) and obtain informed consent. LVN 3 stated licensed nursing staff was responsible for ensuring informed consent was obtained by the provider and completing ICPM documentation. LVN 3 stated medical records staff was responsible to follow up on ICPM's and ensure they were signed electronically. LVN 3 stated Resident 95's sertraline ICPM did not contain an electronic provider signature, and the medication had been administered. LVN 3 stated Resident 108's aripiprazole ICPM did not contain the name of the licensed nurse that prepared the ICPM form and ensured informed consent had been obtained by the provider. LVN 3 stated progress notes or alternative documentation did not replace informed consent. LVN 3 stated it was important to ensure ICPM's were completed accurately and completely to ensure residents and/or RP's were informed of their proposed treatment, risk, benefits and alternatives to treatment. During a concurrent interview and record review on 8/8/25 at 11:38 a.m. with the Medical Records Assistant (MRA), Resident 95's and Resident 108's ICPM's, dated 7/5/25 and 3/19/25 were reviewed. The MRA stated medical record staff reviewed electronic consents by performing audits and ensuring providers electronically signed ICPM's. The MRA stated they reviewed ICPM's to ensure they were filled out completely with the licensed nurses name, resident name, date, time, medication information and electronic provider signature. The MRA stated Resident 95's sertraline ICPM did not contain an electronic provider signature and was therefore incomplete. The MRA stated Resident 108's aripiprazole ICPM did not contain the licensed nurses name that prepared the form or verified informed consent and therefore was incomplete. The MRA stated it was facility policy to ensure all information was documented on the informed consent form prior to medication administration.During an interview on 8/12/25 at 3:45 p.m. with the Pharmacist Consultant (PC), the PC stated informed consent was expected to be obtained prior to medication administration. The PC stated to ensure residents and/or resident RP's were informed of purposed treatment in advance all aspects of the form needed to be filled out and completed, which included resident name, date, time, licensed nursing staff whom prepared the form and provider signature. During an interview on 8/14/25 at 1:49 p.m. with the Director of Nursing (DON), the DON stated sertraline and aripiprazole were psychotropic medications which required informed consent prior to administration. The DON stated informed consents were legal documents and could not be replaced by a progress note. The DON stated all aspects of the informed consent needed to be completed for the document to be valid which included, resident name, medication information, name of licensed nursing staff preparing the form and validating informed consent was obtained by the provider, and a provider signature. The DON stated the provider was responsible to obtain informed consent and electronically sign the informed consent. The DON stated licensed nursing staff were responsible to ensure informed consents forms were completed. The DON stated medical record staff reviewed informed consents by completing audits to ensure ICPM's were completed in entirety. The DON stated Resident 95's sertraline ICPM did not contain an electronic provider signature. The DON stated Resident 108's aripiprazole ICPM did not contain the name of the licensed nurse that prepared the form or verified informed consent was obtained. The DON stated facility policy had not be followed when Resident 95's and Resident 108's ICPM's were not complete. The DON stated it was important to ensure informed consents were complete and accurate to ensure residents and/or resident RP's were informed in advance of the psychotropic medications they were taking, including risks, benefits and alternative treatment options. The DON stated Resident 95 and Resident 108 were at risk of not knowing their rights to the psychotropic medications they were administered. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2023, the P&P indicated, .be notified of his or her medical condition and of any changes in his or her condition.be informed of, and participate in, his or her care planning and treatment. During a review of the facility's P&P titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated 2/2021, the P&P indicated, .each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed.the resident's attending physician, the facility's medical director, or the director of nursing services is responsible for informing the resident of his or her medical condition. Such information includes providing the resident/representative with information about the resident's.psychosocial status.type of care or treatment recommended based on the assessment and care plan).risks and benefits of proposed care or treatment.During a review of the facility's P&P titled, Psychotropic Medication Use/Informed Consent, dated 3/2024, the P&P indicated, .residents, families, and/or the representative are involved in the medication management process.the actual or intended benefit of the medication is understood by the resident/representative. resident's (and/or representatives) have the right to decline treatment with psychotropic medications.the staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.the signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures.

Based on observation, interview, and record review the facility failed to act upon reported drug regimen review irregularities when one of nine sampled residents (Resident 108) had suggested drug regimen updates and there was no action taken to address it or documentation as to why no change in medication was taken. This failure had the potential to lead to unresolved medication related issues and negative health outcomes of Resident 108. Findings: During a review of Resident 108's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/12/25, the AR indicated Resident 108 was admitted to the facility on [DATE] with diagnoses of heart failure (heart does not pump blood properly), atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), repeated falls, and schizophrenia (mental illness which affects ability to think, feel and behave clearly). During a review of Resident 108's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/13/25 , the MDS indicated Resident 108 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 108 was cognitively intact. During a review of Resident 108's eMAR-Medication Administration Note, dated 7/22/25, the document indicated, . resident verbalized feeling dizzy. During a review of Resident 108's Consultant Pharmacist's Medication Regimen Review, dated 7/22/25, the document indicated Resident 108 sustained a fall on 7/22/25 and a medication regimen review was completed due to the change in condition. The document indicated, .change metoprolol [blood pressure medication used to lower high blood pressure] and amlodipine [blood pressure medication used to lower high blood pressure] hold parameters to hold for SBP [systolic blood pressure-pressure in arteries] < 110 [less than 100] (instead of 100). The document indicated metoprolol was a medium risk medication and amlodipine was a low-risk medication. The document was marked and signed by the provider as reviewed on 7/22/25. During a review of Resident 108's Order Summary Report, dated 8/12/25, the Order Summary Report (OSR) indicated, .amlodipine besylate oral tablet 5 MG [milligrams- unit of measurement to determine medication dose].give 1 tablet by mouth one time a day for hypertension hold medication is SBP <100, P [pulse-heart rate] < 60.active.start date 7/2/25. The OSR indicated, .metoprolol succinate ER [extended release-medication with delayed action] tablet extended release 24 hour 25 MG give 1 tablet by mouth one time a day for hypertension hold medication is SBP <100, P <60.active.order start date 7/24/25. During a concurrent interview and record review on 8/12/25 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 108's Electronic Medical Record (EMR- electronic medical record containing all pertinent health information), dated 8/12/25 was reviewed. LVN 6 stated Resident 108 sustained a fall on 7/22/25 which prompted a Change in Condition (COC-documents significant changes in a resident's health status, triggering a review of their care plan) report and a drug regimen review request, which was faxed to the Pharmacist Consultant (PC). LVN 6 stated the PC completed Resident 108's drug regimen review request on 7/22/25 and identified irregularities with recommendations for medication changes. LVN 6 stated the PC recommended, .change metoprolol and amlodipine hold parameters to hold for SBP < 110 (instead of 100). LVN 6 stated the provider, and the Director of Nursing (DON) were responsible to ensure drug regimen review recommendations were implemented or rationale was documented as to why drug regimen recommendations were not implemented. LVN 6 stated the provider signed and dated the drug regimen review on 7/22/25. LVN 6 stated Resident 108's metoprolol and amlodipine order had not been updated to reflect the PC's recommendations. LVN 6 stated she could not locate documented rationale as to why the recommendation was not implemented. LVN 6 stated licensed nursing staff were responsible to follow up on drug regimen review recommendations with the provider and the DON to ensure orders were updated or documentation was completed to provide a rationale as to why recommendations were not implemented. LVN 6 stated metoprolol and amlodipine decrease blood pressure and could have contributed to Resident 108 experiencing dizziness and a fall on 7/22/25. LVN 6 stated Resident 108 was at risked for increased or ongoing dizziness and falls with no follow-up on the drug regimen review recommendations.During a concurrent interview and record review on 8/12/25 at 10:45 a.m. with the Medical Records Supervisor (MRS), Resident 108's EMR, dated 8/12/25 was reviewed. The MRS stated medical record staff were responsible for uploading drug regimen reviews into the EMR. The MRS stated before uploading drug regimen reviews into the EMR medical records audited the form to ensure it was completed and intervention occurred. The MRS stated the recommendation would need an updated order or documentation rationale as to why the recommendation was not implemented before the drug regimen review was uploaded into the EMR. The MRS stated Resident 108 had a drug regimen review completed on 7/22/25 after she fell. The MRS stated Resident 108's orders did not reflect the PC's recommendations and there was no documentation as to why it was not implemented. The MRS stated the provider, the DON and licensed nursing staff were responsible to ensure drug regimen reviews were followed up on. The MRS stated medical records was responsible to ensure the drug regimen review was completed and followed up on before uploading it into the EMR. The MRS stated it was important to follow up on drug regimen reviews after a COC because it was needed following an event to identify potential contributing factors and without a follow-up Resident 108 was at risk for another fall. During a concurrent interview and record review on 8/12/25 at 3:45 p.m. with the PC, Resident 108's EMR, dated 8/12/25 was reviewed. The PC stated Resident 108 sustained a fall on 7/22/25 which prompted a drug regimen review. The PC stated blood pressure medication could have contributed to Resident 108's fall and recommendations were placed to adjust metoprolol and amlodipine hold parameters. The PC stated metoprolol and amlodipine medication orders had not been updated based on drug regimen review recommendations and he could not locate documentation as to why recommendations were not implemented. The PC stated licensed nursing staff and the provider were responsible to implement recommendations or document rationale as to why recommendations were not implemented. The PC stated the provider was not required to implement recommendations, but needed to provide documentation as to why interventions were not implemented based on drug regimen review. The PC stated drug regimen reviews were completed in response to a COC and required follow-up. During a concurrent interview and record review on 8/14/25 at 1:49 p.m. with the DON, Resident 108's EMR, dated 8/14/25 was reviewed. The DON stated when a COC occurred licensed nursing staff faxed a drug regimen review request to the PC. The DON stated it was important to complete drug regimen reviews after a COC to determine contributing factors to the event and prevent the event from occurring again. The DON stated the PC was responsible to complete drug regimen reviews. The DON stated licensed nursing staff, the provider, and herself were responsible to ensure recommendations were implemented or documentation was present as to why recommendations would not be implemented. The DON stated Resident 108 drug regimen review was completed after a COC on 7/22/25 and signed by the provider as reviewed, which indicated the provider agreed with the PC's recommendations. The DON stated resident 108's metoprolol and amlodipine order hold parameters had not be updated to reflect the PC's recommendations. The DON stated licensed nursing staff did not follow up with the provider to ensure metoprolol and amlodipine orders were updated. The DON stated Resident 108 was at risk for repeated dizziness, falls and injuries when her COC drug regimen review recommendations were not implemented as recommended by the PC and agreed upon by the provider. The DON stated proper medication management had not been implemented. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2023, the P&P indicated, .the nurse will notify the resident's attending physician or physician on call when there has been a (an).need to alter the resident's medical treatment significantly.During a review of the facility's P&P titled, Medication Regimen Review, dated 5/2023, the P&P indicated, .the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.the MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems. if the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action ahs ben taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator.the attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.the staff member who identifies the change of condition follows reporting procedure to notify the physician.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent falls for two of five sampled residents (Residents 1 and 9) when: 1. Resident 1 was assessed to be at risk for falls on 3/23/25 and staff were aware of Resident 1's frequent positioning in bed lying on his back leaning against the side rail, right sided paralysis (inability to move), and inability to reposition himself and effective individualized interventions to prevent falls were not implemented. Resident 1 experienced an unwitnessed fall on 4/2/25. This failure resulted in Resident 1's avoidable fall on 4/2/25 when he was found on the floor face down next to his bed, sustaining a nasal fracture [broken nose], a laceration (deep cut in the skin) to the left eyebrow and left shin (front of the leg below the knee) requiring transportation to the emergency department (ED) for assessment and treatment of his injuries. Resident 1 received eleven sutures (stitches holding the edges of a wound together) to his left eyebrow and seven sutures to his left shin. The resident was treated in the ED and transferred back to the skilled nursing facility (SNF). 2. Resident 9 was assessed as needing staff supervision to ambulate (walk) more than 50 feet and had known behaviors of putting herself on the ground and effective individualized interventions to prevent falls were not implemented when she ambulated outside to the memory care unit patio without staff supervision. Resident 9 experienced an unwitnessed fall on 4/6/25. This failure resulted in Resident 9's avoidable fall on 4/6/25 when she sustained a 1-centimeter (cm-unit of measurement) laceration to the back of her head and required transportation to the emergency department for assessment. Resident 9's wound did not require sutures, and she was transferred back to the skilled nursing facility. Findings: 1. During a concurrent observation and interview on 4/14/25 at 10:17 a.m. with Resident 1 in his room, Resident 1 was lying in bed on his back, his upper body was leaning to the left with his weight against a pillow on the side rail. The bed was against the wall on Resident 1's right side and to the left side there was a landing mat on the floor with an overbed table (portable, adjustable table to be placed beside or over the bed) close to him. Resident 1's left eyebrow had a laceration with sutures and the surrounding area was swollen and discolored. The tip of Resident 1's nose pointed slightly to the left. Resident 1 was alert, able to answer yes or no and speak in single words, but unable to carry on a conversation. Resident 1 was asked if he was comfortable in that position, he stated no and attempted to move his body to the right but was unable to. Resident 1 was asked if he had a fall recently and he replied yes and gestured to the floor. During a review of Resident 1's Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness to one side of body) following cerebrovascular disease (disease affecting the blood flow to the brain) affecting the right dominant side (side of body being preferred for tasks), congestive heart failure (chronic condition where heart muscles is weakened and cannot pump blood efficiently), epilepsy (nerve cell activity in the brain is disturbed causing seizures [burst of sudden electrical activity]), abnormalities of gait (manner of walking) and mobility (ability to move freely), aphasia (a language disorder that affects communication), lack of coordination, abnormal posture, and muscle weakness. During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) was based on staff assessment. Resident 1 was assessed as having a memory problem with severe cognitive impairment related to daily decision making. During a review of Resident 1's Post-Fall Review, dated 4/2/25, the note indicated, . Date and Time of Fall . 4/2/25 15:20 [3:20 p.m.] . Discovered on the floor (Unwitnessed) . Resident found lying on the floor by supervisor. Resident lying prone [face down] position with small cut to left upper side of eyebrow. Resident also noted to have blood on his left shin . Residents complain about pain . paramedics [medical professional who provides emergency care outside of a hospital] were called assisted resident to gurney [a wheeled stretcher] and took resident to hospital . resident unable to tell what he was doing . Continence [ability to voluntarily control bowel (feces) and bladder (urine)] at time of fall . Wet . Soiled . returned to the facility around 0430 [4:30 a.m. on 4/3/25] . discharge diagnosis stated that he has a fracture [break in a bone] to his lt [left] and rt [right] nasal bones . laceration to the lt eyebrow and the wound to the lt shin and they were closed with sutures, 11 to the forehead [eyebrow] and 7 to the lt shin . During a concurrent observation and interview on 4/14/25 at 10:20 a.m. with Resident 1's roommate, Resident 2, Resident 2 stated he had been Resident 1's roommate for about a year. Resident 2 stated the day of Resident 1's fall, Resident 2 was lying in bed and heard a loud bam, then Resident 1's overbed table moved. Resident 2 stated the curtain between their beds was closed but he could see Resident 1 lying on the ground next to Resident 1's bed under the curtain. Resident 2 stated he started yelling for a nurse because Resident 1 could not call for one. During an interview on 4/14/25 at 11:19 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she was taking care of Resident 1 today. CNA 4 stated she was not at work when Resident 1 fell on [DATE]. CNA 4 stated Resident 1 would always lean to the left against the side rail, so the staff kept a pillow between him and the siderail for comfort. CNA 4 stated Resident 1 was paralyzed on his right side and was not able to reposition himself or try to get up, so she was not sure how he fell out of bed over the siderail if it was in the proper position. During a concurrent interview and record review on 4/14/25 at 2:12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 on the day of his fall. LVN 1 stated she was at a nurses meeting when Resident 1 fell and was called to his room. LVN 1 stated when she walked into Resident 1's room, he was lying face down on the floor, between his bed and the overbed table, and his eyebrow was bleeding. LVN 1 stated Resident 1 was physically dependent on two people to change his position, move in bed, and required a mechanical lift (device used to safely lift and transfer patients with limited mobility) to be moved out of the bed into a chair. LVN 1 stated Resident 1 was at risk for falls because of his paralysis and limited mobility. Resident 1's fall risk care plan dated 7/9/2018 was reviewed and indicated, . at risk for falls with injury r/t [related to] CVA [cerebrovascular accident-loss of blood flow to the brain damaging tissue] with hemiplegia and hemiparesis, epilepsy, impaired balance . anticipate and meet [Resident 1's] needs . Encourage resident to keep bed low . Encourage [Resident 1] to participate in activities that promote exercise . Pt [physical therapy] evaluate and treat as ordered or PRN [as needed] . LVN 1 stated Resident 1's issue with positioning and leaning up against the side rail was a known problem, but not addressed in the care plan. LVN 1 stated she was unsure how Resident 1 fell out of bed if the side rail was in the correct position. LVN 1 stated she did not notice what Resident 1's bed height or side rail position was at the time of his fall. During a concurrent interview and record review on 4/14/25, at 2:48 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's fall risk assessment dated [DATE] was reviewed, the assessment indicated, .Based on the answers . is resident at risk for falls . yes . The MDS Section GG-Functional Status, dated 2/8/25 was reviewed and indicated, . Mobility . Roll left and right . code 01 [Dependent-helper does all of the effort . Sit to lying . code 88 [not attempted due to medical condition or safety] . The MDSC stated Resident 1 could not physically reposition himself in bed. During an interview on 4/14/25 at 4:37 p.m. with LVN 2, LVN 2 stated she was the evening charge nurse at the time of Resident 1's fall on 4/2/25. LVN 2 stated Resident 1 was at risk for falls because he had a history of leaning to the left against the side rail in bed and was unable to reposition himself and had a diagnosis of seizures. LVN 2 stated Resident 1 would lean against the side rail to the left because his right side was paralyzed, and he could not use the right side of his body to move back to the center of the bed. LVN 2 stated she did not know how Resident 1 fell over the top of his side rail. During a concurrent observation and interview on 4/14/25 at 4:45 p.m. with CNA 3, in Resident 1's room, CNA 3 stated she was assigned to Resident 1 at the time of his fall on 4/2/25. CNA 3 stated she was in a nearby room and heard Resident 2 yelling for help. CNA 3 stated she ran into the room and Resident 1 was face down on the floor between his bed and the overbed table. CNA 3 stated she could not move Resident 1 because of potential injuries so she yelled for a nurse. CNA 3 stated the Assistant Director of Nursing (ADON) came into the room and stated to not move Resident 1 because of a potential back or neck injury. CNA 3 stated Resident 1 was lying flat on his face, agitated and cursing. CNA 3 stated he had blood on his face, and they left him in that position until the paramedics came and put him on the gurney. CNA 3 stated Resident 1 was a high fall risk because the resident was totally paralyzed on the right side of his body and unable to move it which causes him to slide to the left and lean against the side rail while on his back. CNA 3 stated Resident 1 could not pull himself back to the center of the bed because of his paralysis. CNA 3 stated Resident 1 had an electric bed and had behaviors of putting it up in the high position despite being reminded to keep the bed low. CNA 3 stated she was not sure if Resident 1's bed was in high or low position at the time of his fall. CNA 3 stated Resident 1 sustained a cut to his left eyebrow and left shin. CNA 3 pulled Resident 1's covers back with his permission and a long, jagged laceration was observed on his left shin with a reddish swollen scab above it. During an observation on 4/15/25 at 11:19 a.m. with Resident 1 in his room, Resident 1 was sitting in bed with the head at a 45-degree angle (a semi-sitting position). Resident 1 was lying on his back, leaning to the left against a pillow on the side rail. During an interview on 4/15/25 at 2:01 p.m. with LVN 4, LVN 4 stated Resident 1 preferred to lie on his back and would frequently lean against the side rail. LVN 4 stated Resident 1 was non-compliant with using his call light to ask for help with positioning. During a concurrent interview and record review on 4/15/25 at 2:54 p.m. with the ADON, the ADON stated the nursing staff was in a meeting on 4/2/25 at the time of Resident 1's fall. The ADON stated she was walking in the hall and heard a CNA yell for help. The ADON stated she walked into Resident 1's room and he was lying face down on the floor between his bed and the overbed table. The ADON stated he was bleeding from a laceration to his head, but she could not assess the laceration because she did not want to move the resident in case of a neck or back injury. The ADON stated she was not sure if the side rail was in the proper position or what the height of his bed was. The ADON stated the right side of Resident 1's body was paralyzed, and he frequently leaned to the left against the side rail. The ADON stated Resident 1 had the side rails to assist with turning as much as possible during care and to prevent him from falling out of bed. The ADON stated we cannot stop him from falling. The ADON stated the goal was to try to minimize his fall risk and the risk of injury. The ADON stated the staff would remind him to use his call light and keep his bed in a low position, but she was not sure if he could retain any education provided. Resident 1's care plan was reviewed, the ADON stated there were no care plan interventions addressing the resident lying against his side rails throughout the day and his inability to reposition himself. The ADON reviewed the MDS section GG and stated Resident 1 was dependent on staff for bed mobility. During a concurrent interview and record review on 4/15/25 at 4:25 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had an unwitnessed fall on 4/2/25. The DON stated the IDT (Interdisciplinary Team-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident) was unable to determine the root cause of Resident 1's fall. The DON stated Resident 1 was at high risk for falls. Resident 1's fall risk care plan was reviewed, the DON stated Resident 1's fall prevention interventions prior to his 4/2/25 fall was to anticipate needs, encourage the resident to participate in activities, Restorative Nursing Assistant (RNA-provides rehabilitative care to patients to help regain and maintain the physical functioning and independence) program and encourage the resident to keep the bed in a low position. The DON stated Resident 1 had an electric bed and would put it in the high position by himself. The DON stated she was unsure how high the bed was at the time of his fall. The DON stated she was aware Resident 1 would lean to his left side against the side rails but was unable to locate care plan interventions addressing his positioning. During a telephone interview on 4/16/25 at 9:08 a.m. with the Director of Rehabilitation (DOR), the DOR stated she would screen the residents after falls to see if they would benefit from a therapy evaluation. The DOR stated she screened Resident 1 after his fall, but determined he would not benefit from therapy. The DOR stated Resident 1 was at his maximum potential, dependent on staff for mobility and activities of daily living (basic self-care tasks such as eating, bathing, and mobility). The DOR stated Resident 1 had non-compliant behaviors, would not call for assistance with positioning and had a behavior of putting his electric bed in a high position. The DOR stated Resident 1 had no trunk control and was unable to move himself back to center in bed. The DOR stated Resident 1 would frequently lean to the left in bed, against the side rail. The DOR stated Resident 1 needed two staff to move him back to the center of the bed. The DOR stated the CNAs needed to frequently check Resident 1's position and make sure he was lying in the center of the bed and not leaning to the left because he could not reposition himself. During a review of Resident 1's Change in Condition [CIC] Evaluation, dated 4/14/25, the CIC indicated, . cellulitis left lower leg . MD made aware . Carry out new order . During a review of Resident 1's ACH document titled Discharge Instructions, dated 4/2/25, the document indicated, . Reason for Visit . Fall . Discharge Diagnosis . Head trauma (left sided) . History of CVA with right sided deficit . Hematoma [closed wound with a collection of blood] of left lower leg . Long term current use of anticoagulant [medicine to prevent blood clots] . Fall . Nasal bone fracture . You were seen in the emergency department after sustaining a fall from your bed . you did sustain a fracture of your left and right nasal bones . There is minimal deviation [shift in position] of the bones . follow-up with an ear nose and throat doctor . we were able to repair the lacerations above your left eyebrow and on your left leg . During a review of Resident 1's acute care hospital document titled ED Physician Notes, dated 4/3/25, the document indicated, . Procedure . Laceration repair . 4/2/25 . Laceration 1.9 cm in length. Lower extremity: left . Shape: irregular . Skin closure . sutures . During a review of Resident 1's acute care hospital document titled ED Physician Notes, dated 4/3/25, the document indicated, . Procedure . Laceration repair . 4/2/25 . Laceration 3.2 cm in length. Face: left, eyebrow . Shape: linear . clean, surrounding tissue contused [bruised] . Skin closure . sutures . During a review of Resident 1's ACH document titled Radiology Report, dated 4/2/25, the report indicated, . CT [computed tomography scan- type of imaging that uses X-ray techniques to create detailed images of the body] Maxillofacial [jawbones and the face] [wo [without] Con [contrast] . FINDINGS . Soft tissue swelling/laceration in the left frontal scalp and periorbital [area around the eye] region. Acute minimally displaced [broken bone where the ends are not aligned] leftward deviated fracture of the left nasal bone. Acute nondisplaced leftward deviated fracture of the right nasal bone . During a review of Resident 1's ACH document titled XR [x-ray] Tibia [the shinbone] +Fibula [smaller of the two lower leg bones], dated 4/2/25, the Xray indicated, . INDICATION . fall/dropped at rehab facility . FINDINGS . Diffuse Osteopenia [bones are weaker than normal] . No definite acute fracture . Diffuse soft tissue swelling . During a review of the facility's document titled The 4 P's [Potty, Position, Pain, Placement] of Fall Prevention, undated, the document indicated, . Potty . Does your resident need to use the bathroom . Position . Is your resident in a comfortable position . Pain . Is your resident experiencing any pain . Placement . Are all the items your resident would like placed within reach . During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 2/7/24, the P&P indicated, . Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors . Resident conditions that may contribute to the risk of falls . other cognitive impairment . pain . lower extremity weakness . poor grip strength . medication side effects . functional impairments . Medical factors that contribute to the risk of falls . heart failure . neurological [related to the nervous system] disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce their specific risk factor(s) of falls for each resident . During a review of the facility's P&P titled Safety and Supervision of Residents, dated 1/2024, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Safety risks and environmental hazards are identified on an ongoing basis . When accident hazards are identified, the facility staff shall review the events in an attempt to identify the root-cause and possible associated hazards . When safety risks can not be completely eliminated, such as the risk for falls and related injuries, the facility staff shall develop strategies to mitigate the risk for injuries . Resident supervision is a core component of the approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall targe t interventions to reduce individual risks related to hazards in the environment . Resident supervision is a core component of the approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs . 2. During an observation on 4/14/25 at 11:03 a.m., in the memory care unit, Resident 9 was observed sitting in the activities room. Resident 9 was sitting in a chair with her eyes half closed and appeared drowsy. During an observation on 4/14/25 at 11:05 a.m., the memory care unit outdoor patio was observed. The patio had a cement walkway which led to the main outdoor area for the residents. The main area was enclosed with a fence and the patio consisted of cement walkways and grassy areas. During a review of Resident 9's Admission Record, undated, the admission record indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), dementia (progressive loss of memory and thinking), epilepsy (nerve cell activity in the brain is disturbed causing seizures [burst of sudden electrical activity]), abnormalities of gait (manner of walking) and mobility (ability to move freely), muscle weakness and difficulty in walking. During a review of Residents 9's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 9's BIMS scored 03 of 15. The BIMS assessment indicated Resident 9's cognition was severely impaired. During a review of Resident 9's ACH document titled ED Assessment, dated 4/6/25, the document indicated, . Chief Complaint: Fall . Stated Complaint: GROUND LEVEL FALL/HEAD PAIN . Patient had an unwitnessed fall from a chair onto the ground . sustained a small laceration to the back of her head which does not need repair because of that less than 1 cm wide and is not bleeding . Diagnosis . Fall . Laceration of scalp . During an interview on 4/14/25 with CNA 1, CNA 1 stated she was usually assigned to Resident 9 and was caring for her today. CNA 1 stated she was aware Resident 9 had a recent fall but was not working at the time of the fall. CNA 1 stated Resident 9 had known behaviors of putting herself on the ground and walking around the facility with her eyes closed. CNA 1 stated Resident 9 had sustained a laceration to her head during the fall, but she was unsure if the resident had sutures or not. CNA 1 stated Resident 9 was known to be a high fall risk but would ambulate alone in the hallway and out on the patio. CNA 1 stated when she is outside, we keep an eye on her. CNA 1 stated the staff would check on Resident 9 every 15 to 20 minutes while she was outside on the patio. During a concurrent interview and record review on 4/14/25 at 2:48 p.m. with the MDSC, Resident 9's MDS Section GG-Functional Status, dated 2/17/25 was reviewed. The MDS indicated, . Walk 10 feet . code 05 [Setup or clean-up assistance-helper assists only prior to or following the activity] . Walk 50 feet . code 04 [Supervision or touching assistance] . Walk 150 feet . Code 04 . The MDSC stated Resident 9's MDS indicated she should have supervision to ambulate, and a CNA should always be with the resident when she was ambulating. The MDSC stated supervision during ambulation meant to have contact guard (to provide light guiding contact) from an employee. The MDSC stated Resident 9 should not have been on the patio without staff supervision. The MDSC stated she was familiar with Resident 9 had known behaviors of putting herself on the floor and walking with her eyes closed, increasing her need for supervision. During an observation on 4/15/25 at 11:36 a.m., in the memory care hallway, Resident 9 was observed walking in the hallway independently with her eyes half closed. Resident 9 was confused and unable to engage in conversation. CNA 1 took Resident 9 to her room. During a concurrent interview and record review on 4/15/25 at 2:54 p.m. with the ADON, Resident 9's Change in Condition, (CIC-documentation regarding a significant change from baseline) dated 4/6/25, was reviewed. The CIC indicated, . CNA Notified Charge Nurse that resident was found sitting on the floor outside in station 6 patio. Charge Nurse went to assess resident and noted Resident sitting on the floor with her legs extended out in front of her . The ADON stated Resident 9 had an unwitnessed fall on the memory care patio on 4/6/25. Resident 9's Post-Fall Review, dated 4/6/25 was reviewed, and indicated, . Date and time of fall . 04/06/2025 15:18 [3:18 p.m.] . Discovered on the floor (Unwitnessed) . Outside patio . Resident noted to have cut to her back of head with active bleeding at the incident time. Upon investigation resident had pattern of banging posterior head (backside of the head) on the ground . Root cause: May have Put self on the floor or due to poor safety awareness and impaired mobility due to self-transfer that resulting in her falling. Resident has pattern for laying on her back raise her head and drop it on the ground repeatedly . The ADON stated Resident 9 sustained a laceration to the back of her head and was sent to the ED for assessment, but did not require sutures so she was sent back to the SNF. Resident 9's fall risk care plan, dated 10/19/2019, was reviewed. The care plan indicated, . resident is at risk for falls with injury r/t [related to] epilepsy, anxiety [feeing of worry], difficulty in walking, muscle weakness generalized . resident Throws self on the floor, impaired cognition, poor safety awareness, history of falling . Behavior of walking with eyes closed . Anticipate and meet the resident's ADL care needs . Encourage the use of appropriate footwear . Keep bed in lowest position . PT [physical therapy]/OT [occupational therapy] eval [evaluation] and Tx [treat] as needed . Resident is ambulatory . Walk 10 Feet: Set or clean up assistance . Walk 50 Feet: Supervision or touching assistance . The ADON stated Resident 9 had known behaviors of sitting herself on the ground and walking with her eyes closed. The ADON stated Resident 9's care plan indicated she was supposed to have supervision to walk 50 feet and did not have supervision while on the patio at the time of her fall. The ADON stated the memory care unit patio was further than 50 feet from the memory care unit hallway and she should have had supervision. The ADON stated, we cannot prevent her from falling because of her behaviors. During a concurrent interview and record review on 4/15/25 at 4:25 p.m. with the DON, Resident 9's Post Fall Review, dated 4/6/25, was reviewed. The DON stated Resident 9's fall on 4/6/25 was unwitnessed and happened on the memory care unit's patio. The DON stated Resident 9's MDS dated [DATE], indicated she needed supervision to ambulate more than 50 feet, and the memory care unit hallway was more than 50 feet. The DON stated Resident 9 had dementia (decline in mental ability severe enough to interfere with daily life) and Alzheimer's Disease and was unable to make decisions regarding her safety. The DON stated, we cannot stop her from what she is doing. The DON stated she had been told by staff Resident 9 frequently went out to the patio unsupervised with no issues. The DON stated Resident 9 could go to the patio, but the DON declined to state if Resident 9 needed supervision while she was outside. The DON reviewed Resident 9's fall risk care plan and stated there were no interventions to address her known behaviors of putting herself on the floor until after the fall on 4/6/25. During a telephone interview on 4/16/25 at 9:08 a.m. with the DOR, the DOR stated Resident 9 was started on therapy after her fall on 4/6/25. The DOR stated she did a therapy screen for Resident 9, and she was started on physical therapy. The DOR stated Resident 9 was independent for ambulation indoors but was not safe to ambulate outside on uneven surfaces by herself. The DOR stated Resident 9 needed staff supervision while outside on the patio. During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing, dated 2/7/24, the P&P indicated, . Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors . Resident conditions that may contribute to the risk of falls . other cognitive impairment . pain . lower extremity weakness . poor grip strength . medication side effects . functional impairments . Medical factors that contribute to the risk of falls . heart failure . neurological disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce their specific risk factor(s) of falls for each resident .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for three of six sampled residents (Residents 1, 2 and 6) when: 1. Resident 1 was assessed as being a fall risk, had poor safety awareness and needed to be supervised while ambulating (walking) and the facility did not implement effective interventions to prevent falls, including adequate supervision, consistent with the resident ' s needs, goals and care. This failure resulted in Resident 1 ' s unwitnessed fall on 1/30/25, sustaining a right intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis [bony structure near the base of the spine]), pain, decreased mobility and required transportation to the emergency room and admission to the acute care hospital (ACH) for seven days. 2. Resident 2 had left sided paralysis (loss of movement), a history of falls, poor safety awareness and a known behavior of sitting at the edge of his bed unsupervised and the facility did not implement effective interventions including adequate supervision to meet the resident ' s needs. This failure resulted in Resident 2 ' s four unwitnessed falls: one on 2/15/25, two on 2/20/25 and one on 2/26/25. Resident 1 hit his head during a fall on 2/20/25 at 6:15 a.m. causing a skin tear to his left eyebrow and fell again on 2/20/25 at 9:35 p.m. hitting his head in the same area causing further trauma to the left eyebrow resulting in a laceration (cut or tear in the skin caused by blunt force). Resident 2 required transportation to the emergency room for sutures (threads used to close wounds) to repair the wound. 3. Resident 6 had an assessed need for supervision during transfers, poor safety awareness and a known behavior of self-transferring between her wheelchair and an armchair in the hallway and was left sitting unsupervised in an armchair in the hallway. This failure resulted in Resident 6 ' s unwitnessed fall on 3/5/25, sustaining an intertrochanteric fracture of the right hip, an acute fracture of the right radius (one of two long bones in the forearm, located on the thumb side) and a laceration to her left lower lip. Resident 6 was admitted to the ACH from 3/5/25 until 3/12/25 where she had an open reduction internal fixation (ORIF-surgical procedure to repair broken bones) of the right hip on 3/7/25 and required an arm splint on her right arm. Because of the serious actual harm to Residents 1, 2 and 6 and potential serious harm to Residents 3, 4 and 5 and the serious potential harm to all residents related to the facility's inability to implement an effective program to prevent falls, an Immediate Jeopardy (IJ-a situation in which non-compliance with one or more regulatory requirements has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified at a scope and severity of K (pattern of non-compliance when multiple residents are affected) and an IJ was called on 3/5/25, at 3:49 p.m., under Code of Federal Regulations (CFR) 483.25 (F689) with the facility's Administrator (ADM), Administrator Consultant (ADMC) Director of Nursing (DON), and Director of Nursing Consultant (DONC). The CMS IJ Template was shared with the facility on 3/5/25 at 3:49 p.m. The facility submitted a Plan of Removal (POR) version 1 on 3/6/25 at 10:12 a.m. The POR version 1 was not acceptable. The facility submitted a POR version 2 on 3/6/25, at 3:59 p.m. The IJ POR included: 1) facility added 1:1 support and supervision while awake and will remain in sight of Residents 1 and 2. 2) Staff will assist Resident 2 with stability and balance while sitting on side of the bed to minimize risk for falling. 3) Staff will assist Resident 1 with individual toileting plan including upon waking, before and after meals, before bed and every two hours as needed. 4) Resident 6 will be placed on a 1:1 while awake after she returns to the facility, assist with safe transfers, cueing and provide direct care for impulsive attempts to rise or transfer. 5) Facility identified resident falls for 2025, and IDT reviewed Root Cause (RC) Analysis of accident hazards, supervision and assistive devices to prevent avoidable accidents and have updated care plans with person-centered interventions which will be reviewed weekly by the IDT. 6) Facility increased CNA staffing on stations 5 & 6 during the evening and night shifts as identified during RC analysis for falls. 7) The facility assigns monitor staff daily including each unit supervisor for every 15-minute safety checks on identified residents with falls. 8) The activity department added additional snack and crafts cart and staff support during evening hours for identified high fall risk residents with actual falls. 9) Director of Staff Development (DSD) initiated in-service for direct care staff on each shift with specific focus on resident interventions to reduce falls and injuries from falls. The IJ Plan of Removal Version 2 was accepted on 3/7/25 at 9:15 a.m. While onsite, the surveyors validated the POR implementation action items through observations, interview and record reviews and confirmed that all POR action interventions to address the IJ situation were fully implemented. The IJ was removed on 3/7/25 at 4:03 p.m., with the ADM, ADMC, DON and Director of Staff Development (DSD). After removal of the IJ, the facility remained in substantial non-compliance. Findings: 1. During a review of Resident 1 ' s ACH document titled Case Management Discharge Summary/Orders Report, dated 2/7/25, the note indicated, . admitted : 1/31/2025 . discharge date : 2/7/2025 . Slip and fall coming out of bathroom landing on her right hip . Admission Diagnoses: Intertrochanteric fracture . Procedures . Open Reduction Internal Fixation [surgical procedure that treats intertrochanteric hip fractures] Femur (Right) . During a review of Resident 1 ' s Admission Record (AR) undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of T5-T6 vertebra (a break in the bones in your back that stack up to form your spine part of the vertebra [bones that make up the backbone] collapses), COPD (chronic obstructive pulmonary disease-chronic lung disease causing difficulty in breathing), Chronic respiratory failure (medical condition where the blood has low oxygen [colorless odorless gas essential to life] levels), Parkinsonism (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), abnormalities of gait (persons manner of walking) and mobility, history of falling and muscle weakness. During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 12 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had a moderate cognitive impairment. During a review of Resident 1's MDS Assessment, Section GG-Functional Abilities, dated 1/23/25, was reviewed. The MDS Section GG indicated, .C. lying to sitting on side of bed . code 01 [Dependent (when someone needs another person ' s help to move)] . D. sit to stand . code 88 [Not attempted due to medical condition or safety concerns] . F. Toilet transfer . code 88 . Walk 10 feet . code 09 [Not applicable-Not attempted and the resident did not perform this activity] . During a concurrent observation and interview on 2/12/25 at 9:47 a.m. with Resident 1, Resident 1 was lying in bed, the bed was in the lowest position. Resident 1 had involuntary tremors of her arms and legs. Resident 1 stated she was in pain and pointed to her right hip. Resident 1 stated she had recently fallen in the bathroom and became tearful and visually upset. Resident 1 stated I just fell [on 1/30/25]. During an interview on 2/12/25 at 10:04 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1. CNA 1 stated she had taken care of Resident 1 before her fall on 1/30/25. CNA 1 stated Resident 1 required supervision and touch assistance (caregiver assistance intermittent or continuous touch to help maintain balance during activity) for balance and safety while ambulating to the bathroom before the fall. CNA 1 stated she would stay nearby when Resident 1 was in the bathroom because the resident was a high fall risk and was forgetful. CNA 1 stated Resident 1 would not remember to use the call light and wait for help to go back to bed. CNA 1 stated Resident 1 did not have any fall interventions in place prior to her fall. During an interview on 2/12/25 at 11:31 a.m. with CNA 2, CNA 2 stated she was familiar with Resident 1. CNA 2 stated Resident 1 would not consistently use her call light to request help and would sometimes push the call light and forget she had pushed it blaming it on her neighbor. CNA 2 stated Resident 1 did not have any fall prevention interventions in place prior to the fall on 1/30/25. During a concurrent interview and record review on 2/12/25 at 12:17 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was the unit supervisor. LVN 2 stated Resident 1 had fallen on 1/30/25 and fractured her right hip. Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/30/25 at 4:55 p.m. was reviewed, the SBAR indicated, . Change in Condition/s reported . Falls . Does the resident/patient have pain? Yes . resident was heard yelling out for help. On entering room resident is noted to be on the floor of restroom. Resident is on the floor in-between the door way - facing the door- laying on left side trying to hold herself up with left arm, legs are bent at the knees. Resident is not wearing a brief [absorbent underwear to manager urine leakage], barefoot. When asked how she fell , resident stated she slipped in the restroom when getting out . Provider Notification . Recommendation of Primary Clinician(s) . STAT(urgent) X-ray of the right hip, right femur, right knee, right fibula/tibia (are both bones in the lower leg, with the tibia being the larger, weight-bearing shinbone on the inside of the leg, while the fibula is the smaller bone on the outside, primarily providing stability to the ankle joint) . Pain Status Evaluation . Rate pain on a scale of 0 to 10 (0=no pain, 4-5 moderate pain, 10=excruciating pain) . 8/10 . Acute [sudden sharp pain] . right leg . Resident 1 ' s fall risk care plan dated 1/25/25 was reviewed. The care plan indicated, . The resident is at risk for unavoidable falls . admitted with injury . history of falling . Be sure The resident ' s call light is within reach and encourage (The resident to use it for assistance needed . Ensure that the resident is wearing appropriate footwear (shoes, non-skid socks) when ambulating . LVN 2 stated the SBAR indicated Resident 1 was barefoot when she was found on the floor of her bathroom. LVN 2 stated according to the care plan Resident 1 should have been wearing some sort of nonskid shoes or socks when ambulating and the intervention was not followed. LVN 2 stated care plans were used to identify a resident ' s problem and goals and put interventions into place to meet those goals. LVN 2 stated all residents who were a high fall risk needed the interventions of proper footwear and call light within reach, but each resident should also have person-centered, individualized interventions in place. LVN 2 stated, I had heard she was not good about using her call light. LVN 2 stated Resident 1 ' s interventions did not prevent her fall. LVN 2 stated Resident 1 had a history of falls prior to admission to the facility and was at risk for falls. Resident 1's MDS Assessment, Section GG, dated 1/31/25 was reviewed. The MDS Section GG indicated, .C. lying to sitting on side of bed . code 02 [Substantial maximal assistance] . D. sit to stand . code 01 [Dependent] . F. Toilet transfer . code 02 [Substantial/maximal assistance] . LVN 2 stated the MDS assessment indicated Resident 1 needed substantial help to go into the bathroom prior to her fall on 1/30/25. LVN 2 stated the SBAR and progress notes did not indicate how Resident 1 wound up in the bathroom by herself without staff knowledge. LVN 2 stated Resident 1 should not have been in the bathroom without staff supervision. Resident 1 ' s Radiology Note, dated 1/31/25 at 2:50 a.m. indicated, . Received xray results . MD notified . Resident 1 ' s SBAR, dated 1/31/25 at 3:08 a.m., indicated, . Primary Care Provider responded with the following feedback . May send resident out to hospital for further evaluation . During an interview on 2/12/25 at 3:01 p.m. with CNA 3, CNA 3 stated she was assigned to Resident 1 at the time of her fall on 1/30/25. CNA 3 stated Resident 1 was found on the floor in her bathroom by Registered Nurse (RN) 2. CNA 3 stated she had passed Resident 1 ' s room and heard a commotion and when she walked into the room, Resident 1 was on the floor shouting and there were other staff members with her. CNA 3 stated Resident 1 was in extreme pain which made it was difficult to transfer her back to bed because she would not move. CNA 3 stated Resident 1 was barefoot when they found her in the bathroom after she fell and was not good about wearing nonskid footwear. CNA 3 stated Resident 1 needed help transferring, and she was unsure how she wound up in the bathroom alone. CNA 3 stated when she would take Resident 1 to the bathroom, she always stayed in the room with the door cracked open to make sure Resident 1 did not fall. CNA 3 stated Resident 1 was alert and oriented but forgetful and did not remember to use her call light. During a concurrent interview and record review on 2/12/25 at 3:21 p.m. with the Director of Nursing (DON), the DON stated she was new to the facility and not familiar with Resident 1. The DON reviewed Resident 1 ' s Post-Fall Review, dated 1/30/25, the note indicated, . Date and Time of fall . 1/30/25 16:44 [4:55 p.m.] . Resident is laying on left side . legs are bent at an angle. Resident is not wearing a brief, barefoot . IDT [Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] Review and Summary of Root Cause . IDT met to review the fall that happened . Recommendations . INDIVIDUAL SCHEDULED TOILETING PLAN: Assist resident with toileting at the following times . Pain assessment q [every] shift . Follow up with ortho [orthopedic physician] . Verbal education to wait for staff assistance prior to transfer . IDT Members Participating . ADON [Assistant Director of Nursing . UM [Unit Manger] . Activity . [note signed by DON on 2/12/25 . The DON stated the note did not indicate what the IDT determined to be the root cause of Resident 1 ' s fall. The DON stated, I think she was going to fall anyways, even with those interventions in place. During an interview on 2/12/25 at 4:17 p.m. with the Administrator (ADM), the ADM stated he did not attend the post fall IDT after Resident 1 ' s fall. The ADM was not aware of the specifics of Resident 1 ' s fall and stated anything clinical was the responsibility of the DON and clinical staff. During a telephone interview on 2/13/25 at 9:36 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 had falls before admission to the skilled nursing facility. FM 1 stated Resident 1 was not safe going to the bathroom without help. FM 1 stated she was not sure if Resident 1 had gotten up alone but would have needed help because she was not safe to walk on her own because she had tremors to her arms and legs due to Parkinson ' s Disease. FM 1 stated Resident 1 was very forgetful and would not call the nurses for help. FM 1 stated Resident 1 told her she fell because there was something wet on the floor in the bathroom. During a telephone interview on 2/18/25 at 4:52 p.m. with Registered Nurse (RN) 2, RN 2 stated she found Resident 1 barefoot lying on the bathroom floor and was shouting for help. RN 2 stated Resident 1 required supervision and stand by assistance when ambulating. RN 2 stated Resident 1 would be reminded to use the call light but was forgetful and did not use it. RN 2 stated Resident 1 must have walked to the bathroom by herself. RN 2 stated she did not recall if Resident 1 was in severe pain when found on the floor. Resident 1 ' s SBAR, dated 1/30/25 at 4:55 p.m., written by RN 2 was read to her. The note indicated, . Pain Status Evaluation . 8/10 . Acute . right leg . RN 2 declined to state if Resident 1 had outward signs of severe pain when found on the floor. During a review of Resident 1 ' s PT [physical therapy] Evaluation & Plan of Treatment, dated 1/21/25, the note indicated, . Lower Extremity [legs] . RLE [right lower extremity] = 2/5 [muscle strength grading score on scale of 1-5 (2/5 indicates muscle can move through full range of motion but only with gravity eliminated-considered poor strength)] . LLE [left lower extremity] = 2/5 . Pain with Movement = 9/10 [pain scale-numeric scale 1-10 with 1/10 being no pain and 10/10 being severe pain] . Frequency = Constant . During a review of the facility ' s policy and procedure titled Falls and Fall Risk, Managing, dated 2/7/24, the P&P indicated, . Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors . Resident conditions that may contribute to the risk of falls . other cognitive impairment . pain . lower extremity weakness . medication side effects . functional impairments . Medical factors that contribute to the risk of falls . heart failure . neurological disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce their specific risk factor(s) of falls for each resident . During a review of the facility ' s P&P titled Safety and Supervision of Residents, dated 1/2024, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Safety risks and environmental hazards are identified on an ongoing basis . When accident hazards are identified, the facility staff shall review the events in an attempt to identify the root-cause and possible associated hazards . When safety risks can not be completely eliminated, such as the risk for falls and related injuries, the facility staff shall develop strategies to mitigate the risk for injuries . Resident supervision is a core component of the approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs . 2. During a concurrent observation and interview on 3/4/25 at 11:37 a.m. with Resident 2, Resident 2 was dressed and groomed, sitting in his wheelchair in the hallway, his left arm was flaccid (limp). Resident 2 ' s left eyebrow and forehead were swollen. Resident 2 stated he had a history of a gunshot to the head and surgery which caused his left sided paralysis. Resident 2 stated he had fallen a few times since his admission to the facility (on 2/2/25). Resident 2 stated when he was in bed, he would suddenly become very uncomfortable and need to sit up at the edge of the bed. Resident 2 stated it was difficult for him to balance when sitting at the edge of the bed by himself because of his paralysis and he would doze off and fall forward. Resident 2 stated he had hit his head during each fall, and he fell twice on the same day (on 2/20/25), causing a wound to his left eyebrow. Resident 2 stated during the fall on the morning of 2/20/25, he had sustained a small cut above his eyebrow. Resident 2 fell again on 2/20/25 at night and his wound became a deeper cut and did not stop bleeding, so he was sent to the hospital for sutures. During a review of Resident 2 ' s AR, undated, the AR indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses that included fracture of left acetabulum (break in the hip socket), fracture of sacrum (bone located at the base of the spine), paraplegia (inability to voluntarily move parts of the body), muscle weakness, abnormalities of gait and mobility and repeated falls. During a review of Resident 2 ' s MDS assessment dated [DATE], indicated Resident 2 ' s BIMS assessment scored 07 of 15. The BIMS assessment indicated Resident 2 had a severe cognitive impairment on admission. During a review of Resident 2 ' s ACH document titled ED Provider Notes, dated 2/20/25, the notes indicated, . Two ground level falls today . first fall was this morning . during which he slipped out of bed and struck his head . at 23:30 [11:30 p.m.] he slipped out of his bed once again prompting visit to the ED . he is bed bound . presents for a laceration to the left eyebrow . Lac [laceration] repaired in ED . During an interview on 3/4/25 at 11:55 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was familiar with Resident 2. CNA 2 stated Resident 2 was a high fall risk because he was known to get himself up to the edge of the bed without assistance, had left sided weakness, and a history of falling. CNA 2 stated Resident 2 did not have any fall prevention interventions in place. During a concurrent interview and record review on 3/4/25 at 12:35 p.m. with RN 3, RN 3 stated she was assigned to Resident 2. Resident 2 ' s Change in Condition Evaluation (CIC-documents short term or significant change in resident ' s health or functioning), dated 2/15/25 at 4:40 a.m., indicated, . Resident was yelling for help writer walked in the room and saw patient kneeling on the floor next to his bed . resident stated I fell down, . I was sitting here on the bed and was falling asleep, and I fell forward luckily the wheelchair was in front of me, I think I hit my head on the chair . Resident 2 ' s CIC, dated 2/20/25 at 6:15 a.m. indicated, . Writer heard loud thump when passing medication . Resident was on the floor sitting next to his bed. Upon assessment noted skin tear to Left eyebrow . Resident stated that he was just sitting on the side of the bed and fell asleep. He said he fell forward and hit his head on the bedside table . Resident 2 ' s Post Fall Review, dated 2/20/25 at 10:52 p.m., indicated , . Date and Time of Fall . 2/20/25 . 21:35 [9:35 p.m.] . Resident 2 ' s CIC, dated 2/20/25 at 10:35 p.m., indicated, . Resident stated he was sitting on the side of the bed and fell forward and hit his head on the bedside table . MD [Medical Doctor] notified and transfer to acute hospital . Writer heard some noise in the room . Resident was sitting on the floor right side of bed . resident has a laceration to the left side of forehead noted, bleeding noted . RN 3 stated she took care of Resident 2 on the day shift after his first fall on 2/20/25. RN 3 stated Resident 2 had a skin tear above his eyebrow at that time and did not require sutures. RN 3 stated Resident 2 fell during the evening/night shift report on 2/20/25, hit his left eyebrow again and it became a laceration, so he was sent out to the emergency room for sutures. RN 3 stated Resident 2 had left sided weakness and poor balance which made him a high fall risk. RN 3 stated all of Resident 2 ' s falls happened while he sat unsupervised at the edge of his bed and fell forward to the floor. Resident 2 ' s fall care plan dated 2/4/25 was reviewed, the care plan indicated, . The resident is at risk for unavoidable falls with injury r/t [related to] repeated falls . the resident is (High, Moderate, Low) risk for unavoidable falls with injury r/t limited mobility . Interventions . Anticipate and meet the resident ' s needs . RN 3 stated the care plan was not edited to indicate Resident 2 ' s fall risk level and the intervention to anticipate and meet needs was not specific and person centered. Resident 2 ' s fall care plan dated 2/15/25 indicated, . Had a fall on 2/15/25 . Pain assessment . neuro check . Monitor for delayed trauma . Modification of Bed mobility program . When [Resident 2] is wanting to sit on the side of the bed, staff to encourage activities of choice . monitor every shift for any COC [change of condition] . RN 3 stated she did not know what the bed mobility program was. RN 3 was unable to state how the care plan interventions addressed Resident 2 ' s left sided weakness, balance issues and need for supervision while sitting on the edge of the bed. RN 3 stated Resident 2 needed supervision and assistance to sit safely at the edge of the bed. Resident 2 ' s CIC, dated 2/26/25 at 11:37 p.m. indicated, . writer heard resident calling for help, upon entering room resident was found sitting on floor . abrasion to R [right] knee. Resident state he woke up and fell forward going under side table and hitting face against wall . During a concurrent interview and record review on 3/4/25 at 4:00 p.m. with Minimum Data Set Coordinator (MDSC) 2, Resident 2 ' s MDS assessment Section GG-Functional Abilities, dated 2/8/25 was reviewed. The MDS Assessment indicated, .C. lying to sitting on side of bed . code 01 . D. sit to stand . code 01 . F. Toilet transfer . code 88 . Walk 10 feet . code 88 . MDSC 2 stated the MDS indicated Resident 2 was dependent to sit at the edge of the bed. MDSC 2 reviewed Resident 2 ' s CIC, dated 2/15/25 and stated he was sitting at the edge of the bed and fell forward hitting his head on the wheelchair. MDSC 2 reviewed Resident 2 ' s fall care plan dated 2/4/25 and stated it did not specify if Resident 2 was at high, moderate or low risk for falls and the intervention was to anticipate and meet the resident ' s needs. MDSC 2 stated the intervention was not person centered or effective because it did not prevent his fall on 2/15/25. Resident 2 ' s fall care plan interventions were updated on 2/17/25 to include: encourage non-slip footwear, monitor for delayed trauma, pain assessment, anticipate and meet resident ' s needs, keep bed low, educate about safety and encourage activities. MDSC 2 stated the care plan interventions were not effective because Resident 2 fell twice on 2/20/25. MDSC 2 reviewed both of Resident 2 ' s CIC, dated 2/20/25 and stated both falls happened while Resident 2 sat unsupervised on the edge of his bed. Resident 2 ' s care plan dated 2/20/25 indicated, . Had a fall on 2/20/24 as a result of sitting on the side of the bed then falling asleep resulting in [Resident 2] losing his ability to maintain his stability . Assess pain every shift . Notify MD of fall and laceration . Obtain v/s [vital signs] as needed . ongoing monitoring . Send out to the acute [acute care hospital] . Social services to visit . MDSC 2 stated the interventions did not address the cause of Resident 2 ' s falls or how to prevent a recurrence. Resident 2 ' s care plan dated 2/21/25 indicated, . Persistent to sit on the side of his bed ad lib [as often as desired]. At risk for falling that may cause injury that could result in death. Has poor safety awareness, [Resident 2] has unsteadiness while sitting on the side of the bed and has history of falling asleep causing him the inability to maintain stability . Redirect [Resident 2] while addressing any concerns he may have when he is falling asleep on the side of the bed . Social services to visit . MDSC 2 stated the root cause of Resident 2 ' s need to sit up suddenly without supervision needed to be figured out so effective fall interventions could be put into place. MDSC 2 stated Resident 2 ' s care plans were not person-centered and did not address the amount or frequency of supervision he required. During a concurrent observation and interview on 3/5/25 at 10:00 a.m. with Resident 2, Resident 2 sat in a wheelchair at bedside. Resident 2 stated while in bed he would suddenly become very restless and uncomfortable, so he had to sit up at the edge of the bed frequently. Resident 2 stated he thought his falls were caused by sitting at the edge of the bed and dozing off, unable to use his left arm to catch himself. Resident 2 stated he used the call light to ask for help getting to the edge of the bed, but the staff were slow to respond, and he could not wait. Resident 2 stated, I get anxious and desperate, so I get to the edge of the bed without them. Resident 2 stated the staff would come in quickly after he fell . During a concurrent interview and record review on 3/5/25 at 10:15 a.m. with the Director of Rehabilitation (DOR), Resident 2 ' s physical therapy (PT) evaluation dated 2/3/25 was reviewed. The PT evaluation indicated, . history of gunshot wound to the head requiring an operation with residual [remaining side effects of a condition after it has been treated] L [left] side paralysis . Patient presents with deficits in strength, balance, safety, postural [position of the body] instability . the patient is at risk for: falls and further decline in function . The DOR stated the PT evaluation indicated Resident 2 needed minimal assistance for static sitting (maintain single posture), but he needed help with dynamic sitting (when you move while sitting). The DOR stated Resident 2 had paralysis on the left side of his body and his left arm was flaccid from the gunshot and brain surgery. The DOR stated the left sided paralysis would not improve completely. The DOR stated Resident 2 would always have balance issues and require assistance to sit safely. The DOR stated as soon as Resident 2 moved while sitting, he would fall to the left side which increased his fall risk. The DOR stated she spoke to Resident 2 ' s Responsible Party (RP) and was told he had a history of sitting at the edge of his bed and falling at home. During an interview on 3/5/25 at 10:28 a.m. with the Physical Therapy Assistant (PTA), the PTA stated she worked with Resident 2 daily. The PTA stated Resident 2 fell twice on 2/20/25. The PTA stated she saw Resident 2 after his first fall on 2/20/25 and he told her he sat at the edge of the bed and started to fall asleep, falling forward. The PTA stated Resident 2 was impulsive and was frequently leaning forward, sitting at the edge of the bed unsupervised when she picked him up for therapy. The PTA stated the resident needed supervision to sit at the edge of the bed safely. During a review of Resident 2 ' s Post-Fall Review, dated 2/15/25 at 4:40 p.m., the note indicated, . IDT met to review the incident happened on 2/15/2025 . Root cause: Falling asleep while sitting up. Recommendations: 1. Pain assessment . Neuro check . Monitor for delayed trauma . Modification of bed mobility program . When [Resident 2] is wanting to sit on the side of the bed, staff to encourage activities . signed by the DON on 2/17/25. During a review of Resident 2 ' s Post-Fall Review, dated 2/20/25 at 6:15 a.m., the note indicated, . IDT met to review Resident ' s fall on 2/20/2025 [first fall] . Resident was sitting on the edge of the bed and started to fall asleep. He fell forward and hit his head on the edge of the bedside table. He received a skin tear to his Left Eyebrow with some bleeding . IDT recommends: When Resident is observed at edge of bed assist him to lie down in the bed as he allows . signed 2/20/25 [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of five sampled residents (Residents 2 and 8) and to prevent elopement for one of two sampled residents (Resident 1) when: 1. Nursing staff were aware of Resident 2 ' s decline in functional status, poor safety awareness and need to be supervised while ambulating and failed to assign staff to supervise Resident 2. On 1/2/25 Resident 2 was left unsupervised, and he ambulated unassisted to the outdoor patio where he was found on the ground after an unwitnessed fall. This failure resulted in Resident 2 ' s fall on 1/2/25 sustaining a laceration (cut in the skin caused by an injury) above the left eyebrow requiring transportation to the emergency department (ED) for sutures (a row of stitches holding together edges of a wound) and placed him at risk for emotional distress due to his altered cognitive status (person ' s ability to process and understand information) from dementia (loss of cognitive functioning-thinking, remembering and reasoning). 2. Nursing staff were aware of Resident 8 ' s severe cognitive impairment, poor safety awareness and failed to implement effective supervision to prevent a history of falls. These failures resulted in Resident 8 suffering avoidable falls on the following dates: 10/13/24, 12/20/24, 12/29/24, 1/1/25, and 1/8/25 and placed the resident at risk of injury. 3. Facility staff were aware of Resident 1 ' s exit seeking behavior and high risk of elopement and failed to implement effective measures and assistive devices to prevent elopement. On 12/15/24 the elopement detection device failed to function and alarm and Resident 1 eloped undetected and unsupervised. This failure resulted in Resident 1 leaving the facility after dark into the surrounding neighborhood until a neighbor called the police who found the resident alone and confused placing Resident 1 at risk for injuries from cold exposure, being hit by a car or physical attack. Findings: 1. During an observation on 1/6/25 at 11:33 a.m. in the activities room, Resident 2 sat in a chair. Resident 2 had a sutured laceration above the left eyebrow with yellowish discoloration around the left eye. Resident 2 was confused and unable to verbalize what happened to his eye. During a review of Resident 2 ' s Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, epilepsy (nerve cell activity in the brain is disturbed causing seizures [burst of sudden electrical activity]), muscle weakness, and difficulty in walking. During a review of Residents 2 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 2 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 06 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2 ' s cognition was severely impaired. During a review of the Acute Care Hospital (ACH) document titled, Clinical Notes, dated 1/2/25, the note indicated ( . patient is a 67 y.o. [year old] male . presents to the ED [emergency department] after fall. Per skilled nursing facility, patient had an unwitnessed ground level fall outside . Left eyebrow laceration was repaired . follow up for wound check and suture removal . During an interview on 1/6/25 at 11:35 a.m. in the memory care unit hallway with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 2 ' s health had been declining since early November 2024. CNA 2 stated Resident 2 required supervision to ambulate (walk) safely. During a telephone interview on 1/7/25 at 4:48 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated she was on duty 1/2/25 when Resident 2 fell . LVN 7 stated Resident 2 had an unwitnessed fall on the patio outside and was found face down on his stomach. LVN 7 stated when Resident 2 was assessed, he had a bleeding laceration above his left eyebrow and was sent to the hospital by ambulance. LVN 7 stated Resident 2 ' s fall may have been prevented if he had been supervised by staff at the time of the fall. During a concurrent observation and interview on 1/8/25 at 10:45 a.m. with CNA 6 in the memory care unit activities room, Resident 2 had a laceration above his left eyebrow with yellowish discoloration around the eye. Resident 2 would suddenly stand up on his own and CNA 6 would redirect him to sit down. CNA 6 stated he required close monitoring because he was unsafe to ambulate alone. CNA 6 stated Resident 2 ' s functional and health had been declining since early November and he required supervision because his ability to ambulate fluctuated throughout the day. CNA 6 stated she was on duty when Resident 2 fell on [DATE]. CNA 6 stated at lunchtime on 1/2/25 she saw two nurses walk out to the patio and Resident 2 was found on the ground with a bleeding cut above his left eyebrow. CNA 6 stated the memory care residents did not require constant supervision on the outside patio because the staff would check on them every 10-15 minutes. CNA 6 stated the staff was busy passing out lunch trays and had not noticed Resident 2 was not in the dining room at his usual time. The memory care outdoor patio was observed, the exit door was heavy to open and there was a slight incline at the building entrance. CNA 6 showed where Resident 2 was found on the ground near the entrance door to the facility and stated she was not sure why he fell . During an interview on 1/8/25 at 11:11 a.m. with CNA 7, CNA 7 stated at the beginning of December the CNAs noticed the resident started to walk bent forward with a shuffling gait (walking pattern where someone drags their feet). CNA 7 stated Resident 2 needed supervision to ambulate safely because his gait made him unsteady and the staff was concerned, he would fall forward while ambulating. CNA 7 stated while she passed lunch trays on 1/2/25 she heard a nurse say Resident 2 fell outside. CNA 7 stated Resident 2 was found on the ground with blood above his left eyebrow. CNA 7 stated the residents were allowed to be on the outside patio without direct supervision because the staff would check on them frequently. During an interview on 1/8/25 at 11:41 a.m. with CNA 8, CNA 8 stated she was assigned to Resident 2 at the time of his fall on 1/2/25. CNA 8 stated Resident 2 would frequently walk to the patio by himself. CNA 8 stated Resident 2 ' s health and activities of daily living (ADL-skills to care for oneself such as eating, bathing and mobility) abilities had declined since the beginning of November. CNA 8 stated, he needs more assistance with everything. CNA 8 stated during lunch on 1/2/25 Resident 2 was outside on the patio, she told him to come in for lunch and left the resident unsupervised on the patio. CNA 8 stated she did not walk Resident 2 back inside because he would normally come back into the facility by himself. CNA 8 stated Resident 2 fell before he reached the door. CNA 8 stated Resident 2 had episodes of leaning forward with a shuffling gait when he walked, so he required supervision to ambulate safely. CNA 8 stated, he must have had one of those episodes [on the patio] and fell . CNA 8 stated she left Resident 2 on the patio because she could not leave the dining room unattended and thought he would come back into the building on his own. CNA 8 stated Resident 2 did not have the mental capacity to call for help which increased the need for supervision. During a concurrent interview and record review on 1/8/25 at 2:42 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 2 ' s health had declined since early November 2024, and he required supervision for safety. RN 1 stated Resident 2 had episodes of leaning forward with a shuffling gait which increased his fall risk and need for supervision. Resident 2 ' s care plan dated 11/2/24 was reviewed, the care plan indicated, . Resident c/o lower back pain, headache and unsteady gait . RN 1 stated the care plan indicated Resident 2 ' s gait had been unsteady gait since 11/2/24. Resident 2 ' s Post-Fall Review, (PFR) dated 1/2/25 was reviewed. The PFR indicated, . Date and Time of Fall . 1/2/25 13:20 [1:20 p.m.] . Discovered on the floor (Unwitnessed) . Went outside to give the resident his medication. CNA called for him to come in to eat his lunch. Resident was taking long time to come in so I went to go check outside. Found resident lying face down on the floor with a laceration to his eyebrow . describe location where resident was found . outside on dementia patio . Was resident using assistive device for ambulation or transfer . no . IDT [Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] Review and Summary of Root Cause . 1/2/2025 IDT met to review regarding resident ' s fall obtaining a laceration on his R [right] eyebrow and was send to hospital per physician ' s order . Resident has a poor safety due to poor cognition, adverse effects of medication . IDT recommendations . Continue on PT & OT . PT with recommendations to use a wheelchair for resident ' s mobility . Put resident bed in low position . RN 1 stated Resident 2 should have been supervised when ambulating and all residents from the memory care unit should be supervised while on the patio. Resident 2 ' s fall care plan dated 11/2/24 was reviewed. RN 1 stated she was unable to find a fall risk assessment performed after Resident 2 ' s fall on 12/13/24 and 1/2/25. RN 1 stated the facility did not perform fall risk assessments before and after falls. During a concurrent interview and record review on 1/8/25 with Minimum Data Set Coordinator (MDSC) 1, Resident 2 ' s MDS was reviewed. MDSC 1 stated Resident 2 had a change in condition MDS on 12/31/24 because his health and function had declined significantly. MDSC 1 stated his decline was in cognition, bowel and bladder and ambulation. MDSC 1 stated Resident 2 ' s quarterly MDS had been completed on 11/23/24. The MDS Section GG was reviewed, MDSC 1 stated the MDS indicated he was independent with ambulation. Resident 2 ' s care plan for pain and unsteady gait dated 11/2/24 was reviewed. MDSC 1 stated the care plan indicated Resident 2 had poor balance and she would have expected the 11/23/24 MDS to be coded as needing supervision with ambulation. MDSC 1 stated Resident 2 ' s care plan indicated was unsteady when walking and he would have required supervision for safety. During a concurrent interview and record review on 1/9/25 at 11:05 a.m. with LVN 8, Resident 2 ' s electronic medical record (EMR) was reviewed. LVN 8 was unable to locate Resident 2 ' s fall risk assessment and stated the facility did not utilize fall risk assessments. LVN 8 stated fall risk assessments were important to determine how high of a fall risk a resident was so appropriate interventions could be put in place. LVN 8 stated memory care residents would frequently go to the patio unsupervised. LVN 8 stated Resident 2 was at high risk for falls because of his medications, impaired cognition and decline in functional abilities and was not safe on the patio unsupervised. During a concurrent interview and record review on 1/9/25 at 2:30 p.m. with the Director of Nursing (DON), Resident 2 ' s care plan dated 11/2/24 was reviewed. The DON stated the care plan indicated Resident 2 ' s health and function was declining, and he was not safe to ambulate without assistance. The DON stated Resident 2 had dementia and did not have the capacity to understand to call for help. The DON stated Resident 2 was not safe on the patio without supervision and his fall on 1/2/25 could have been prevented if the CNA walked him back into the building for lunch. During a review of Resident 2 ' s Physical Therapy Treatment Encounter Note(s), dated 12/31/24, the note indicated, . Pt [patient] appeared seated on bench . Provided pt gait training with FWW [front wheeled walker] . without AD [assistive device], [NAME] [maximum assistance] . Pt demonstrates unsafe navigation of AD, Pt appeared falling over multiple times, requiring [NAME] for balance recovery . During a review of the facility ' s policy and procedure titled Falls and Fall Risk, Managing, dated 3/2018, the P&P indicated, . Based on previous evaluations and current data the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Fall Risk Factors . Resident conditions that may contribute to the risk of falls . other cognitive impairment . lower extremity weakness . medication side effects . functional impairments . Medical factors that contribute to the risk of falls . neurological disorders . balance and gait disorders . implement a resident-centered fall prevention plan to reduce their specific risk factor(s) of falls for each resident . During a review of the facility ' s P&P titled Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Safety risks and environmental hazards are identified on an ongoing basis . When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) . Employees shall be trained on potential accident hazards and demonstrate competency . and try to prevent avoidable accidents . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . 2. During an observation on 1/8/25 at 3:23 p.m., in Resident 8 ' s room, Resident 8 was dressed, lying in bed. Her bed was in the low position with no fall mats at the bedside. During a review of Resident 8 ' s AR, undated, the AR indicated, Resident 8 was admitted to the facility on [DATE] with diagnosis including encephalopathy (disturbance of brain function), cerebral infarction (blood flow to brain is disrupted), dementia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), muscle weakness, abnormalities of gait (manner of walking) and mobility and repeated falls. During a review of Residents 8 ' s MDS assessment dated [DATE], indicated Resident 8 ' s BIMS scored 03 of 15. The BIMS assessment indicated Resident 8 ' s cognition was severely impaired. During an interview on 1/8/25 at 3:53 p.m. with CNA 10, CNA 10 stated she was assigned to Resident 8. CNA 10 stated Resident 8 was a high fall risk because she had dementia and would stand without assistance. CNA 10 stated interventions such as redirecting the resident or reminding to use the call light were not successful because the resident was confused and was unable to remember instructions. During a concurrent interview and record review on 1/8/25 at 3:50 p.m. with MDSC 1 and MDSC 2, Resident 8 ' s MDS was reviewed. MDSC 2 reviewed Resident 8 ' s MDS section GG and stated Resident 8 was wheelchair bound. MDSC 2 stated Resident 8 required maximum assistance from the CNAs for care and mobility due to safety awareness, wheelchair bound and low cognition. During a concurrent interview and record review on 1/9/25 at 11:05 a.m. with LVN 8, Resident 8 ' s EMR was reviewed. LVN 8 was unable to locate Resident 8 ' s fall risk assessment or a fall risk score. LVN 8 stated Resident 8 had severely impaired cognition and interventions such as reminding to use call light or call for help were not effective because she was unable to remember. Resident 8 ' s falls since 10/6/24 were reviewed and were as follows: 10/13/24- found on floor next to bed. 12/20/24- found on floor next to bed. 12/29/24-found on floor next to bed. 1/1/25- found on floor next to bed. 1/8/25- found on floor next to bed. LVN 8 stated Resident 8 ' s falls happened while she was in bed. LVN 8 reviewed Resident 8 ' s care plan dated 3/23/24, the care plan indicated, . resident is (high) risk for unavoidable falls with injury r/t [related to] limited mobility, Deconditioning [decline in physical function as a result of physical inactivity] and has history of falls, poor safety awareness d/t [due to] DX [diagnosis] Dementia, hx [history of] multiple falls, non-compliance, impulsive behaviors . Interventions . Toileting scheduled . Keep in visual areas . IDT Recommends . Keep Resident in visual areas when not in bed . Continue with therapy . Be sure The resident ' s call light is within reach and encourage to use it for assistance . Increase monitoring of resident . Increase supervision specially [especially] when up in wheelchair and put resident at the nurse ' s station where other staff can supervise resident . LVN 8 stated Resident 8 ' s falls happened while she was in bed and the interventions of keeping the resident in visual areas, increased monitoring when up in wheelchair would not address the cause of her falls which happened while she was in bed unsupervised. LVN 8 stated Resident 8 needed supervision when in bed to prevent her falls. During an observation on 1/9/25 at 12:54 p.m. in Resident 8 ' s room, Resident 8 was lying in bed, dressed, the head of bed was elevated to a 45-degree angle and her lunch on the bedside table in front of her. There were no staff members present in the room. Resident 8 had both feet hanging off the edge of the bed and her body was lined up at the edge of the bed almost hanging off. During an interview on 1/9/25 at 1:45 p.m. with the DON, the DON stated Resident 8 was a high fall risk and the facility could not prevent her falls. Resident 8 ' s fall care plan dated 3/23/24 was reviewed. The DON stated the IDT updated the care plan after each fall. The DON stated some interventions were not appropriate for Resident 8 due to her cognitive impairment. The DON stated the intervention of increased monitoring indicated she needed more supervision. The DON stated the staff would put her in a visible area if there was no one with her. The DON reviewed the list of Resident 8 ' s five falls between 10/13/24 and 1/8/25. The DON stated the falls occurred when she was in bed unsupervised, and she would need one on one supervision while in bed to prevent falls. During a review of a professional reference located at https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html titled Module 3: Falls Prevention and Management, dated 10/2014, the reference indicated, . An important job for licensed nurses is to assess residents ' risk of falling. This is best done using a protocol or instrument that asks the licensed nurse to look at or test several features about the residents . Implement an individualized care plan . nursing should add an individualized approach for falls to the resident ' s care plan . An individualized care plan for falls is not a one-time solution. Licensed nurses and other staff must revisit the plan to make sure it is effective in preventing additional falls and injuries from falls . 3. During a review of Resident 1 ' s Health Status Note, dated 12/15/24, the note indicated, . At 1900 [7:00 p.m.], received a phone call to facility phone that one of facility ' s resident is outside around south A street . at 1910 [7:10 p.m.], Police Officers brought resident back to facility in wheelchair . Per officer ' s statement, A house owner called the [NAME] police department around 1844 [6:44 p.m.] that he was at their house outside, confused . Resident ' s Wander guard [system that alarms (sound notifying staff) when a resident with a Wander guard bracelet (signaling detection device) attempts to exit a door with a Wander guard alarm] checked, noted to be not working properly . During a concurrent observation and interview on 1/6/25 at 10:13 a.m. in Resident 1 ' s room, Resident 1 was dressed, lying in bed. Resident 1 was confused and unable to remember leaving the facility on 12/15/24. Resident 1 stated, it sounds like something I would do. Resident 1 had a wander guard alarm bracelet on his right ankle. During an interview on 1/6/25 at 10:17 a.m. with CNA 1, CNA 1 stated Resident 1 was sometimes verbally aggressive and difficult to redirect. CNA 1 stated Resident 1 had behaviors of wandering around the facility. CNA 1 stated after Resident 1 ' s elopement on 12/15/24, a wander guard bracelet was also placed on his wheelchair. During a review of Resident 1 ' s AR, undated, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including cerebral aneurysm (bulge in a weakened artery wall), dementia, mood disorder (mental health condition), muscle weakness, abnormalities of gait and mobility and need for assistance with personal care. During a review of Residents 1 ' s MDS assessment dated [DATE], indicated Resident 1 ' s BIMS scored 03 of 15. The BIMS assessment indicated Resident 1 ' s cognition was severely impaired. During a concurrent interview and record review on 1/6/25 at 3:19 p.m. with LVN 2, Resident 1 ' s Post-Event Review, dated 12/15/24, indicated, . Date and Time of Event . 12/15/2024 19:00 [7:00 p.m.] . describe event . Elopement . IDT Summary Review and Recommendations . Resident was successfully eloped 12/15/24 . Based on interview and investigation IDT determined that there is a malfunctioning of the resident ' s wander guard and after incident resident was assessed by LN . a new functioning wander guard was replaced immediately . Resident is at risk for elopement . LVN 2 stated Resident 1 would wander and exit seek when he had episodes of agitation. LVN 2 stated Resident 1 ' s wander guard should be checked for placement and function every shift. LVN 2 stated the facility tested Resident 1 ' s wander guards by taking him to a wander guard alarmed door and check if the alarm sounded when the resident was near it. During a concurrent interview on 1/6/25 at 3:39 p.m. with the DON and Assistant Director of Nursing (ADON), the DON stated the root cause of Resident 1 ' s elopement was his wander guard was not working, he left the building and got lost. The ADON stated the wander guards needed to have placement and function checked every shift. The DON stated if the wander guard was on the resident without checking the function it would be useless. During a telephone interview on 1/7/25 at 4:13 p.m. with LVN 6, LVN 6 stated she was on duty when Resident 1 eloped on 12/15/24. LVN 6 stated shortly after she had returned from lunch at 6:45 p.m., they received a call there was a resident outside. LVN 6 stated the staff went outside the facility on A street and the police were bringing Resident 1 back to the facility in a wheelchair. LVN 6 stated she had last seen Resident 1 about an hour before the police brought him back. LVN 6 stated Resident 1 had a wander guard on when he eloped and when he was brought back into the building, the wander guard door alarm did not go off and they realized his wander guard bracelet was not working. LVN 6 stated she had not checked Resident ' s 1 wander guard for function before he eloped. During a concurrent observation and interview on 1/8/25 at 2:01 p.m. with the Director of Maintenance (DOM), the DOM stated the facility had three doors armed with a wander guard system. The DOM stated the wander guard was a system to prevent elopements. The DOM stated he checked the doors alarmed with wander guard alarms for function every Friday. The DOM stated the A street door alarm was working the Friday before Resident 1 eloped. During an interview on 1/8/25 at 4:21 p.m. with the DON, the DON stated his expectation was for the residents ' wander guards to be checked for placement and function every shift. The DON stated the facility nurses checked the wander guards by taking the resident wearing the wander guard to an alarmed door and check if the wander guard detection alarm goes off. The wander guard manufacturer instructions provided with each wander guard was reviewed. The instructions indicated, .Resident Wristband Transmitter . Testing . It is very important to test your Resident Wristband Transmitters on a regular basis. It is the facility ' s responsibility to implement a regular testing procedure . Take Door System Tester . pass tester within proximity of resident wearing Resident Wristband Transmitter . The DON stated the facility did not have a wand to test the wander guards, so they took the residents to an alarmed door. During a telephone interview on 1/9/25, at 9:14 p.m., with the Wander Guard Vendor (WGV), The WGV stated according to manufacturer ' s guidelines, the correct way to test the wander guard was to take a handheld testing device to the resident. The WGV stated once the wrist band is properly activated it was good for six months. During a review of the document supplied by the WGV, the document indicated, . Cordless and wireless systems and devices are intended as an adjunct to good care giving practices and are not a substitute for proper staffing and patient management practices. We recommend that all caregivers receive periodic training in the operation of these systems and that the devices are tested daily . the system is not designed to replace good caregiving practices including, but not limited to . Direct patient supervision . Adequate training for staff . Testing the system before each use . Failure to comply with the warning may result in injury or death . This device is not a substitute for visual monitoring by a caregiver . During a concurrent interview and record review on 1/9/25 at 1:45 p.m. with the DON, the document provided by the WGV was reviewed. The DON stated the instructions indicated there should be a portable device to take to the resident to test the wander guard and the facility was not following the manufacturer ' s guidelines by taking the resident to the door. During a review of the facility ' s P&P titled Wandering and Elopements, dated 3/2019, the P&P indicated, . facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . If identified as at risk for wandering, elopement . resident ' s care plan will include strategies and interventions to maintain resident ' s safety . if a resident is missing initiate the elopement/missing resident emergency procedure . When the resident returns to the facility . examine the resident for injuries . document relevant information in the resident ' s medical record .

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was provided treatment and care in accordance with professional standards of practice when nurses did not act on the deterioration of Resident 1's physical condition, which included Congestive Heart Failure (is a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen) and edema (swelling caused by too much fluid trapped in the body's tissues) and weight gain. Facility staff failed to provide the necessary treatment, personalized plan of care, nutritional support, and the facility's Interdisciplinary team (IDT) did not collaborate to address the resident's critical medical needs. These failures resulted in Resident 1's transfer to the emergency department (ED) and admission to the acute care hospital (ACH) for a right foot infection with erythema (reddening of the skin), desquamation (shedding the outer layers of skin) and sepsis (a life-threatening medical emergency caused by the body's extreme response to an infection) caused by pitting edema (when excess fluid builds up in the body causing swelling and when pressure is applied to the area it causes a pit measured on a scale from 1+ [least] to 4+ [most]) to her bilateral lower extremities (lower legs) and a ruptured blister to the right foot. The right foot infection and sepsis contributed to Resident 1's death on [DATE]. Findings: During a review of Resident 1's Admission Record (AR-a document containing resident demographic information and medical diagnosis), undated, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included congestive heart failure (CHF-heart does not pump enough blood to meet the body's needs), severe protein-calorie malnutrition (nutritional deficiency), iron deficiency anemia (a lack of iron in the body), and atrial fibrillation (irregular heart rhythm). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (mental process) and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 13 (a score of ,d+[DATE] indicates cognitively intact, ,d+[DATE] indicates moderately impaired, ,d+[DATE] indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Medical Provider Note, dated [DATE] at 6:17 p.m., written by Resident 1's Physician (PHY), the note indicated, . History and Physical . Patient is admitted for rehab s/p [status post] recent hospitalization for CHF . Extremities: no edema . decreased peripheral pulses (impaired blood flow) . CHF: Monitor for fluid overload (too much fluid in the body) . During a review of Resident 1's ACH document titled H&P [history and physical], dated [DATE] at 9:56 p.m., the H&P indicated, . Assessment/Plan . Acute [severe and sudden onset] right foot infection . with erythema and desquamation, pitting edema up to the ankle . given 1 dose of antibiotics [medicines that fight bacterial infections] in the ER [emergency room ] though family decided comfort care [end-of-life medical treatment] . new onset A-fib [atrial fibrillation] with RVR [rapid ventricular response-rapid contractions of the ventricles (lower chambers of the heart)] likely secondary to severe dehydration [condition when the body loses too much water and other fluids] and sepsis secondary to problem #1 [foot infection] . Very malnourished [diet does not contain the right amount of nutrients] and cachectic [physical loss of weight and muscle mass due to disease] with history of dementia [impaired ability to remember, think or make decisions] . Chief Complaint . Wound Infection . BIBA [brought in by ambulance] from [name of facility] with right foot infection X 2 weeks . presents to the ED (Emergency Department) for evaluation of Wound Infection . the SNF [skilled nursing facility] reported that the infection has been present for about 2 weeks . gotten worse over the last couple days . does have a history of severe malnourishment . past medical history . CHF . physical exam . severely malnourished and cachectic, appears to be in significant pain with any movement of the right lower extremity . Cardiovascular [relating to heart and blood vessels] . Tachycardia [rapid heart rate] . Skin . Right foot infection with erythema and desquamation, pitting edema up to the ankle . unable to palpate (examine by touch) DP [dorsalis pedis-upper surface of the foot] pulse secondary to edema . During an interview on [DATE] at 12:07 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 while she was in the facility. CNA 1 stated Resident 1 was very thin, and the staff would turn her every two hours because her weight made her a high risk for skin breakdown. CNA 1 stated Resident 1 had a lot of swelling in her lower legs, and staff would try to elevate her lower legs, but she was not compliant. During an interview on [DATE] at 12:41 p.m. with CNA 2, CNA 2 stated, she [Resident 1] was really skinny. CNA 2 stated she remembered Resident 1 because her lower legs were really swollen, and she would not keep her feet elevated. During an interview on [DATE] at 12:54 p.m. with CNA 3, CNA 3 stated she was familiar with Resident 1. CNA 3 stated Resident 1's feet were really swollen and pinkish while she was at the facility. CNA 3 stated Resident 1's legs were really big for a little skinny lady. CNA 3 stated Resident 1 had supplement drinks ordered for nutrition, but she usually refused them. During a telephone interview on [DATE] at 2:24 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was familiar with Resident 1 and was the charge nurse on [DATE] when she was transferred to the hospital. LVN 1 reviewed Resident 1's electronic medical record (EMR) and stated Resident 1 had a weight gain of 6 pounds (lbs.- unit of measurement) between admission and [DATE]. Resident 1's Change in Condition, (CIC) dated [DATE] was reviewed. LVN 1 stated the CIC indicated Resident 1 had a new onset of edema to her bilateral lower extremities. LVN 1 was unable to answer why it was important to monitor residents with CHF for weight gain and/or edema. During a concurrent telephone interview and record review on [DATE] at 2:56 p.m. with the Director of Nursing (DON), Resident 1's weight measurements were reviewed. Resident 1's weights were: [DATE] - 83 lbs. [DATE] - 84 lbs. [DATE] - 86 lbs. [DATE] - 89 lbs. (6.74 % gain since [DATE]) The DON stated Resident 1's weight had increased six pounds between her admission on [DATE] and [DATE], which is a weight gain of more than 5%. The DON stated a weight gain of more than 5% in less than one month would be considered significant and was a change in condition. The DON reviewed Resident 1's Change in Condition, dated [DATE], the CIC indicated, . Signs & symptoms identified Edema in both feet Started on . [DATE] . Date and time of clinician notification . [DATE] 14:30 [2:30 p.m.] Recommendation . Furosemide Oral Tablet 20 MG . The DON stated Resident 1's CIC indicated the physician was notified of the edema but was unable locate documentation indicating the provider was notified of her weight gain. The DON stated Resident 1's weight gain and edema was considered a change in condition. The DON stated the facility's IDT normally met and discussed any residents with a change in condition, but they did not meet regarding Resident 1's weight gain and edema. The DON stated IDT meetings were important to discuss the changes in condition, identify the causes and make recommendations for care. During a concurrent interview and record review on [DATE] at 12:14 p.m. with the Nurse Practitioner (NP), the NP stated she saw Resident 1 on [DATE] for edema to her bilateral lower extremities. The NP stated she was not notified Resident 1 had a six-pound weight gain between [DATE] and [DATE]. The NP stated Resident 1's CHF could have caused the six-pound weight gain from fluid retention (body is unable to maintain fluid levels) and edema in her legs. The NP reviewed Resident 1's EMR and stated she prescribed Resident 1 furosemide (a diuretic medication- used to reduce extra fluid in the body) 20 mg (milligrams-unit of measurement) twice daily for 10 days for the edema. The NP stated she evaluated Resident 1 after 10 days and the resident continued to have edema, so she ordered to continue the diuretic, elevate her feet, and place TED (thromboembolic deterrent-prevent blood clots) hose (compression stockings to help maintain blood circulation and decrease the odds for severe swelling) on the resident. The NP reviewed Resident 1's Order Summary Report [OSR], and stated she was unable to locate an order for the TED hose. The NP stated she had given the nurse an order verbally and was unsure why it was not entered. Resident 1's progress notes written by the NP were reviewed. The progress notes dated [DATE], [DATE], [DATE], indicated, . Pitting edema 3 + to to [sic] bilateral lower extremities noted with SOB [shortness of breath-intense tightening in the chest] with activity . The NP stated she thought Resident 1 had probably finished physical therapy before her visits which may have caused the SOB. Resident 1's NP progress note dated [DATE] indicated . cardiovascular . Edema 3+ to bilateral lower extremities . Respiratory . non-labored respirations . Assessment/Plan . ted hose application for bilateral lower extremities . may elevate bilateral feet with pillows for fluid retention . Resident 1's NP progress note dated [DATE] indicated . Addendum . Change furosemide 40 mg BID [twice daily] for 10 days . The NP stated she added the addendum because she had forgotten to document she increased the furosemide because Resident 1 continued to have edema to her extremities. Resident 1's edema care plan was reviewed, the care plan indicated, . Focus . edema in both feet . Goal . resolve without complication . Interventions . elevate feet . Furosemide Oral Tablet 20 MG . Notified RP [responsible party], NOTIFY MD [doctor] . The NP stated, there should have been more interventions to improve edema. During a concurrent interview and record review on [DATE] at 1:29 p.m. with LVN 1, Resident 1's CIC dated [DATE] at 2:08 p.m., written by LVN 1 was reviewed. The CIC indicated, . Charge [nurse] noticed that resident has edema in both feet. Upon assessment resident denies any pain or discomfort, respiration even and unlabored. Vitals stable and skin intact. Laydown the resident in bed, put pillow under both feet . Plain [plan] of care going on . cardiovascular Status Evaluation . Is a cardiovascular assessment relevant to the change in condition . Not clinically applicable . Is a skin assessment relevant to the change in condition . not clinically applicable . LVN 1 stated Resident 1 had edema in both feet and the skin was intact on [DATE]. LVN 1 stated Resident 1 had a diagnosis of CHF with edema and the CIC should include cardiovascular and skin assessments as part of the CIC. Resident 1's CIC dated [DATE], at 3:48 a.m., was reviewed. The CIC indicated, . Signs and Symptoms Identified . edema in both feet, and blister pooped [popped] on right foot and weeping . resident has edema on both feet CNA informed this writer while ADL (Activities of Daily Living) care resident left foot is weeping, this writer did assessment resident have blisters on right foot blisters popped and watery discharge coming out . LVN 1 stated she was the day shift charge nurse on [DATE]. LVN 1 would not answer if the night nurse had communicated the change in condition to her during shift change report that Resident 1's blisters had popped, and her feet were weeping. Resident 1's CIC dated [DATE] at 3:35 p.m., written by LVN 1, was reviewed. The CIC indicated, . change . Edema to both feet/ popped blister to edema site . started on [DATE] . what time of day did this start? . morning . resident has edema on both feet treatment nurse informed this writer while doing treatment that resident left foot is weeping, this writer. Did assessment resident have blisters on right foot blisters pooped [sic] and water discharge coming out . foot covered with dressing, and put pillows under the foot to elevate, placed call MD, MD stated that transfer resident to hospital for further assessment . Were the change in condition and notifications reported to primary care clinician . yes . cardiovascular Status Evaluation . Is a cardiovascular assessment relevant to the change in condition . Not clinically applicable . Is a skin assessment relevant . Not clinically applicable . additional pertinent diagnosis . CHF . LVN 1 stated Resident 1 had blisters caused by the edema to both feet and she had documented which foot incorrectly as the left foot, but the blister had popped on the right foot. LVN 1 stated Resident 1's left foot blister was resolving. LVN 1 stated the CIC process was to complete the CIC note, call the physician, responsible party, progress note, start 72-hour charting and update the care plans. Resident 1's edema care plan, dated [DATE] was reviewed, LVN 1 stated the care plan should have been updated [DATE] when her blisters had popped and there was a CIC. LVN 1 stated the care plan did not have personalized interventions, which should have included care for the blisters and weeping to the lower extremities, weighing the resident frequently and to apply a dry dressing for the weeping. LVN 1 stated Resident 1's care plan should have included the interventions from the physician orders, such as a fluid restriction and I&Os (intake and output-measurements of fluid that enters and leaves the body). LVN 1 stated care plans should be updated whenever there was a change in condition and should include timeframes for interventions and meeting the resident's goals. Resident 1's NP notes were reviewed which indicated to apply TED hose. LVN 1 reviewed the OSR and stated she was unable to locate an order for TED hose. LVN 1 was unable to find the TED hose documented on the care plans, treatment administration record (TAR). LVN 1 stated she did not remember Resident 1 wearing TED hose. During a concurrent interview and record review on [DATE] at 3:11 p.m. with the Unit Manager (UM), the UM stated, she [Resident 1] was a little lady. Resident 1's weights were reviewed, the UM stated Resident 1's six-pound weight gain between [DATE] and [DATE] was significant because she was very underweight and had CHF and edema. The UM stated the change in condition process was to assess the resident, notify the doctor and Responsible Party (RP), start 72-hour charting, and enter a care plan. The UM stated Resident 1's CIC note dated [DATE] documented the lower extremity edema but she was unable to find any documentation reporting the six-pound weight gain. The UM reviewed Resident 1's EMR and stated she was unable to locate an IDT note for Resident 1 regarding the weight gain or edema. The UM stated Resident 1 had CHF so it was important to monitor her for signs and symptoms of fluid overload including weight gain, lungs sounds if the resident was wheezing (high pitched lung sound from airflow throw a compressed airway) or gurgling (low pitched sound caused by obstruction in the airway), vital signs (measurement of the body's most basic function), pulse (number of heart beats per minute), BP (blood pressure-pressure of blood pushing against arteries), respirations (breaths per minute), and edema which could signify the heart was not pumping well. Resident 1's care plans were reviewed. The UM stated care plans were important because they were the basis of patient care and the way the facility meets the resident's goals. Resident 1's CHF care plan, dated [DATE], was reviewed, the care plan indicated, . The resident has Congestive Heart Failure . Goal . The resident will have clear lung sounds, heart rate and rhythm within normal limits through the review date . Interventions . Check breath sounds and monitor/document for labored breathing. Monitor/document for the use of accessory muscles [muscles that assist in breathing, can signal respiratory distress] while breathing . Monitor/document/report to MD PRN (as needed) any s/sx [signs/symptoms] of Congestive Heart Failure: dependent [influenced by gravity] edema of legs and feet . weight gain unrelated to intake . crackles [rattling] and wheezes upon auscultation [listening to sounds] of the lungs . Monitor/document/report to MD PRN any s/sx of digitalis [medication to treat heart conditions] toxicity [poisonous]: Fatigue [exhaustion], muscle weakness, anorexia [eating disorder with low body weight], nausea, yellow halos around objects .Monitor/document/report to MD PRN any s/sx of hypokalemia [low potassium in blood] in residents receiving diuretic therapy . Vital signs as ordered . The UM stated the care plan was a generic, prepopulated care plan and was not accurate or personalized for Resident 1 because she was not on digitalis, it did not specify an individualized goal and did not address the symptoms she was having such as edema. The UM stated Resident 1's care plan was not acceptable to meet her needs. Resident 1's care plan for edema was reviewed, the UM stated the care plan was not customized to resident 1. The UM stated the care plan should have included interventions to monitor Resident 1's weight, lung sounds and vital signs frequently and addressed the fluid restriction and I&Os as ordered by the PHY. The NP's progress notes were reviewed. The UM stated the notes reference TED hose, but she did not remember if Resident 1 wore them. Resident 1's OSR was reviewed, the UM stated she was unable to locate an order for TED hose. The UM stated there should be an order and care plan for TED hose if they were worn. The UM stated she did not remember any signs of an infection to Resident 1's feet while she was at the facility. The UM stated when Resident 1's blisters had popped, she was transferred to the ACH. The UM stated she was not aware Resident 1 had a right foot infection when she was admitted to the ACH. The UM stated symptoms of a foot infection would be redness, warmness, and pain when touched and shiny skin from the swelling. The UM stated the open blisters on Resident 1's foot increased her risk to develop a skin infection. During a concurrent telephone interview and record review on [DATE] at 1:10 p.m. with the Registered Dietitian (RD), Resident 1's Nutrition Assessment, dated [DATE], written by the RD was reviewed. The assessment indicated, . height 63 in (inches-unit of measurement) . Most Recent Weight . 83 lbs . Usual weight 101 [lbs.] . Desired/Goal Body Weight . Gradual wt [weight] gain to 115 lbs would be beneficial . Weight status . Underweight BMI [body mass index-measurement of body fat] < [less than] 18.5 . The RD stated he saw Resident 1 only for her initial assessment. The RD stated Resident 1 was slowly gaining weight when he saw her, and his focus was on residents with weight loss. The RD reviewed Resident 1's weights in the EMR and stated she had gained 6 pounds between admission and [DATE]. The RD stated the weight gain was greater than 5% within a month which would be considered a significant weight gain. The RD stated the EMR would automatically trigger a notification to the nurse there was a change in condition. The RD stated Resident 1 had CHF and the expectation would be for the nurse to assess the resident for edema, check the vital signs and notify the physician because the weight gain could be a sign of fluid retention. The RD stated he was not notified Resident 1 had gained weight and about the edema. The RD stated Resident 1 was malnourished which could also cause edema and he would have reassessed the resident's nutritional needs if had he known. The RD stated Resident 1's weight gain and edema was never reviewed by the IDT because the IDT's focus was on residents who were losing weight. The RD stated Resident 1's weekly weights were not continued after [DATE], because she was underweight and when he assessed her, she was gradually gaining weight which was considered desirable. The RD stated, If I knew about the edema, I would have continued the weekly weights. The RD stated when a resident had edema it was important to monitor their weight frequently to assess for fluid overload. The RD stated, The weights need to be monitored to make sure that we are not going overboard on the diuretics, it could lead to dehydration. The RD stated the protocol for routine weights was to weigh new residents weekly for four weeks and then change to monthly. The RD stated the Restorative Nursing Assistants (RNAs) would perform the weekly or monthly weights and he would review the weights after they were all complete. The RD stated during that time, he was only at the facility two days a week which made it difficult to see all the residents he should have. The RD stated the facility was recently given a deficiency regarding the weight process, communication and follow up on weight changes and had recently improved the process. The RD stated he now visited the facility three times weekly which had improved his ability to follow up with residents. During a concurrent telephone interview and record review on [DATE] at 2:41 p.m. with the Director of Nursing (DON), Resident 1's weights were reviewed. Resident 1's CIC dated [DATE], at 3:48 a.m., was reviewed. The CIC indicated, . Signs and Symptoms Identified . edema in both feet, and blister pooped [popped] on right feet and weeping . resident has edema on both feet CNA informed this writer while ADL care resident left foot is weeping, this writer did assessment resident have blisters on right foot blisters popped and watery discharge coming out . Date and time of clinician notification . [DATE] 03:59 [3:59 a.m.] . Recommendation of Primary Clinician [blank] .Is a cardiovascular assessment relevant to the change in condition . Not clinically applicable . Is a skin assessment relevant to the change in condition . Not clinically applicable . The DON stated the cardiovascular status assessment should have been completed by the nurse because the edema was caused by CHF and the skin assessment should have been completed because the skin weeping and ruptured blisters to the resident's feet. The DON stated Resident 1 was on a fluid restriction which was important to follow because if fluid was imbalanced, the resident could retain too much fluid which would stress the heart. The DON stated Resident 1's edema started on [DATE] and had not improved which eventually caused blisters to her feet. The DON stated on [DATE] a blister had popped on Resident 1's right foot, causing weeping and a watery discharge, so she was transferred to the acute care hospital. The DON stated she had examined Resident 1's feet on [DATE] and the edema had improved on the left foot, but the right foot was worse. The DON stated Resident 1's right leg was very swollen, hard to palpate the pedal (foot) pulse, the skin was tight when she was transferred to the hospital. The DON stated she did not remember seeing multiple blisters, but the right foot was reddish but cool. The DON reviewed Resident 1's EMR and stated her examination was not entered in the CIC note or a progress note but should have been. Resident 1's CHF care plan was reviewed. The DON stated the care plan had an intervention to monitor for signs and symptoms of digitalis toxicity and was obviously not customized to Resident 1 because she was not on digitalis. The DON stated the EMR had a care plan library, and the staff would select the focus, goals and interventions which applied to the resident's diagnosis. The DON stated the staff were expected to edit the prepopulated care plans and personalize them for each resident. The DON stated it was apparent the care plans entered were not specific to Resident 1. The DON stated the plan of care should be individualized to each resident's needs, and the purpose of care plans were to indicate what care and interventions were needed to meet a resident's healthcare goals. The DON stated care plans needed to indicate the time frame within which the interventions would be done, and goals would be met. Resident 1's care plan for edema was reviewed and the DON stated the care plan did not have the necessary interventions to meet Resident 1's needs for management of the edema. The DON stated the care plan should have included interventions such as the physician ordered fluid restriction and I&Os, and added monitoring the leg size, skin temperature, vital signs, and weights. The DON stated Resident 1's six-pound weight gain on [DATE], prior to the onset of edema should have been included in her care plans. During a concurrent telephone interview and policy and procedure (P&P) review on [DATE] at 3:25 p.m. with the DON, the P&P titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated ,d+[DATE] was reviewed. The P&P indicated, . The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time . The Staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline . The physician will review for medical causes of weight gain . For individuals with recent or rapid weight gain or loss . the staff will review for possible fluid and electrolyte imbalance (occurs when your body's minerals are too high or low) as a cause . Conditions such as heart failure and renal failure (is a condition when the kidneys suddenly become unable to filter waste products from the blood) can cause rapid weight gain . The physician, with the help of the multidisciplinary team [IDT], will identify conditions and medications . The physician will help identify medical conditions (cancer, cardiac or renal disease .) and medications that may be causing weight gain or loss . The physician (or staff based on a discussion with the physician) will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations such as where multiple causes coexist . The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions . The DON stated the IDT should have met to discuss Resident 1's weight gain and edema. The DON stated when the CIC for edema was completed on [DATE], the physician should also have been notified about her weight gain. The DON stated Resident 1's weight gain was caused by CHF, fluid retention and edema. The DON stated the P&P was not followed. During a review of the ACH's document titled Discharge Summary, dated [DATE], the summary indicated, . Admission Diagnosis . severe malnutrition . Atrial fibrillation with rapid ventricular response . septic shock (occurs when a body wide infection leads to dangerously low blood pressure) . sepsis . Discharge Weight 80 lb. Hospital Discharge Diagnosis . Acute right foot infection X 2 weeks . New onset A-fib with RVR . Severe malnutrition from chronic illness . Advanced dementia . Hospital Course . presents to [hospital name] ED for evaluation R [right] foot infection . patient was hypotensive (sudden drop in blood pressure) and tachycardic (increased heart rate) . They [EMS] stated that the staff at the SNF reported that the infection has been present for about 2 weeks now and has gotten worse over the last couple days . Patient's family has requested hospice . Discharging to: Hospice Inpatient Facility . Condition: Poor . During a review of Resident 1's Certificate of Death, dated [DATE], the certificate indicated, . Cause of Death . Atrial Fibrillation with Rapid Ventricular Rate . Right Foot Infection . Advanced Dementia . Other Significant Conditions . Severe Malnutrition . During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT) . develops and implements a comprehensive, person-centered care plan for each resident . the comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . which professional services are responsible for each element of care . includes the resident's stated goals upon admission and desired outcomes . reflects currently recognized standards of practice for problem areas and conditions . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making . When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . The interdisciplinary team reviews and updates the care plan . when there has been a significant change in the resident's condition . when the desired outcome is not met . when the resident has been readmitted to the facility from a hospital stay . During a review of a professional reference retrieved from https://www.ahajournals.org/doi/10.1161/HHF.0000000000000005 titled Heart Failure Management in Skilled Nursing Facilities, dated [DATE], the reference indicated, . Heart failure (HF) is a complex syndrome . Data available suggest that HF patients discharged to SNFs [skilled nursing facilities] are at very high risk for rehospitalization and death . avoidable hospitalization s are common in the general SNF population, many of whom have HF as a comorbidity (the condition of having two or more diseases at the same time) . Examples of factors related to avoidable hospitalization s include lack of on-site primary care clinicians . lack of integration of HF assessment and interventions into nursing care . Frailty is usually described by reduced function in multiple domains, including nutrition or body weight, muscle strength . management of decompensated HF, or volume overload resulting in worsened HF symptoms in SNFs . Decompensation [hearts inability to deliver oxygenated blood] is usually recognized by a gain in weight, worsened HF symptoms . On admission and with a change in status, goals of care should be identified . Monitoring for presence of increasing fatigue, dyspnea [difficulty breathing] on exertion, cough, edema, and weight gain should signal nursing staff to intervene to avoid further decompensation . Management of worsened congestion in SNF residents should be patient centered, highly individualized, and based on shared decision making between a knowledgeable, well-coordinated, proactive healthcare team . based on their goals for care . Initial management of volume overload is appropriate in the SNF. Nursing care staff should incorporate monitoring for symptoms and signs of volume overload and intervene to avoid symptomatic congestion . Diuretic agents are an essential component of HF symptom management and remain the most effective agents for relieving pulmonary congestion [too much fluid in lungs] and edema . Diuretic agents require careful monitoring of volume status (using weight and physical examination) . Nursing Care of HF patients in SNFs should include assessment of sym [TRUNCATED]

Based on interview and record review, the facility failed to ensure licensed nurse immediately consulted with resident's physician during a significant change in resident's physical status for two of three sampled residents (Resident 1 and 2) when: 1.Licensed nurses did not immediately notify Resident 1's physician, after Resident 1 experienced a severe unplanned weight loss of 18 pounds (lbs- a unit of measurement) or 9.8% in 28 days; on 12/3/23 weighed 166 lbs. Nursing staff obtained weekly weights documenting the rapidly declining weights and did not notify the physician of the change in condition (CIC) in accordance with physician expectations and policy and procedure; and did not conduct an Inter Disciplinary Team (IDT-an interdisciplinary team comprised of professionals from various disciplines who work in collaboration to address a resident with multiple physical and psychological needs) meeting to discuss the CIC. The Registered Dietitian (RD) input orders to fortify (added nutrition) Resident 1 ' s diet on 12/22/23 and Licensed Nurses (LNs) did not implement the orders until 12/28/23. LNs did not call the RP (responsible party) in accordance with the signed Power of Attorney (POA- legal document allowing someone else to act on your behalf) when Resident 1 had a change of condition. These failures resulted in not providing Resident 1 ' s physician the opportunity to determine the cause of the rapid decline in weights and clinical status, a delay in providing nutritional support to Resident 1 and contributed to Resident 1 being found unresponsive on 1/15/24 which required an ambulance transport to a higher level of care to a local acute care hospital (ACH). At the ACH, Resident 1 was immediately treated for high levels of ammonia (waste product processed by liver) in the blood and hepatic encephalopathy (damaged liver causes temporary worsening of brain function). 2. Resident 2 had blood in the urine on 12/30/23 and Licensed Nurses (LN's) did not ensure timely physician notification to provide prompt UTI [urinary tract infection-infection in bladder] treatment to Resident 2 which resulted in the delay in collecting the urine sample on 1/3/24. This failure resulted in prolonging the start of antibiotics to treat UTI. Resident 2 received the first dose of antibiotics on 1/11/24. Findings: 1. During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included constipation, hypertension (high blood pressure), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive (mental process) and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment scored was 11 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1 ' s Advanced Health Care Directive Form (AD) dated 12/22/23, the AD indicated, .When agents authority becomes effective: My agent ' s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I make the following box. If I mark this box [box marked], my agent ' s authority to make health care decisions for me takes effect immediately . During a telephone interview on 2/14/24 at 3:20 p.m. with Social Services (SS), SS stated Resident 1 ' s Responsible Party (RP) came to the facility on [DATE] with a notary (appointed official serving as an impartial witness) to sign the POA. SS stated she was present when the notary and Resident 1 ' s RP were signing the POA. SS stated from 12/22/23, LNs should call the RP for any health-related decisions. During a telephone interview on 2/15/24 at 9:36 a.m. with RP, RP stated she became the POA in 12/22/23 and wanted the facility to call her with any changes Resident 1 experienced. RP stated prior to Resident 1 being sent out to the hospital she had voiced her concerns to the LNs that Resident 1 was not responsive, not eating, and was sleeping most of the time. RP stated she had been asking the LNs to do blood work to find the underlying cause of Resident 1 ' s decline. RP stated losing 20 lbs in less than a month was a red flag and the LNs did not act upon her requests. RP stated if the LNs had called her when Resident 1 had a change of condition, she would have instructed them to send Resident 1 to the hospital. During a concurrent telephone interview and record review on 2/16/24 at 10:55 a.m. with RD, Resident 1 ' s weight review dated 12/15/23 was reviewed. The RD weight review indicated, .Wt [Weight] 172 [pounds] . Wt change: -12 lbs x 1 week .Res [Resident] continues to tolerate diet as ordered with an excellent PO [by mouth] intake which meets estimated needs .wt loss is likely r/t [related to] fluid balance shifts. No new RD recommendations . RD stated Resident 1 had edema [swelling caused fluid trapped in the body's tissues] and was taking medications to eliminate excess fluids. RD stated the goal was to maintain Resident 1 ' s weight in the 180lb range. During a concurrent telephone interview and record review on 2/16/24 at 11:10 a.m. with RD, Resident 1 ' s weight review dated 12/22/23 was reviewed. The RD weight review indicated, .Wt [Weight] 167 [pounds] . Wt change: -5 lbs x 1 week .Res [Resident] continues to tolerate diet as ordered, . intake is excellent and meets estimated needs . however, res continues to have wt loss .Res was happy with wt loss before as it was likely r/t fluid balance shifts, however this further wt loss may be r/t underlying medical conditions .RD recommends fortified [added nutrition], large portion diet with PBJ [peanut butter jelly] sandwich TID [three times a day] between meals to increase energy intake and minimize risk for further wt loss .Goal: resident will tolerate diet to meet estimated needs and will have gradual wt gain to maintain 172 +/- 5 lbs . RD stated when Resident 1 continued to lose weight and no longer had edema the weight loss became a concern. RD stated LNs should contact the physician when there is a significant weight loss so the physician can order laboratory (labs- facility conducting testing and analysis). RD stated he communicates his recommendations via email to the Director of Nurses (DON), LNs, and MDS. RD stated his expectation was for LNs to implement his recommendations within 48 hours. RD stated his recommendation was not started until 6 days later, the purpose of his recommendation was to increase calories (nutritional value of foods). RD stated increasing calories was intended to minimize tissue loss and decrease the chances of malnutrition (lack of proper nutrition). During a concurrent telephone interview and record review on 2/16/24 at 11:20 a.m. with RD, Resident 1 ' s weight review dated 1/2/24 was reviewed. The RD weight review indicated, .Wt [Weight] 166 [pounds] . Wt change: -8 lb x 1 week, -18 lbs x 1 month .skin intact no edema noted. Res continues to tolerate diet as ordered with a good PO intake which meets estimated needs .Res Is concerned with wt loss and requests high calorie . To ensure that needs are met .RD recommends [nutritional drink] 4 oz [ounce-unit of measure] TID to ensure that needs are met and weight is maintained at 166 +/-5lb . RD stated he was worried about Resident 1 ' s weight loss and recommended [nutritional drink]. RD stated he did not know why Resident 1 kept losing weight as he was a good eater, but his weight kept declining. RD stated on 1/2/24 was his last assessment of Resident 1. During a concurrent interview and record review on 2/20/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Care Plan (CP) dated 12/10/23 was reviewed. The CP indicated, .Monitor/record/report to MD [medical doctor] PRN [as needed] .significant weight loss: 3lbs in 1 week, > [greater than]5% in 1 month . LVN 1 stated the purpose of the care plan was for staff to follow interventions created for Resident 1. LVN 1 stated the care plan was not followed because Resident 1 had weight loss since 12/15/23 and the physician was not called until 1/4/24. During a concurrent interview and record review on 2/20/24 at 11:10 a.m. with LVN 1, Resident 1 ' s Progress Notes (PN) dated 12/28/23 was reviewed. The PN indicated, RD recommendations fortified large portion diet and PBJ sandwich .between meals reviewed with MD, order in place . LVN 1 stated RD placed the recommendation on 12/22/23 and was not implemented until 12/28/23 (six days after the RD written recommendations). LVN 1 stated the RD ' s recommendation should be implemented right away. LVN 1 stated the purpose of the recommendation was to ensure Resident 1 received adequate nutrition. During a concurrent interview and record review on 2/20/24 at 11:20 a.m. with LVN 1, Resident 1 ' s electronic medical record (EMR) for weights and vitals summary dated 11/30/23 to 1/14/22 was reviewed. The vital signs weights indicated Resident 1's weights were: 11/30/23 181 lbs 12/3/23 184 lbs 12/10/23 172.0 lbs 12/17/23 167 lbs 12/24/23 174 lbs 12/31/23 166 lbs 1/9/24 163 lbs 1/14/24 161 lbs LVN 1 stated the physician should have been notified of the three pound plus or minus weight change for Resident 1 when it was identified. LVN 1 stated the physician was not notified until 1/4/24. LVN 1 stated the purpose of calling the physician was so he could conduct an assessment and make recommendations. LVN 1 stated there should have been a Change in Condition (CIC) done for Resident 1 ' s weight loss which would have triggered the LN to call the physician but was not done until 1/4/24. During a review of Resident 1 ' s Progress Notes (PN) dated 1/4/24, the PN indicated, . weight loss . meal intake is good . recently started on [nutritional drink] three times a day . no edema to exts [extremities] noted . primary care provider responded . recommendations: weekly weights . MD . in facility and made aware . During a concurrent interview and record review on 2/20/24 at 11:30 a.m. with LVN 1, Resident 1 ' s PN dated 1/10/24 was reviewed. The PN indicated, .Resident [RP] in facility .Per resident OK to talk to her regarding care/medications .per [RP] she would like [MD] to see resident she expressed concerns: .over weight loss .wants labs .kidney [part of body removing waste] function .possible underlying causes of weight loss .unable to reach Dr .vm [voicemail left] . LVN 1 stated Resident 1 ' s RP was concerned and the LN should have called the MD more than once. LVN 1 stated there was no other calls placed to the MD until Resident 1 had a CIC on 1/4/24. LVN 1 stated there were two other MD ' s and a Nurse Practitioner (NP) that could have been called. LVN 1 stated if it was not documented it was not done. LVN 1 stated the LN should have followed up with the RP ' s request to prevent delaying interventions the MD may order. During a concurrent interview and record review on 2/20/24 at 11:40 a.m. with LVN 1, Resident 1 ' s PN dated 1/12/24 was reviewed. The PN indicated, . change in condition . seems different than usual tired, weak, confused, or drowsy . at medication pass, resident c/o[complained of] not feeling good, feeling really tired . Resident refused to go out to hospital for further eval[evaluation]. Refuse to eat breakfast and lunch. Recent weight loss noted . complains of feeling sleepy . primary care provider responded . blood tests urinalysis or culture . LVN 1 state RP was Residents 1 ' s POA and should have been called when Resident 1 had a CIC and refused to go to the hospital. LVN 1 stated there was no documentation that the RP was called. During a review of Resident 1 ' s PN dated 1/13/24, the PN indicated, . received the lab result notified the M/D [Medical Doctor] put the result M/D binder . During a review of Resident 1 ' s PN dated 1/15/24, the PN indicated, . unresponsive .CNA [certified nursing assistant] reported that patient was not responding to her. Upon assessment patient was found unresponsive. Eye open blinking tongue sticking out slightly MD notified . may transfer to hospital for further evaluation . During a telephone interview on 2/20/24 at 12:49 p.m. with MD, MD stated his expectation was that LNs call and notify him when there is a significant weight change. MD stated he has provided the facility with his cell phone, home phone and office number. MD stated he was the medical director of the facility, and the ultimate goal was to keep residents safe. During a review of Resident 1 ' s General Acute Care Hospital History and Physical (H&P) dated 1/15/24, the H&P indicated, . altered mental status . called [facility name] . per charge nurse she does not usually take care of patient and so she only has a very limited information . mentioned that patient reported that he was not feeling good and was feeling tired last few days. She does not have any further information . also spoke with patients [RP] . she states that for past several days patient has been sleepy and lethargic [drowsy or sleepy] and in recent few weeks, he has had significant weight loss. She states that she has had to repeatedly ask the staff at the nursing facility to order some labs and do work up to figure out why he was so sleepy . ammonia [waste product processed by liver] noted to be 135 [normal range 10-47] lactulose [medication used to treat complications of liver (organ in the body)] . and rectal [anus] tube ordered .admit to telemetry [hospital unit] . During a concurrent interview and record review on 2/20/24 at 1:15 p.m. with the Director of Nursing (DON), the facility Policy and Procedure (P&P) titled Weight Assessment and Intervention dated 3/2022 was reviewed. The P&P indicated, . resident weights are monitored for undesirable or unintended weight loss or gain . undesired weight loss will be based on the following criteria .1 month -5% weight loss is significant . undesirable weight changes evaluated by the treatment team . the physician and the multidisciplinary team identify conditions and medications that may be causing . weight loss or increasing the risk of weight loss . care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident ' s legal surrogate . Interventions for undesirable weight loss are based on careful consideration . The DON stated there was no IDT meeting until 1/4/24 for Resident 1 ' s weight loss. The DON stated the purpose of the IDT meeting was to identify trends and preventions for continuous weight loss taking risk factors into consideration. The DON stated the care plan should be implemented and followed by LNs. The DON stated the RD sends his recommendations to herself, managers, and the dietary supervisor. The DON stated recommendations from the RD should be communicated and implemented the day it was recommended. During a concurrent interview and record review on 2/20/24 at 1:20 p.m. with the DON, the facility Policy and Procedure (P&P) titled Change in a Resident ' s Condition or Status 02/2021 was reviewed. The P&P indicated, . our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition .A significant change of condition is a major decline or improvement in the resident status that . will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions . unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when . there is a significant change in the resident ' s physical, mental or psychosocial [individual's mind or behavior] status . The DON stated when Resident 1 had significant weight loss the physician should have been notified so he can review and identify the cause. The DON stated the expectation was that LN ' s call other physicians when they were unable to reach Resident 1 ' s primary physician. The DON stated there were more than three physicians the LNs could have attempted to call but did not. During a concurrent interview and record review on 2/20/24 at 1:31 p.m. with the DON, the facility Policy and Procedure (P&P) titled Advance Directives dated 09/2022 was reviewed. The P&P indicated, . resident has the right to formulate an advance directive . Advance directives are honored in accordance with state law and facility policy . the residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings . the plan of care for each resident is consistent with his or her documented treatment preferences and/or advanced directive . The DON stated Resident 1 ' s RP should have been called when he had significant weight loss, CIC and when Resident 1 refused to go to the hospital. The DON stated Resident 1 ' s RP was the POA and should be the one to make decisions for Resident 1. During a telephone interview on 3/4/24 at 1:08 p.m., with RD, RD stated Resident 1 lost a total of 18 lb ' s from 12/3/23 to 12/31/23 which was 9.8% weight loss. RD stated since admission 11/30/23 to 1/14/24 Resident 1 had 20 lb 11% weight loss. During a review of the facility LN ' s Duty Statement (DS) titled Floor Nurse undated, the DS indicated, . the purpose of your job position is to provide each resident with routine daily nursing care and accordance with current federal, state, and local standards that govern the facility and as directed by your supervisor . they will relate all pertinent information concerning a resident ' s condition to a charge nurse when required . Timely reporting of change in resident ' s condition to the nurse supervisor . Abiding with all facility policies and procedures . During a professional reference reviewed retrieved from https://my.clevelandclinic.org/health/diseases/21220-hepatic-encephalopathy, Hepatic Encephalopathy, dated 12/19/23, indicated, . These toxins build up in your blood and affect your brain, causing confusion, disorientation, and other changes. Hepatic encephalopathy can get better with treatment, but it can be life-threatening . Hepatic encephalopathy is brain dysfunction caused by liver dysfunction. Encephalopathy is brain dysfunction, and hepatic means liver-related . Any symptoms of overt hepatic encephalopathy are serious. It ' s important to treat the condition as soon as possible to prevent it from worsening or causing permanent damage. Severe hepatic encephalopathy can advance to coma or even death . In general, if the causes affecting you are brief, and if they ' re relatively mild, you ' re more likely to recover fully. If you have a permanent condition, you ' ll need ongoing therapy . 2. During a review of Resident 2's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnosis included chronic kidney disease (inability to filter waste products from your blood). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 2's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment scored was 6 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2 had severe cognitive impairment. During a review of Resident 2 ' s Progress Notes (PN) dated 12/30/24, the PN indicated, .during brief change resident had blood in urine, blood bright red .will notify MD [medical doctor] . During a review of Resident 2 ' s PN dated 12/31/24, the PN indicated, .Resident has x1 episode of slight red in urine .faxed .communication to doctor .no response at this time . During a concurrent interview and record review on 2/20/24 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s PN dated 1/1/23 was reviewed. The PN indicated, .Received fax from M.D. new orders received u/a [urinalysis -test if the urine] with c&s [culture and sensitivity-test used to determine medication used for infection] . LVN 1 stated the purpose of promptly notifying the physician was to get recommendations on interventions for the blood in urine. LVN 1 stated LN ' s should have attempted to call each shift or called another physician since 12/30/23 to prevent any delays. LVN 1 stated there was no documentation that the physician was called each shift to address the blood in urine from 12/30/23 -1/1/24. During a review of Resident 2 ' s PN dated 1/1/24, the PN indicated, .15:12 [3:12 p.m.] .Unable to collect urine specimen refused for catheterization [flexible tube used to collect urine] PM shift . During a review of Resident 2 ' s PN dated 1/2/24, the PN indicated, .01:41 [a.m.] .Unable to collect UA via catheter, resident refused x3 times, will endorse to oncoming shift . During a review of Resident 2 ' s PN dated 1/2/24/, the PN indicated, 20:59 [8:59 p.m.] .Staff offered to use the bathroom in PM shift refuses to get OOB [out of bed]. MD notified . During a concurrent interview and record review on 2/20/24 at 11:55 a.m. with LVN 1, Resident 2 ' s PN written by the Nurse Practitioner (NP) dated 1/3/24 was reviewed. The PN indicated, .Today the patient was seen for painful urination .Patient was complaining of urinary urgency, frequency, and painful urination .collected urine sample by myself using .cath [catheter] .cloudy in appearance . LVN 1 stated it took 5 days from when blood was identified in the urine to collect the urine for laboratory (facility provides test results). LVN 1 stated LN ' s should have called the MD when they were unable to collect the urine but didn ' t until 1/2/24 at 8:59 p.m. LVN 1 stated if it was not documented it was not done. During a telephone interview on 2/20/24 at 1:05 p.m. with MD 2, MD 2 stated if a resident refuses to have the UA collected, LN ' s should call him to ask for any follow up recommendations. During a review of Resident 2 ' s PN dated 1/11/24, the PN indicated, .order for [levofloxacin-medication used to treat infection] 500 mg [milligram-unit of measure] x10 days for UTI [urinary tract infection-infection in bladder] . During a concurrent interview and record review on 2/20/24 at 1:58 p.m. with the DON, the facility Policy and Procedure (P&P) titled Change in a Resident ' s Condition or Status was reviewed. The P&P indicated, .our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition .The nurse will notify the resident ' s attending physician or physician on call when there has been a .significant change in the resident ' s physical .condition .refusal of treatment or medications two (2) or more consecutive times .The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition . The DON stated after the second refusal of collecting the urine the LN ' s should have called the MD but didn ' t. The DON stated the blood in the urine was identified on 12/30/23 and took 5 days to collect the urine on 1/3/24. The DON stated the expectation was that LN ' s call other physicians when they were unable to reach Resident 2 ' s primary physician. During a professional reference reviewed retrieved from https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447, titled Urinary Tract Infection, dated 9/14/22, indicated, . A urinary tract infection (UTI) is an infection in any part of the urinary system . UTIs don't always cause symptoms. When they do, they may include . signs of blood in the urine . When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, UTIs can cause serious health problems .

Based on interview and record review, the facility failed to ensure the use of proper assistive devices (mechanical lift-used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone by using a battery powered bar and sling to lift the resident from the bed or a wheelchair) to prevent accidents for one of three sampled residents (Resident 1) who was assessed as a high risk for falls and fell on [DATE] when Certified Nursing Assistant (CNA) 1 permitted Resident 1 to scoot to the edge of the bed unassisted and unsupervised in preparation to transfer to the wheelchair. CNA 1 was at the bedside with Resident 1, turned around to retrieve an unapproved assistive device (transfer board-devise designed for helping those with a physical disability to move from one surface like a bed to another like a wheelchair) and did not provide direct supervision to Resident 1. This failure resulted in Resident 1 experiencing an avoidable fall from bed, striking her knees onto the floor, and experienced pain. Resident 1 was transferred to an acute care hospital for evaluation where a fracture (break in the bone) to the left femur (also known as the thighbone) was diagnosed . Resident 1 was hospitalized from 6/13/22 to 7/6/22 (24 days) and required surgical repair, experienced decreased mobility, and treated for pain. Findings: During a review of Resident 1 ' s Admission Record (AR) dated 6/15/2022, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Age Related [CONDITION(S)] (condition of reduced bone mass with decreased thickness resulting in increased fracture incidence). During a review of Resident 1 ' s Minimum Data Set (MDS- comprehensive, standardized assessment of resident ' s functional capabilities and health needs) assessment dated [DATE], the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS- assessment of cognitive function) was 15 of 15 points which indicated Resident 1 had no cognitive impairment. During an interview on 6/29/22, at 9:38 a.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 was going to use the mechanical lift to transfer Resident 1 from her bed to the wheelchair with the assistance of CNA 2. The DSD stated Resident 1 requested a transfer board that Resident 1 ' s family had brought into the facility to use. The DSD stated Resident 1 ' s family had used it at home to transfer Resident 1 from the bed to the wheelchair. The DSD stated the CNAs in the facility had not been trained on using sliding boards to transfer Resident 1 and the sliding board was not approved to use for Resident 1 by the Physical Therapy department (treatment of disease or injury by physical methods such as exercise). During an interview on 6/29/22, at 10:46 a.m., with the Licensed Vocation Nurse (LVN) 1, LVN 1 stated on 6/13/22 at around 5:20 a.m., CNA 1 informed her that during an attempt to transfer Resident 1 from her bed to the wheelchair, Resident 1 slipped from the bed and fell on the floor. LVN 1 stated Resident 1 was being transferred into her wheelchair to go to her [CONDITION(S)] (process of purifying the blood of a person whose kidneys are not working normally) appointment. LVN 1 stated Resident 1 would have needed the mechanical lift to transfer from bed to the wheelchair using a sling (flexible strap used in the form of a loop to support the resident). LVN 1 stated Resident 1 ' s family had brought in a sliding board for assisting with transfers, but the Physical Therapy department had not approved the sliding board for Resident 1 to use. LVN 1stated Resident 1 did complain of pain in the left leg after the fall, so she notified the physician and got an order for an x-ray (imaging process used create pictures of the inside of the body). LVN 1 stated the x-ray did show a left femoral fracture. LVN 1stated Resident 1 was sent to the hospital for further evaluation on 6/13/22. During an interview on 6/29/22, at 11:20 a.m., with CNA 1, CNA 1 stated on 6/13/22, at around 5 a.m. she was going to transfer Resident 1 from the bed to the wheelchair for her [CONDITION(S)] appointment. CNA 1 stated she was going to get a mechanical lift to transfer Resident 1, but the mechanical lift needed to have the battery charged and was going to get another one that was charged. CNA 1 stated Resident 1 told her she did not want to use the mechanical lift and wanted to use her sliding board that her family brought in from home. CNA 1 stated Resident 1 was alert and cognitively intact to request her wants and CNA 1 took Resident 1 ' s word that it was ok to use the sliding board. CNA 1 stated she went to get the sliding board instead and when she turned her back, Resident 1 had slipped off the edge of the bed and fell on the floor. CNA 1 stated Resident 1 scooted herself to the edge of the bed to be transferred from the bed to the wheelchair but had scooted too far and fell . CNA 1 stated she went to alert CNA 2 for help assisting Resident 1 back into bed as well as the LVN. CNA 1 stated she had not been trained on using the sliding board to transfer Resident 1. CNA 1 stated the facility used a Kardex Report (electronic form used to see the different care interventions used for residents such as transferring, eating, toileting etc.) to see how to transfer residents. CNA 1 stated she had seen Resident 1 ' s Kardex Report and indicated that Resident 1 used a mechanical lift to transfer from bed to wheelchair. CNA 1 stated using the mechanical lift would have prevented Resident 1 from falling as she would not have needed to scoot to the edge of the bed but remained in the center of the bed, and therefore not slipped and fallen on the floor. CNA 1 stated she should have used the mechanical lift for transferring Resident 1 as instructed in the Kardex Report to ensure Resident 1 ' s safety during transfers. During a review of Resident 1 ' s Post Fall Review (PF), dated 6/13/22 at 5:56 a.m., the PF indicated, .IDT (interdisciplinary team-approach to healthcare that integrates multiple disciplines through collaboration) met to review resident ' s fall that occurred on 6/13/2022. This incident occurred when staff was on the process of transferring resident to her w/c (wheelchair). Per CNA (1) resident voice to use transfer board to transfer to her chair. Resident slid off her bed landing on her knees. Resident has dx (diagnosis) of [CONDITION(S)], osteopenia (bone related diseases that do not allow for new bone to grow to otherwise brittle bones). Resident x-ray concluded resident has a fracture to left femur and she was sent to acute (hospital) for further evaluation and tx (treatment) . During a review of Resident 1 ' s Fall Risk Assessment (FRA), dated 2/12/22, the FRA indicated, .Based on the answers to questions 2-11, is resident at risk for falls? a. Yes . During a review of Resident 1 ' s Minimum Data Set Section G Functional Status assessment dated [DATE], the MDS indicated, .B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position .1. Self-Performance .3. Extensive assistance-resident involved in activity; staff provide weight bearing support .2. Support .3. Two-person physical assist .Functional Limitation in Range of Motion .B. Lower extremity (hip, knee, ankle, foot) 1. Impairment on one side . During a review of Resident 1 ' s Radiology Results Report (RR), dated 6/13/22, the RR indicated, .Findings: Left femur show a oblique fracture of the midshaft of the femur (bone broken at an angle in the middle of the bone) . During a review of Resident 1 ' s Care Plan (CP), dated 3/27/19, the CP indicated, The resident is at risk for falls r/t (related to) Age related [CONDITION(S)] .Fall on 6/13/22 with fracture Fall risk assessment score = 11 (indicating fall risk) .The resident has an ADL (activities of daily living-toileting, dressing, transferring, eating) Self Care Performance Deficit r/t (related to) weakness, [CONDITION(S)] (end stage renal disease-condition in where the kidneys cannot filter out wastes in the body requiring [CONDITION(S)] treatment), muscle weakness and impaired mobility .Transfer: The resident has required Mechanical Aid ([brand name lift] Lift-type of mechanical lift used to assist in transferring residents who cannot bear weight, Sling) x 2 (times two) staff assistance for transfers . During a review of Resident 1 ' s Kardex Report (KR), dated 6/29/22, the KR indicated, Transferring .Transfer: The resident has required Mechanical Aid ([name of lift], Sling) x 2 staff assistance for transfers . During an interview on 6/29/22, at 11:45 a.m., with the Director of Nursing (DON), the DON stated Resident 1 needed to use the mechanical lift for transferring. The DON stated Resident 1 used a sling to transfer in the mechanical lift. The DON stated the CNAs could see how residents transferred and what devices to use on the Kardex Report. The DON stated CNA 1 needed to transfer Resident 1 using the mechanical lift with the assistance of another CNA. The DON stated the sliding board in Resident 1 ' s room was not approved to be used as a transfer device as the CNAs had not been trained to use the sliding board to transfer Resident 1. The DON stated the physical therapy department would have needed to assess the use of the sliding board for Resident 1 prior to using it. The DON stated CNAs did not know if the sliding board was safe to use for Resident 1. The DON stated CNA 1 should have followed the instructions on Resident 1 ' s Kardex Report to ensure her safety during transferring. The DON stated if CNA 1 would have used the mechanical lift, Resident 1 would not have needed to scoot to the edge of the bed and would not have slipped and fell . The DON stated CNA 1 should have used the appropriate transfer devices for Resident 1 to ensure safety. The DON stated Resident 1 was taken to the hospital on 6/13/22 for surgery to repair her broken left femur. During an interview on 6/29/22, at 5:20 p.m., with CNA 2, CNA 2 stated on 6/13/22, CNA 1 had asked for assisting Resident 1 from the floor after having a fall. CNA 2 stated Resident 1 had requested to use the sliding board for transfers before. CNA 2 stated she had used the sliding board to transfer Resident 1 from the bed to the wheelchair. CNA 2 stated because Resident 1 was alert and cognitively intact, she followed Resident 1 ' s word on transferring her with the sliding board. CNA 2 stated she knew to look at the Kardex Report to see how residents transferred. CNA 2 stated she did not follow the Kardex Report because she wanted to carry out Resident 1 ' s request of using the sliding board. CNA 2 stated Resident 1 could have fallen if the CNAs did not use the proper transferring device. CNA 2 stated using the mechanical lift for Resident 1 ' s transfers would have ensured prevention of falls and resident safety. During a review of Resident 1 ' s ED Progress Note (EDN), dated 6/13/22, the EDN indicated Resident 1 was given 100 mcg (micrograms - unit of measurement) of [MEDICATION(S)] (medication use to treat severe pain) IM (intramuscular injection-used to deliver medication into the muscle to be absorbed quicker and have immediate effect) in the ambulance on route to the hospital due to pain on her lower left leg. During a review of Resident 1 ' s hospital Emergency Department Physician Notes (EDPN), dated 6/13/22, the EDPN indicated, Resident 1 was admitted to the hospital on 6/13/22 with a left femoral fracture and Resident 1 was complaining of pain. The EDPN indicated Resident 1 was administered 4 mg (milligrams) of [MEDICATION(S)] (medication used to treat moderate to severe pain). The EDPN indicated the orthopedic department would follow up with patient the next day for possible surgery. During a review of Resident 1 ' s hospital Radiology Interpretation (RI), dated 6/13/22, the RI indicated, .XR (x-ray) Pelvis .Impression: Acute fracture of left femur shaft the proximal one third level (indicating upper third of the femur bone that includes the head, neck and upper portion of the femoral stem) . During a review of Resident 1 ' s Operative Procedure Report (OPR), dated 6/16/22, the OPR indicated Resident 1 had surgery on the left proximal third femur shaft . During a review of Resident 1 ' s Discharge Summary (DC), dated 7/27/22, the DC indicated, .Inpatient, 6/13/2022 - 7/6/2022 . During a review of the facility policy and procedure (P&P) titled, Safety and Supervision of Residents dated July 2017, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .4. Implementing interventions to reduce accidents risks and hazards shall include the following .d. Ensuring that interventions are implemented .Resident Risks and Environment Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in the dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed Safety; b. Safe Lifting and Movement of Residents; c. Falls . During a review of the facility P&P titled, Comprehensive Person-Centered Care Plans, dated March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan .d. builds on the resident ' s strengths; and e. reflects current recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons .12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident ' s condition .

Based on observations, interviews, and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program to prevent communicable (infectious) diseases when: 1. Housekeeping (HK) staff used the same toilet bowl brushes on multiple patients' toilets for an unknown amount of time. There was no manufacture's IFU (information provided by the manufacturer to inform the device user of the device's intended purpose and proper use and of any precautions to be taken) that was provided that indicated the toilet bowl brushes could be used on multiple residents' toilets; The facility had no policy or procedure for HK staff that directed the re-use of the toilet bowl brushes on multiple residents' toilets; There was no policy or procedure in place to address the use of toilet bowl brushes in residents' rooms with isolation (proper precautions to prevent the spread of infection in the health care setting.) precautions; 2. Two of two Housekeeping (HK) staff (HK 4 and HK 7) did not follow (brand name) disinfectant's (a chemical solution used to sanitize (to make clean) surfaces and devices and approved to destroy bacteria [MEDICAL CONDITION]) IFU and bleach's IFU when the two products were mixed and used to disinfect the toilet bowl brushes; 3. Two of two HK staff (HK 3 and HK 7) did not follow the IFU of bleach, specific to contact time (time the disinfectant needs to stay wet on surface in order to work) when disinfecting surfaces; 4. Social Service Director (SSD) shared an office with Social Service Staff (SSS) 1 and did not wear a mask; 5. Six of six facility staff (Housekeeping Supervisor (HKS), Medical Record Staff (MRS 1), SSD, Certified Nurse Assistant (CNA) 1, Physical Therapist (PT) 1, and Licensed Vocational Nurse (LVN) 1) did not wear a N95 respirator (respiratory protective device designed to achieve a very close facial fit that protects the wearer from inhaling particles) as intended. The HKS and SSD wore a N95 respirator that contained a valve. MRS 1, CNA 1, PT 1, and LVN 1 did not wear their N95 respirator correctly that promoted a tight seal around the face to protect the wear from COVID-19 (a serious respiratory illness caused by [MEDICAL CONDITION] which is the cause of a current worldwide pandemic (prevalent over a whole country or the world)); 6. The facility did not follow standards of practice of Personal Protective Equipment (PPE -protective equipment designed to protect the wearer's body from injury or infection) use when the facility implemented the practice to reuse N95 respirators when the facility was not experiencing a shortage with N95 respirators; and 7. The Infection Preventionist (IP) failed to oversee the operations of the facility's practices to mitigate (to reduce the spread) COVID-19 and other communicable disease when she was unaware of the HK staff's reused toilet bowl brushes in multiple residents' rooms and mixed disinfectants when the IFUs indicated it can cause harm. These failures resulted in the risk for cross contamination (inadvertent transfer of germs from one surface or person to another) and transmission of disease, including but not limited to COVID-19 to 139 residents and staff in the facility. An Immediate Jeopardy (IJ) situation was called on 11/5/20, at 12:07 p.m., with the Administrator (ADM), the Director of Nursing (DON), the Infection Preventionist (IP), and the Housekeeping Supervisor (HKS), under CFR (Code of Federal Regulation) 483.80 Infection Control. Serious issues were identified with infection control standards not being followed when HK staff reused toilet bowl brushes in multiple residents' toilet bowls for an unknown amount of time. There was no IFU that indicated the toilet bowl brushes were intended for multiple resident use. There was no policy or procedure in place to direct the reuse of toilet bowl brushes in multiple residents' toilet bowl. There was no IFU to indicate how to clean the toilet bowl brushes in between use. The HK staff mixed (brand name) disinfectant solution with bleach. The IFU for bleach indicated to not mix with toilet bowl solutions as it can cause a hazard (a danger or risk). The ADM was provided with the IJ template which documented the immediate actions necessary to address the IJ situation. The ADM was provided an explanation to submit an acceptable Action Plan to address the IJ situation. An acceptable Action Plan was accepted on 11/6/20 at 3:39 p.m., the facility's practice of reusing toilet bowl brushes on multiple residents' toilet bowls was immediately stopped. The reused toilet bowl brushes that were used on multiple residents' toilets were disposed of and the facility implemented the use of a single use scrub pad that would be disposed of after one use. The IP and HKS provided education to the housekeeping staff that included following disinfectant products' instructions for use (IFU) and the hazard of mixing bleach and other disinfectants. The components of the IJ Action Plan were validated through observations, interviews, and record review. The IJ situation was removed on 11/6/20 at 5:41 p.m., with the ADM, DON and IP. Findings: 1. During a concurrent observation and interview on 11/3/20, at 11:20 a.m., in the hallway of the yellow zone (area where persons under investigation for COVID-19 are located), with HK 3, HK 3 removed a cut out container (handmade holder made from an empty bleach container) that contained bleach with water and a toilet bowl brush from the housekeeping cart, walked into room [ROOM NUMBER]'s restroom and cleaned the toilet. HK 3 sprayed (brand name) disinfectant solution into the toilet bowl and scrubbed the toilet bowl with a toilet bowl brush. When HK 3 finished cleaning the toilet, HK 3 returned the used toilet brush into the cut-out container that had bleach with water and placed the cut-out container back into the housekeeping cart. HK 3 stated she re-used the toilet bowl brush for all residents' toilets located in the yellow zone. During an interview on 11/3/20, at 3:47 p.m., with the HKS, the HKS stated the process of cleaning resident's toilets was the toilet bowl brushes were to be re-used for multiple residents' toilets. The HKS stated he did not work with the IP on whether the toilet bowl brushes could be used in multiple residents' toilet bowls. The HKS stated each housekeeping cart had a reusable toilet bowl brush and the brushes were replaced every two weeks. A request was made for the toilet bowl brushes' IFUs, the HKS stated the facility was not able to provide the toilet bowl brush's IFU for cleaning and disinfecting of the toilet bowl brushes. During a concurrent observation and interview on 11/4/20, at 10:02 a.m., with HK 7, in the hallway, HK 7 removed a cut out container and stated the cut out container contained (brand name) disinfectant solution and bleach mixed. HK 7 walked into room [ROOM NUMBER]'s restroom and cleaned the toilet. HK 7 sprayed the (brand name) disinfectant solution into the toilet bowl and scrubbed the toilet bowl with a toilet bowl brush. When HK 7 finished cleaning the toilet, HK 7 did not disinfect the toilet bowl brush. HK 7 returned the used toilet bowl brush back into the cut out container that had (brand name) disinfectant solution and bleach mixed and placed the cut out container back into the housekeeping cart. HK 7 stated she re-used the same toilet brush for all residents' toilet bowls. HK 7 stated housekeeping staff re-used the same toilet brush twice a day, daily and replaced the toilet brushes every two weeks. HK 7 went into room [ROOM NUMBER]'s restroom and cleaned the toilet with the same toilet bowl brush that was used in room [ROOM NUMBER]. When HK 7 finished cleaning the toilet, the toilet bowl brush was not disinfected after use and HK 7 returned the used toilet bowl brush back into the cut out container with the (brand name) disinfectant solution and bleach mixture and placed the cut out container back into the housekeeping cart. During an interview on 11/4/20, at 3:20 p.m., with the IP, the IP stated she did not have oversight (action of overseeing something) on how housekeeping cleaned and disinfected residents' toilets and was unaware of the practice of reusing toilet bowl brushes when cleaning residents' toilets. The IP stated the HKS was responsible for all HK employees. During an interview on 11/6/20 at 8:31 a.m., with HK 5, HK 5 stated for three years, she had implemented the practice of reusing toilet bowl brushes and utilizing the cut-out bleach container to hold the brush. HK 5 stated she had reused the toilet brushes for up to three weeks. During a concurrent interview and record review on 11/6/20, at 10:15 a.m., with the DON, the DON stated the HK staff should not have re-used the toilet bowl brushes on multiple residents' toilets if there were no IFUs on how to clean and disinfect the toilet bowl brushes. The DON stated manufacturer's IFU would have guided the user on the length of time equipment/tools could be used and how to properly clean and disinfect the equipment/tools. The DON stated the facility was unable to provide the manufacturer's IFU on the toilet bowl brushes. The DON stated she was not certain if the brushes were intended for multiple resident toilet use. The DON stated the IP should have oversight and should have been aware of the HK staff practice on cleaning and disinfecting residents' toilets. During an interview on 11/6/20 at 11:30 a.m., with HK 1, HK 1 stated during the process of toilet bowl cleaning, the toilet brush container used was a cut out bleach plastic gallon container. HK 1 stated she used the same toilet bowl brush for two weeks from one resident's toilet to another resident's toilet. HK 1 stated she was a new employee and had employed for two weeks. During an interview on 11/6/20 at 2:50 p.m., with HK 7, HK 7 stated the used cut-out bleach container contained a toilet bowl brush and (brand name) disinfectant solution and bleach mixed. HK 7 stated she was not supposed to mix the disinfectant solution and bleach together. HK 7 stated she had used the same toilet bowl brush for up to three weeks. HK 7 stated the facility had not educated staff on when to dispose the toilet bowl brushes. During an interview on 11/9/20, at 2:18 p.m., with HK 7, HK 7 stated since 2019 (when she started her employment), the facility's practice was to reuse toilet bowl brushes for multiple residents' toilets. HK 7 stated the new process was to use a disposable scrubber after one time use to prevent infection. During an interview on 11/9/20, at 2:37 p.m., with HK 4, HK 4 stated he used the toilet bowl brush for multiple residents' toilets for two years. HK 4 stated he was educated on the facility's new process to use a disposable scrubber and dispose of it after one use to prevent infection. During an interview on 11/10/20 at 8 a.m., with HK 9, HK 9 stated she had reused the same toilet bowel brush for up to three months. HK 9 stated the practice of reusing toilet brushes for multiple residents' toilets had been in effect for as long as she had been employed, a little over a year. A request was made for the toilet bowl brush's IFU on 11/4/20, 11/5/20, 11/6/20, 11/9/20, and 11/10/20 from the ADM, DON, IP, and HKS and the facility was unable to provide a document prior to the exit of the survey. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces revised June 2009, the P&P indicated, Policy Statement .Environmental Surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities .Policy Interpretation and Implementation .5. Manufactures' instructions will be followed for proper use of disinfecting (or detergent) products including: safe use .14 .The disinfectant (or detergent) will be prepared as recommended by the manufacturer . During a professional reference review from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, retrieved on 11/20/20, titled, Healthcare-associated Infections - Environmental Cleaning Procedures dated 4/21/20, the professional reference indicated, .The determination of environmental cleaning procedures for individual patient care areas, including frequency, method, and process, should be based on the risk of pathogen transmission .this risk is a function of the: probability of contamination, vulnerability of the patients to infection, potential for expose .For higher-risk areas, change cleaning cloths between each patient zone (i.e., use a new cleaning cloth for each patient bed) .Never double-dip cleaning cloths into portable containers (e.g., bottles, small buckets) sued for storing environmental cleaning products (or solutions) .Never leave soiled mop heads or cleaning cloths soaking in buckets . During a professional reference review from https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdf, retrieved on 11/22/20, titled, Best Practices for Environmental Cleaning in Healthcare Facilities dated 2019, the professional reference indicated, .Facility Environmental Cleaning Policies .list of approved cleaning products, supplies, and equipment and any required specifications on their use .4.3. Patient area toilets .Toilets in patient care areas can be private (within a private patient room) or shared (among patients and visitors). They have a high patient exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, they pose a higher risk of pathogen transmission than in general patient areas . 2. During a concurrent observation and interview on 11/4/20, at 10:02 a.m., with HK 7, in the hallway, HK 7 took a cut out container that contained an unknown solution from the housekeeping cart. HK 7 stated the solution in the cut-out container was a mixture of ¼ cup bleach and (brand name) disinfectant solution. HK 7 stated she used the mixed solution to disinfect the toilet brush. HK 7 stated she was not aware of the manufacturer's IFU for bleach, which indicated not to mix with other disinfectant products. During an interview on 11/4/20, at 3:20 p.m., with IP, the IP stated she was unaware of the HK staff's practice of mixing (brand name) disinfectant solution and bleach. The IP stated bleach should not be mix with any other solution, other than water. The IP stated she was not aware of the effects of mixing (brand name) disinfectant solution and bleach. The IP stated she did not have oversight over the practices of HK staff, and she should have had oversight to ensure effective cleaning and disinfection were implemented to prevent and control the spread of infection. During a concurrent observation and interview on 11/4/20, at 3:59 p.m., with HK 4, in the HK storage room, HK 4 was observed measuring two and a half cup water and (brand name) disinfectant solution into a cut out container. HK 4 added ½ cup of bleach to the water and disinfectant solution mixture. HK 4 stated he was not aware of the manufacturer's IFU for bleach not to mix with other disinfectant. During a concurrent observation and interview on 11/4/20, at 4:09 p.m., with the HKS, in the hallway, the HKS confirmed the above observation of HK 4. The HKS stated HK 4 should not have mixed (brand name) disinfectant solution and bleach together. During an interview on 11/6/20, at 10:15 a.m., with the DON, the DON stated the HK staff should not have mixed (brand name) disinfectant solution with bleach. The DON stated the HK staff should have followed the manufacturer's IFU of both (brand name) disinfectant solution and bleach. The DON stated the practice of mixing (brand name) disinfectant solution and bleach was a potential hazard to residents and staff. During an interview on 11/6/20 at 2:50 p.m., with HK 7, HK 7 stated the used cut out bleach container contained the toilet bowl brush and (brand name) disinfectant solution and bleach mixed. HK 7 stated she was made aware by the facility she was not supposed to mix the (brand name) disinfectant solution and bleach. During an interview on 11/9/20, at 2:18 p.m., with HK 7, HK 7 stated she has mixed (brand name) disinfectant and bleach for six months. HK 7 stated she thought when she mixed (brand name) disinfectant solution and bleach, it would be more effective against COVID 19. During an interview on 11/9/20, at 2:37 p.m., with HK 4, HK 4 stated he has mixed (brand name) disinfectant and bleach for two years. HK 4 stated he made the decision to mix the two products. During a review of the manufacturer's IFU for bleach, dated 2020, the IFU indicated, .DANGER: CORROSIVE (attack and chemically destroy exposed body tissue) . PHYSICAL OR CHEMICAL HAZARDS: Product contains a strong oxidizer (type of chemical which a fuel requires to burn) . Do not use or mix with other chemicals, such as toilet bowl cleaners .To do so will release hazardous irritant gasses . During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces revised June 2009, the P&P indicated, Policy Statement .Environmental Surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities .Policy Interpretation and Implementation .5. Manufactures' instructions will be followed for proper use of disinfecting (or detergent) products including: safe use .14 .The disinfectant (or detergent) will be prepared as recommended by the manufacturer . During a professional reference review of https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html retrieved on 11/21/20, titled, Disinfecting Your Facility dated July 28, 2020, the professional reference indicated, .Disinfect .Follow the instructions on the label to ensure safe and effective use of the product .Always read and follow the directions on the label to ensure safe and effective use .Avoid mixing chemical products . Never mix household bleach with ammonia or any other cleanser. This can cause fumes that may be very dangerous to breathe in . 3. During a concurrent observation and interview on 11/3/20, at 11:20 a.m., with HK 3, outside room [ROOM NUMBER] in the hallway, HK 3 was observed cleaning room [ROOM NUMBER]. HK 3 wiped the bedside table, call light and remote control with bleach. After 30 seconds, HK 3 used a dry washcloth and wiped the bedside table, call light and remote. HK 3 stated bleach left mark on the surface, therefore, to prevent marks, she wiped it immediately with a dry washcloth. HK 3 stated she was not aware bleach's contact time was five minutes. During an interview on 11/3/20, at 3:47 p.m., with the HKS, the HKS stated HK staff should follow bleach's contact time of five minutes per the IFU. The HKS stated the purpose of leaving the bleach solution wet for five minutes was to ensure all microorganisms (bacteria, virus, or fungus) were killed and to prevent the transmission of infectious diseases such as COVID-19. During a concurrent observation and interview on 11/4/20, at 10:02 a.m., with HK 7, outside room [ROOM NUMBER] in the hallway, HK 7 was observed cleaning room [ROOM NUMBER]. HK 7 wiped the bedside table with bleach and let it dry for two minutes. HK 7 then mopped the floor with a bleach and let it dry for two minutes. HK 7 stated bleach did not need to stay wet for a long time. HK 7 was not aware of bleach's contact time of five minutes. During an interview on 11/4/20, at 3:20 p.m., with the IP, the IP stated she was not aware of the bleach's manufacturer's IFU the HK staff used. The IP stated the HKS was the person that made decisions on what disinfectant solution were to be used by HK staff and the HKS was the person in charge of HK staff. During a review of the manufacturer's IFU for bleach, dated 2020, the IFU indicated, .Instructions for [DIAGNOSES REDACTED]-CoV-2 (type of virus) .contact time used to kill [DIAGNOSES REDACTED]-COV-2 five minutes Instructions for hard, non-porous surface disinfection 2. Apply solution to contact surface 3. Allow solution to contact surface for at least 5 minutes . During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, revised June 2009, the P&P indicated Policy statement-Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities .5. Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution b. Material compatibility c. Storage d. Shelf-life and e. Safe use and disposal .14 .The disinfectant (or detergent) will be prepared as recommended by the manufacturer . During a professional reference review from https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html, dated 7/28/20, retrieved on 11/21/20, titled, Disinfecting Your Facility, indicated, . How to clean and disinfect .Disinfect .Follow the instructions on the label to ensure safe and effective use of the product . 4. During a concurrent observation and interview on 11/3/20, at 11 a.m., with the ADM, in the hallway, the SSD was observed in a shared office with Social Service Staff (SSS) 1 and SSD did not have a mask on. The ADM stated the SSD should have worn a mask as source control (refers to the use of masks to cover a person's mouth and nose and to help reduce the spread of large respiratory droplets to others when the person talks, sneezes, or coughs) inside the facility. During an interview on 11/3/20, at 2:24 p.m., with the SSD, the SSD validated she was not wearing a mask earlier that morning at 11 a.m. while in the shared office with SSS 1. SSD stated was unaware that masks should always be worn when inside a shared office. During an interview on 11/5/20, at 2:17 p.m., with the IP, the IP stated facility staff should wear a N95 respirator when in a shared office to prevent the spread of infections like COVID-19. During a review of the facility's P&P titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated April 2020, the P&P indicated, Policy Statement .This facility follows recommended standard and transmission-based precautions, environmental cleaning .to prevent the transmission of COVID-19 within the facility .3. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented .a. anyone entering the facility is required to have a cloth face covering regardless of symptoms .(2) .staff should wear a facemask at all times when in the facility . During a professional reference review of https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, retrieved on 11/21/20, titled, Considerations for Wearing Masks updated 11/12/20, indicated, .Masks are a simple barrier to help prevent your respiratory droplets from reaching others. Studies show that masks reduce the spray of droplets when worn over the nose and mouth. You should wear a mask, even if you do not feel sick. This is because several studies have found that people with COVID-19 who never develop symptoms (asymptomatic) and those who are not yet showing symptoms (pre-symptomatic) can still spread [MEDICAL CONDITION] to other people. The main function of wearing a mask is to protect those around you, in case you are infected but not showing symptoms . 5. During a concurrent observation and interview on 11/3/20, at 2 p.m., with the HKS, in the activity room, the HKS wore his N95 respirator that contained a valve (exit of air). The HKS stated the facility provided the N95 respirators with the valve. The HKS was not aware N95 respirators with a valve should not be worn inside the facility. During a concurrent observation and interview on 11/3/20, at 2:15 p.m., with MRS 1, at the nurse's station of the yellow zone, MRS 1 wore a surgical mask between her face and the N95 respirator. The surgical mask was directly on her face, and the N95 respirator was on top of the surgical mask. MRS 1 stated, .The N95 mask was fuzzy (indistinct texture) that's why I wear surgical mask between my face and N95 mask . MRS 1 was not aware when she wore her surgical mask between the N95 respirator and her face, it can result to a poor seal, resulting in unfiltered air to be inhaled by the wearer. MRS 1 stated she will just use the N95 respirator and remove the surgical mask. During a concurrent observation and interview on 11/3/20, at 2:24 p.m., with the SSD, in the activity room, the SSD wore an N95 respirator with a valve. The SSD stated the facility provided the N95 respirators with that contained a valve. The SSD was not aware N95 respirators with a valve should not be worn inside the facility. During a concurrent observation and interview on 11/3/20, at 2:55 p.m., with CNA 1, in the facility lobby, CNA 1 wore a surgical mask between her face and the N95 respirator. The surgical mask was directly on her face, and the N95 respirator was on top of the surgical mask. CNA 1 stated, .I use surgical mask to protect my nose from the N95 mask . CNA 1 was not aware when she wore a surgical mask between the N95 respirator and her face, it can result to a poor seal, resulting in unfiltered air to be inhaled. CNA 1 stated she will just use the N95 respirator and remove the surgical mask. During an interview on 11/5/20, at 2:17 p.m., with the IP, the IP stated facility staff should not use N95 respirators with a valve and all facility staff should not wear their surgical mask between their N95 respirator. The IP stated staff should properly use their N95 respirators to get a proper (fitting) seal and fit to protect themselves, their coworkers, and residents at the facility against COVID-19. During a concurrent observation and interview, on 11/5/20, at 3:24 p.m., with Physical Therapist (PT) 1, in the facility lobby, PT 1 wore his N95 respirator with the top elastic strap secured to the back of his head. PT 1's N95 respirator's bottom elastic head strap was loosely hanging (not secured to the back of his head). PT 1 stated he should have worn his N95 respirator with both top and bottom elastic straps secured at the back of his head to protect him and staff and residents against COVID-19. During a concurrent observation and interview, on 11/5/20, at 6 p.m., with LVN 1, in the hallway, LVN 1 wore an N95 respirator, the lower elastic head strap was broken. LVN 1 stated she should have not used an N95 respirator that had a broken strap. LVN 1 stated she will change to a new N95 respirator with both elastic bands intact to get a proper fit to protect her, other staff, and residents. During a concurrent observation and interview on 11/5/20, at 6:05 p.m., with the IP, in the hallway, the IP validated the observation of LVN 1's N95's broken respirator strap. The IP stated LVN 1 should have worn a N95 respirator with both top and bottom strap secured to have a proper seal of the N95 respirator to prevent the spread of infection of all facility staff and all residents in the facility. During an interview on 11/6/20, at 10:15 a.m., with the DON, the DON stated PT 1 should have properly secured his N95 respirator with the use of both top and bottom straps over the back of his head. The DON stated the bottom elastic strap was positioned around the neck and below the ears. The DON stated staff should follow proper steps and instruction of wearing a N95 respirator as source control. During a review of the facility's P&P titled, Personal protective Equipment - Contingency and Crisis Use of N-95 mask Respirators (COVID -19 Outbreak), dated April 2020, the P&P indicated, Purpose: To guide the use of PPE through contingency (unforeseen event or circumstance) and crisis capacity (measures that are not adequate with standards of care but may need to be employed during periods of known shortage) strategies when supply is limited .Managing the Supply of PPE 1. Inventory of PPE is managed systematically, based on the facility calculations for PPE Burn Rate (rate to determine how many PPE are used each day) .Procedure of Donning (putting on) and Doffing (putting off) N95 Respirator mask 1. To put on an N95 respirator mask: a. Secure ties or elastic bands at middle of head and neck. b. fit flexible band to nose bridge and fit mask snug to face and below chin. C. Fit-check respirator . During a professional reference review from the Centers for Disease Control and Prevention titled, Considerations for Wearing Masks Coronavirus Disease 2019 (COVID-19), dated November 4, 2020, the professional reference indicated .Masks are most likely to reduce the spread of COVID-19 .Masks with exhalation valves or vents should NOT be worn to help prevent the person wearing the mask from spreading COVID-19 to others (source control) . Masks with Exhalation Valves or Vents the purpose of masks is to keep respiratory droplets from reaching others to aid with source control .masks with one-way valves or vents allow air to be exhaled through a hole in the material, which can result in expelled respiratory droplets that can reach others. This type of mask does not prevent the person wearing the mask from transmitting COVID-19 to others. Therefore, CDC does not recommend using masks for source control if they have an exhalation valve or vent . During a professional reference review from https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html, retrieved on 11/22/20, titled, Coronavirus Disease HealthCare Workers PPE FAQs (frequently asked questions) dated 8/8/20, the professional reference indicated, .Respirators .My N95 respirator has an exhalation valve. Is that okay? .An N95 respirator with an exhalation valve does provide the same level of protection to the wearer as one that does not have a valve . If you only have a respirator with an exhalation valve available, cover the exhalation valve with a facemask (surgical or procedure mask) that does not interfere with the respirator fit .Can a respirator with an exhalation valve be used as source control . Respirators with exhalation valves protect the wearer from [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, but may not prevent [MEDICAL CONDITION] spreading from the wearer to others (that is, they may not be effective for source control) .Wear a respirator without an exhalation valve when both source control and respiratory protection are required . 6. During a concurrent observation and interview on 11/3/20, at 9:50 a.m., with Screener (SC) 1, in the lobby, there were used N95 respirators stored in separate containers. SC 1 stated staff reused their N95 respirators and the facility's process was for each staff to have four N95 respirators rotated throughout the week. During an interview on 11/3/20, at 1:11 p.m., with the IP, the IP stated the facility reused their N95 respirators. When the IP was asked if the facility was under crisis capacity (measures that are not adequate with standards of care but may need to be employed during periods of known shortage), the IP stated she was unaware of what crisis capacity was. The IP stated the facility had enough N95 respiratory supplied. The IP stated the local county provided the facility with around two thousand N95 respirators. The IP was unaware of the facility's daily burn rate (rate to determine how many PPE are used each day), the IP stated the ADM was responsible in calculating the burn rate. During an interview on 11/6/20, at 2:22 p.m., with the ADM, the ADM stated all staff in the facility should wear an N95 respirator and face shield as part of their process to mitigate (lessen) the outbreak. The ADM stated, .We were not aware of the process not to re-use N95 masks (respirator), we were under the impression that we can still re-use N95 mask . The ADM stated the facility would change their process, N95 respirators will only be used once per shift (work period for a give (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were labeled in accordance with accepted professional standards of practice for three of 35 sampled residents (Resident 28, Resident 65 and Resident 9) when: 1. Medication cart 2 stored Resident 28's insulin flex pen (an insulin pen used to inject insulin for the treatment of [REDACTED]. [REDACTED]. Medication cart 2 (two of six medication carts) stored insulin flex pen with a hand-written label for Resident 28 and without a pharmacy prescription label. 2. Medication cart 1 stored Resident 65's [MEDICATION NAME] (specific brand) insulin vial (a rapid acting insulin used to lower blood sugar level) without a pharmacy prescription label. The [MEDICATION NAME]vial was pulled from the facility's emergency kit (e-kit - emergency medications supplied by pharmacy that was stocked with 4-10 day supply of the most common medication each facility may use). 3. Medication cart 1 stored an insulin flex pen without a prescription label. A torn label was found in the same storage compartment for Resident 9 and was attached to the unlabeled insulin flex pen against facility policy and procedure and safe medication storage and administration practice. The facility demonstrated a system (a coordinated body methods) of storing medications in an unsafe manner and did not follow acceptable professional standards for labeling medications. These deficient practices resulted in residents being given insulin that were not labeled or did not have a label from pharmacy which placed the residents at risk of receiving the wrong medication that could cause [MEDICAL CONDITION] or [DIAGNOSES REDACTED] (low blood sugar) that could potentially lead to serious complications ([MEDICAL CONDITION], coma). An Immediate Jeopardy (IJ) situation on a K level (a pattern - involving three residents) was called on 6/28/18 at 7:35 p.m. The medication nurses had been using insulin pens and vial without a pharmacy label on the insulins for Resident 28, Resident 65 and Resident 9. The Administrator and Director of Nursing (DON) were notified verbally. The facility's Action Plan which included taking out the unlabeled insulins from the medication carts, checking all medication in the medication carts were labeling and providing in-services on medication storage and labeling to the licensed nurses was accepted on 7/2/18 at 8:30 a.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 7/2/18 at 4:26 p.m. Findings: 1. On 6/28/18 at 3:13 p.m., during an observation of medication cart 2 and concurrent interview at station 1 hallway, Resident 28's [MEDICATION NAME]flex pen was observed without a pharmacy prescription label and without an open date (the date medication was opened for the first time). The [MEDICATION NAME]flex pen was observed with Resident 28's name hand written. Licensed Nurse (LN) 12 stated, I don't know where it (insulin pen) came from, it wasn't here (medication cart) yesterday. Once the [MEDICATION NAME] flex pen is open, it should be dated and used within 28 days. The [MEDICATION NAME] flex pen will be ineffective (loses its potency which could result to very high blood glucose levels) and will have a potential negative effect (damage to nerves, blood vessels, and organs) to the resident (if used after 28 days). On 6/28/18 at 3:34 p.m., during an interview, Unit Manager (UM) 1 stated, The [MEDICATION NAME] flex pen should have a pharmacy prescription label and should be dated once opened. We (licensed nurses) don't even know if that's for the specific resident since it has no pharmacy prescription label. UM 1 stated an insulin flex pen without a pharmacy prescription label should never be used on a resident and should be returned to the pharmacy. UM 1 stated it is not a safe practice to administering an insulin pen without a pharmacy prescription label. On 6/28/18 at 7:04 p.m., during an interview, the Director of Nursing (DON) stated, I'm hoping the (unlabeled) [MEDICATION NAME] flex pen was for that resident. I wasn't here so I don't know. The nurses are not allowed to write the residents name on an unlabeled medication. The pharmacist and the doctor are the only ones allowed to label medications. I don't know if the [MEDICATION NAME]flex pen came out from that box (medication delivered by local pharmacy) and I don't know for how long it was in the medication cart. The box (insulin flex pen) was delivered from the satellite (local pharmacy) and it contained three insulin flex pens without individual prescription labels. It has always been delivered by the satellite pharmacy like that (without an individual prescription label). The nurse receiving the medications should check the medications being delivered and make sure it has a label. On 6/29/18 at 2:20 p.m., during an interview, the Consultant Pharmacist (CP) 2 stated, .There is room for medication error without the insulin's having a prescription label. A new insulin pen should have been ordered. I have not reviewed any medication carts for insulin pens until today. ISMP (Institute for Safe Medication Practices) Professional Reference titled, ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults dated (YEAR), (found at www.ismp.org) indicated . 3. Administration and Monitoring of Subcutaneous Insulin, 3.1 Patient-specific insulin pens are stored on clinical units in a manner that prevents their inadvertent use on more than one patient. If an institution chooses to use insulin pen devices, each should contain a patient-specific label and be stored in a patient-specific bin/drawer on the clinical unit to prevent contamination from inadvertent misuse on another patient . Insulin as a High- Alert Medication. Medications that are associated with the highest risk of injury when used in error are known as high-alert medications . The survey findings suggest a consensus among pharmacists and nurses that hospitalized patients are vulnerable to errors with subcutaneous insulin, and that more must be done to prevent patient harm with this high alert medication . On 6/29/18 at 2:20 p.m., during an interview, the CP 1 stated, Licensed Nurses cannot label the insulin pens. The insulin pens cannot be in the building (facility) unlabeled. On 6/29/18 at 3:51 p.m., during an interview, LN 6 stated, The previous DON told us (licensed nurses) that it is okay to just put a date on the insulin vial pulled from the e-kit. We (licensed nurses) have just been putting the insulin vial inside the pill crusher pouch (clear plastic pouches safely contains pills during crushing process). We (licensed nurses) thought it was okay to use the insulin pulled from the e-kit multiple times until the medication arrives from our pharmacy. For the insulin flex pen, I just put the room number and the resident name because when the insulin flex pen was delivered, it does not come with a name or a label from the pharmacy. LN 2 then pulled a black marker out of her pocket and stated, That's why I always have a black marker with me so I can write the resident's name and room number in the insulin flex pen. Everybody (licensed nurses) has been doing that because that's what we were told during new hire orientation. I don't remember an in-service training before on how to store and label medications. During a review of the facility document titled, Current Employees with Hire Date indicated LN 6 was hired in the facility on 5/20/03 ([AGE] years). During a review of the facility document titled, Delivery Manifest: (Name of City) 05 dated 6/22/18 at 6:13 am, indicated Resident 65's Humalog (specific brand) insulin vial was delivered to the facility and was signed by facility's Registered Nurse (RN) 3. 2. On 6/28/18 at 8:35 p.m., during an observation of medication cart 1, and concurrent interview, an opened vial of Humalog insulin was found inside a pill crusher pouch with Resident 65's handwritten name and room number. LN 9 stated, The Humalog insulin came from the e-kit. It (Humalog insulin) was ordered on [DATE] and was not delivered by the pharmacy. I was off for four days and when I came back, we were still using the same Humalog insulin vial from the e-kit. On 6/29/18 at 3:18 p.m., during an interview, LN 13 stated, We (licensed nurses) don't have a policy (medication storage and labeling) before that we can only use medications from the e-kit once. Our nursing supervisor just told me to put it (insulin vial) in the pill crusher pouch and that's okay. We (licensed nurses) just have to put a name and date outside the pill crusher pouch. Since I started working, I never got a training on how to label or store medications so that's how I have been doing it ever since. I thought that was okay to use the unlabeled [MEDICATION NAME]vial again (without a pharmacy label). I did not know that insulin vials pulled from the e-kit cannot be used multiple times. During a review of the facility document titled, Current Employees with Hire Date indicated LN 13 was hired in the facility on 4/27/11 (7 years). On 6/29/18 at 2:23 p.m., during an interview, LN 14 stated, Prior to the in-service today, we did not get any training on medications pulled from the e-kit. We (licensed nurses) would just stock the insulin vial inside the pill crusher pouch and wait for the medications to be delivered by our pharmacy. On 6/29/18 at 3:15 p.m., during an interview, CP 1 stated, E-kit medications are single dose use for residents. The nurses need in-servicing that insulin's pulled from the e-kit are single use. On 7/2/18 at 12:43 p.m., during an interview, the Director of Staff Development (DSD) stated medication storage checklist topic was not included in the facility new hire orientation and annual competencies skills checklist. The DSD stated the facility missed the licensed nurses' competency evaluation for medication storage review and there was no means of measuring the licensed nurses' comprehension on medication storage and labeling. On 7/2/18 at 5:17 p.m., during an interview, the DON stated, The facility needs to improve their education system on training licensed nurses to benefit the safety of all residents. 3. On 6/28/18 at 4:48 p.m., during a concurrent observation of medication cart 1 and interview at station 1 hallway, one compartment contained multiple insulin flex pens. One insulin flex pen was stored without a prescription label. A torn prescription label was found under the other insulin flex pens. LN 13 picked up the prescription label and attempted to attach the pharmacy prescription label to the unlabeled insulin flex pen. LN 13 stated, This is the only medication for this lady (Resident 9) so maybe this (torn prescription label) goes with it (insulin flex pen). I found the paper (torn prescription label) underneath all the pens (insulin flex pens). Maybe it happened when somebody (licensed nurses) picked it up and it ripped. I have no way of knowing that the label (torn prescription label) belongs to that pen (insulin flex pen). On 6/28/18 at 9:48 p.m., during a concurrent observation and interview at medication cart 1 in station 1 hallway, LN 13 and the DSD were reviewing medications. Resident 9's insulin flex pen was on top of the medication cart. The DSD opened the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. LN 13 stated, The insulin pen for (Resident 9) was put back here inside the medication cart. The DON gave it to me and told me she had re-attached the torn label and that it was okay for me to give it to (Resident 9). On 6/28/18 at 10:09 p.m., during an interview, the DON stated, I remember I had 3 insulin pens I was holding. I don't remember if I said that it was okay to use the insulin pen with the torn label. I don't remember who I gave it to. I must have told her that it was okay to use the insulin pen. The facility policy and procedure titled, Labeling of Medication Containers dated 4/07, indicated Policy Statement- All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . 1. Medication labels must be legible at all times. 2. Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all necessary information, such as: a. The resident's name, b. The prescribing physician name, c. The name, address, and telephone number of the issuing pharmacy, d. The name, strength, and quantity of the drug, e. The prescription number, f. The date that the medication was dispensed, g. Appropriate accessory and cautionary statements, h. The expiration date when applicable; and i. Directions for use . 7. Only the dispensing pharmacy can label or alter the label on a medication container or package . The facility policy and procedure titled, Administering Medications dated 12/12, indicated Medications shall be administered in a safe . manner, and as prescribed . 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . 14. Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident . CDC (Centers for Disease Control) Professional Reference titled, CDC Clinical Reminder: Insulin Pen Must Never Be Used for More than One Person dated 1/5/12, indicated . Anyone using insulin pens should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. Insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual. Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices .

Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents (Resident 773) was provided with the necessary behavioral health care services to encompass whole emotional, mental and psychosocial wellbeing when the facility was aware Resident 773 had a history of [REDACTED]. The facility's interdisciplinary team (IDT) (team composed of a Physician, Nurse, Social Service Worker, Activity Director and Dietary Manager) failed to recognize Resident 773's need for a safety plan and make referrals to behavioral health care professionals after Resident 773 engaged in behaviors of binge eating, progressive weight gain, and leaving the facility to purchase illegal street drugs for self-medication. These failures resulted in lack of treatment for [REDACTED]. Resident 773 ultimately purchased alcohol and a handgun during an outing from the facility and committed suicide by a self-inflicted gunshot wound to the head. This deficient practice resulted in the unmet mental health care and wellbeing for Resident 773, his potential narcotic overdose and the purchase of a hand gun used to commit suicide with a self-inflicted gunshot to the head and placed the residents and staff of the facility at risk for harm. Findings: Review of Resident 773's skilled nursing facility (SNF) clinical record face sheet (document with resident profile information) indicated Resident 773 was a [AGE] year old male diagnosed with [REDACTED]. Review of Resident 773's General Acute Care Hospital (GACH) clinical record dated 09/09/16, titled Emergency Department Notes, indicated, Patient Location: ER (emergency room ) .Patient information Chief Complaint: 5150 (is a section of the California Welfare and Institutions Code (WIC) which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to him-or herself, a danger to others, and/or gravely disabled) XXX[AGE] year old (male) placed in 5150 hold for DTO (danger to others). Per 5150, (Resident 773) states that he is depressed and wants to kill himself. He stated he mixed his medication with his alcohol in an attempt to kill himself due to his depression. (Resident 773) also stated he attempted to cut his wrist with a paper clip . (Resident 773) is extremely obese. Review of Resident 773's GACH clinical record titled, Patient Summary Report dated 9/10/16 at 12 p.m., indicated, .Talked with (family member) about placement concerns. Patient normally lives with father however father is ill and not living at home. Patient cannot care for self, making him an unsafe discharge. Patient is currently on 5150 for DTO and grave disability (condition in which a. person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). Patient attempted SI (suicide) with pills and alcohol. Also attempted to cut wrist with paperclips while in hospital . Review of Resident 773's clinical record from the acute care hospital titled, Patient Summary Report dated 9/10/16 at 12:35 p.m., indicated, Face to face evaluation .Client is on 5150 hold for DTS (danger to self). Client presented as calm and cooperative. Client reported that he has experienced depressions throughout his life and has daily thought of suicide . Review of Resident 773's clinical record from the acute care hospital titled, Patient Summary Report dated 9/10/16 at 2:10 p.m., indicated, BEHAVIORAL HEALTH CRISIS EVAL .(Client) continues to endorse desire to die. (Client) indicated his father is dying [MEDICAL CONDITION], he has serious chronic health issues and sees no hope. (Client) indicated if he were to be discharge he would use a weapon at this home. (Client) further stated he collects knives' and they are all over his house. (Client) was not willing to give up his weapons .(Client) would not agree to safety plan and indicated if he were to be released, he would kill himself with a weapon at his home. He was unwilling to give up weapons . Review of Resident 773's clinical record from the acute care hospital titled, Patient Summary Report dated 9/10/16 at 11:49 p.m., indicated, BEHAVIORAL HEALTH CRISIS EVAL .Client was alert and cooperative. Client presented with a flat affect. Client reports that he is suicidal presently and will find a way to kill myself if sent home. Client reports severe depression. Client reports that his meds are not working and he does not get much help from therapy. Client would not agree to a safety plan . Review of Resident 773's acute care hospital discharge summary dated 9/20/16 indicated, Discharge Diagnosis: [REDACTED]. Review of Resident 773's Minimum Data Set (MDS) assessment (evaluation of memory recall, mood and functional abilities) dated 9/27/16, indicated Resident 773 had no cognitive impairment and had a PHQ-9 (is an evaluation to determine severity of depression)score of 8. (score of 1-4 Minimal depression, 5-9 Mild depression, 10-14 Moderate depression, 15-19, 20-27 Severe depression 20-27 Severe depression). Review of Resident 773's clinical record titled, S[NAME]IAL SERVICES INITIAL assessment dated [DATE], indicated, S[NAME]IAL HISTORY: (Resident 773) .fell and could not get up. (Right) leg does not work .MOOD RESIDENT MOOD INTERVIEW (PHQ-9) = 8 (score of 1-4 Minimal depression, 5-9 Mild depression, 10-14 Moderate depression, 15-19, 20-27 Severe depression 20-27 Severe depression) BEHAVIOR EXHIBITED: (NONE) . DANGER TO SELF/OTHERS? NO. (History of) suicidal ideation's INTERVENTIONS: (no entry was recorded) .[MEDICAL CONDITION](S): MED .[MEDICATION NAME] ([MEDICAL CONDITION]) sad face. NON-MEDICATION INTERVENTIONS ATTEMPTED: (Resident 773) likes to read Sci-Fi and (history) books .SUBSTANCE ABUSE, ALCOHOL HISTORY, TOBACCO USE: (Resident 773) does not smoke-drinks occasionally. PSYCHOLOGICAL CONCERNS: New environment .during mood survey (Resident 773) stated that he almost always feels depressed and half the time he feels bad about himself and has trouble concentrating and once in a while he feels tired. Review of Resident 773's Care Area assessment dated [DATE], indicated, 17. [MEDICAL CONDITION] (medications that affect mental state) Drug Use. Triggering conditions .3. Antidepressant medication administered to resident in last 7 days or since admission as indicated .Antidepressant .Adverse consequences of ANTIPSYCHOTICS exhibited by this resident .Lethargy (drowsy and difficult to arouse) .Depression .Care Plan Considerations .Will [MEDICAL CONDITION] Drug Use - Functional Status be addressed in the care plan? Yes. If care planning for this problem, what is the overall objective? Avoid complications .Minimize risks .Is a referral to another discipline warranted? No . Review of Resident 773's clinical record titled, NURSES PROGRESS NOTES & CARE PLAN dated 1/20/17, indicated, 4:45 a.m .CNA reported .the resident .was not responding upon verbal request nor touch .went to the resident's room and heard loud snoring .called the resident, no response received from the resident. Staff shook the resident lightly still no response .O2 (oxygen) sats (saturation) (concentration of oxygen detected through a device placed on a finger) 39% (normal value should be above 90%) O2 applied via mask. MD (physician) notified new order received to send out to ER (emergency room ) .resident remained unresponsive .4:50 a.m., ambulance transported resident to (acute care hospital) Review of Resident 773's acute care clinical record titled, History and Physical dated 1/20/17, indicated, .Morbidly obese male who was brought in form (Skilled Nursing Facility) after being found unresponsive at the facility. On arrival at the ER, (resident 773 was alert and oriented to person, place and time) per ER (Physician) he does not wish to be intubated and that he understands the consequences. He was hypercarbic (excess of carbon [MEDICATION NAME] in the blood) in the 60's and 70's (normal 23-29) and pH was 7.2 (that the normal pH of blood is between 7.35-7.45. If blood pH is lower than 7.3, it is considered acidic and can lead to health related complications) . positive for Opiates (narcotic pain reliever generally safe when taken for a short time and as prescribed by a doctor), and was given [MEDICATION NAME] (medication used to treat narcotic drug overdose) at the ER. (Patient) has a (history of) prior episodes of (respiratory) failure and was intubated at his last hospital admission for same reason . Review of Resident 773's SNF clinical record titled, Social Service Review dated 2/3/17, indicated, a check off assessment with the following items checked, .Psychosocial (Check all that apply) Chronic Pain .Young adult (below 55) . Mood/Behavior Patterns: Half of the time, (Resident 773) feels down, depressed or hopeless. Once in a while, (Resident 773) feels bad about themselves or that they are a failure or have let themselves or their family down. PHQ-9 score is 3 .Resident has behavior monitors for sad facial expressions. Non-pharmacological interventions in place Resident enjoys Karaoke, cooking class and bingo .Resident is well adjusted to this facility . Review of Resident 773's SNF clinical record titled, Physician Progress Record dated 2/25/17, indicated, (complaints of) bilateral knee pain [MEDICATION NAME] (medication used to treat nerve pain) has not been helping .has been buying [MEDICATION NAME] from the street to control his pain since the last time I was here. The street pain control helps him enough that he is able to stand .will report to facility that he is self-medicating with [MEDICATION NAME] that he is buying from the street. I asked him not to self-medicate with street drugs. He agreed to try [MEDICATION NAME] (medication used to treat nerve pain) for pain control failed on [MEDICATION NAME] . Review of Resident 773's SNF clinical record titled, REPORT OF INCIDENT . dated 2/25/17, indicated, 4:00 p.m., Resident reported to (Physician) (PCP 1) he is self-medicating from street drugs. Upon assessment (Resident 773) stated he is taking [MEDICATION NAME] (narcotic) from outside (did not specify source) He agreed to give all medications he had to (nurse) risks explained . (PCP 1) here in facility for rounds. (PCP 1) reported that (Resident 773) confessed to him that he is self-medicating himself with street drugs .per (Resident 773) he stated Yes I've been taking oxy because I needed it. when resident was explained of the risks of such behavior and noncompliance with facility then he stated, I have it in a place where no one will ever find it .(Resident 773) then willingly gave all medications to writer two bottles were given to nurse .per (Resident 773) it is [MEDICATION NAME] no other medications were found .states his pain is not as bad and stated last time he self-medicated was around noon today . Review of Resident 773's short term care plan dated 2/25/17, indicated, Resident stated is self-medicating himself with outside medications. Patient Goal: Resident will comply with facility procedure X (for) 14 days. Approach Plan: MD and (responsible party) aware, inform MD of changes in his condition, (vital signs as needed and every) shift for 3 days, assess for pain (every) shift. Review of Resident 773's updated care plan numbered 6 dated 4/24/17, indicated, PROBLEM/CONCERN .USE OF ANTIDEPRESSANT MEDICATION (MANIFESTED BY) sad facial expressions. Goal .Verbalize feelings of contentment by 90 days. Interact peacefully in social situations by 90 days. Be able to complete an assigned task by 90 days. Will have less than 1-2 episodes of sad facial expression (every day) by 90 days. Medication [MEDICATION NAME] .APPROACH/INTERVENTION The staff will Evaluate effectiveness/side effects of medication, Medicate as ordered (specify) [MEDICATION NAME], Provide diversional activities, Hold conversation with Resident, Provide reality orientation, Explain all procedures, Give praise to activities completed, Provide enough time to respond, Observe conversational content, change mental status, and cognitive ability .psyche consult as needed, IDT to review medication quarterly and (as needed) . Review of Resident 773s updated care plan numbered 8 dated 4/24/17, Uneasy about being depressed Displeased about: depressed mood does not work for him. Preoccupied of health: Depression. Recent change in environment .Encourage to verbalize grief and begin to resolve loss, Encourage to resolve relationship problems, Encourage to verbalize a positive aspect .Resident likes to read and watch Sci-Fi or fantasy stories. Provide the literature for him or put TV on Sci-Fi channel, Promote homelike environment. Review of Resident 773's MDS assessment dated [DATE], indicated Resident 773 had a PHQ-9 score of 1. Review of Resident 773's SNF clinical record titled, Social Service Review dated 5/31/17, indicated, a check off assessment with the following items checked, Psychosocial .Chronic illness, Chronic pain .During mood survey (Resident 773) state that he has trouble falling or staying asleep or sleeping too much .PHQ-9 score is 01. Resident has behavior monitor for sad (facial) expressions. Resident enjoys cooking and bingo. On 6/2/17 at 11:20 a.m., during an observation and concurrent interview, the Director of Nursing (DON) pointed to a cement patio outside of Resident 773's room. A wheelchair covered with dried blood sat on the patio outside Resident 773's room. Dried blood was observed on the cement floor of the patio. The patio was enclosed and was accessible from multiple resident rooms. The DON stated Resident 773 committed suicide early that morning, sitting in his wheelchair on the patio. The DON stated Resident 773 used a hand gun to inflict a gunshot to the head. The DON stated Resident 773 was able to go out to the community without staff supervision and may have gotten the gun during one of his outings. On 6/2/17 at 11:25 a.m., during an observation of an external patio outside of Resident 773's room, and a concurrent interview, the Director of Nursing (DON) sated Resident 773 committed suicide in the exterior patio of his room during the night shift on 6/2/17. The DON stated Resident 773 used a hand gun to inflict a gunshot to the head. The DON stated Resident 773 was able to go out to the community without staff and may have gotten the gun during one of his outings. Review of Resident 773's clinical record titled, Release of Responsibility for Leave of Absence indicated, Resident 773 signed himself out of the facility on 1/3/17, 2/17/17, 2/11/17, 3/27/17, 4/1/17, 4/14/17, 5/2/17, 5/3/17 and 5/4/17. Review of Resident 773's SNF clinical record titled, ACCIDENT/UNUSUAL [NAME]CURRENCE REPORT undated, indicated, (Resident 773) .INCIDENT DATE: 6/2/17 .BRIEF DESCRIPTION: Resident committed suicide .GENERAL .Death .Self-inflicted injury . On 6/2/17 at 11:30 a.m., during an interview, and concurrent record review, Licensed Nurse (LN 1) stated she worked the night shift that Resident 773 committed suicide. LN 1 stated Resident 773 was awake and responsive at 11:50 p.m. LN 1 stated Resident 773 verbalized trouble sleeping because he felt the room was too hot. LN 1 stated Resident 773 seemed normal and did not exhibit any emotional distress. LN 1 stated Resident 773 requested to open the sliding door to his room. LN 1 stated she offered Resident 773 a fan but Resident 773 declined the fan and insisted on going to the outside patio. LN 1 stated Resident 773's was observed by the Certified Nursing Assistant (CNA 1) going to the outside patio next to his room prior to LN 1's first encounter at 11:50 p.m. LN 1 stated the only difference in Resident 773 was that he was doing more for himself. LN 1 stated Resident 773 was taking himself to the restroom and wheeling himself longer distances. LN 1 stated, I never noticed anything that would indicate a plan for suicide. LN 1 stated she last saw him at 3:15 a.m. in the outside patio sitting in his wheel chair and looking at his lap top. LN 1 stated at around 4:25 a.m., she opened the curtain from a room next to his and noticed it was very quiet. LN 1 stated, I went into his room, the sliding door was closed. Everything was dark but I could see that there was something on his face and on the floor. LN 1 stated Resident 773 was found unresponsive with his head tilted back. LN 1 stated, I called his name three times but he did not answer. I went to the cart to get a flashlight and asked (CNA 1) to come with me .when we wound him he was dead. LN 1 stated Resident 773 was always very joyful and talkative. LN 1 stated Resident 773 was being monitored for sad facial expressions. LN 1 stated she did not know Resident 773 had a history of [REDACTED]. LN 1 stated Resident 773's care plan for depression did not indicate his history of suicidality. On 6/2/17 at 1:05 p.m., during an interview, LN 2 stated she was a close relative of Resident 773. LN 2 stated, (Resident 773) had a long history of depression. LN 2 stated Resident 773 had a lot of medical comorbidities and his obesity was a big factor affecting his depression. LN 2 stated, He never said flat out that he wanted to kill himself but he would do things to hurt himself. Like drink himself to the point where he needed emergency assistance. LN 2 stated Resident 773 suffered the loss of his mother two years ago and most recently lost his father in (MONTH) of (YEAR). LN 2 stated Resident 773 depended a lot on his parents and was having a difficult time adjusting with the loss of both parents. Review of Resident 773's monthly weight record dated 9/20/16, indicated a weight of 452 lbs. (pounds). Review of Resident 773's monthly weight record dated 10/2/16, indicated a weight of 471 lbs. Review of Resident 773's monthly weight record dated 11/16/16, indicated a weight of 532 lbs. Review of Resident 773's monthly weight record dated 12/14/16, indicated a weight of 559 lbs. Review of Resident 773's monthly weight record dated 1/24/17, indicted a readmit weight of 546 lbs. Review of Resident 773's monthly weight record dated 2/10/17, indicated a weight of 542 lbs. Review of Resident 773's monthly weight record dated 3/6/17, indicated, (Refused three times by Resident 773) there was no weight recorded. Review of Resident 773's monthly weight record dated 4/25/17, indicated a weight of 617 lbs. Review of Resident 773's monthly weight record dated 5/8/17, indicated, (Refused three times by Resident 773) there was no weight recorded. Review of Resident 773's SNF clinical record titled, Physician Progress Record dated 11/26/16, indicated, .He continues to eat snacks and drinks fluids throughout the day. I spoke to him .he states that he is not eating or drinking that much. However, his responses and attitudes are not suggestive of him being sincere . On 6/2/17 at 1:48 p.m., during an interview, CNA 1 stated, I took care of (Resident 773) last night, I clocked in at 11 p.m., I saw him in his room, he was sitting in his wheel chair and he was on his lap top at around 11:15 p.m., I went into his room at 11:30 p.m. and was doing care to his two roommates. I was in his room at 12:30 a.m., 1:30 a.m. and 2:15 a.m. He was awake at 3 a.m., and at 3:20 a.m., his sliding door was closed. I just figured he wanted more privacy. I was asked by his nurse to help her because something was wrong with him. She took a flashlight and I thought he had another incident like the time when he was unresponsive. I think he had taken a lot of pills or something . CNA 1 stated, When we found him he had blood on his face and the gun was on the ground. CNA 1 stated, A few months ago (Resident 773) was unresponsive and later they found out that he was buying street drugs. CNA 1 stated he did not know if that was a suicide attempt but he knew Resident 773 was transferred to the acute care hospital. Review of Resident 773's SNF clinical record titled, NURSES PROGRESS NOTES & CARE PLAN dated 1/20/17, indicated, 4:45 a.m .CNA reported .the resident .was not responding upon verbal request nor touch .went to the resident's room and heard loud snoring .called the resident, no response received from the resident. Staff shook the resident lightly still no response .O2 (oxygen) sats (saturation) (concentration of oxygen detected through a device placed on a finger) 39% (normal value should be above 90%) O2 applied via mask. MD (physician) notified new order received to send out to ER (emergency room ) .resident remained unresponsive .4:50 a.m., ambulance transported resident to (acute care hospital) On 6/2/17 at 2 p.m., during an interview, and concurrent record review, the DON stated Resident 773 was admitted to the facility from the local acute care hospital on [DATE]. The DON stated Resident 773 was diagnosed with [REDACTED]. In (MONTH) (YEAR) he took street drugs because he said he was in pain. He had to be hospitalized for [REDACTED]. The DON stated she did not think this incident was a suicide attempt because Resident 773 was seeking pain control. The DON stated she could not say for certain Resident 773's incident of self-medication was not a suicide attempt because this question was not asked to Resident 773 by anyone in the facility. The DON stated she was aware of Resident 773's history of suicidality. The DON stated Resident 773's depression was care planned and was monitored for sad facial expressions. The DON stated, (Resident 773) was always smiling with everyone. The DON stated the IDT did not meet to discuss a plan to ensure Resident 773's safety. The DON stated a safety plan was not developed because it was not brought up. The DON stated, I didn't know or think we could develop a plan to ensure his safety .I know that we couldn't restrict his outings because it was his right to come in and out of the facility. The DON stated, We did not do any type of agreement with him to ensure his safety, we did not ask him to let us go through his belongings. On 6/2/17 at 2:30 p.m., The DON stated Resident 773 stopped attending activities a few weeks before his suicide because the activities were too boring. The DON stated Resident 773 was also very non-compliant with his diet and was consuming a lot of food. The DON stated Resident 773 gained over 100 lbs. (pounds) in the last few months (September (YEAR) through (MONTH) (YEAR). The DON stated, All we could do was talk to him but we could not restrict him from buying his food because it was his right. The DON stated Resident 773 was referred to the Psychologist and seen on 10/6/16 and 12/6/16. There were no additional referrals made to the Psychologist and the DON was unable to explain why. On 6/22/18 at 4:50 p.m., during a telephone interview, PCP (Primary Care Physician) 1 stated he was Resident 773's primary care physician and remembered Resident 773 had issues with depression, struggled with obesity and had a history of [REDACTED]. PCP 1 stated, I don't remember who told me, but I recall staff telling me that they had found beer cans around his room .the day of his suicide. I'm thinking he possibly drank enough to depress his mood enough to commit suicide. On 6/2/17 at 3 p.m., during an interview, and concurrent record review, the DON stated she did not know what additional interventions could be implemented for Resident 773's follow up visit with the psychologist on 12/6/16. The DON stated, (The psychologist) could have (followed up on Resident 773) if we would have made the request, but I do not know what happened. The DON was asked if the facility had identified Resident 773's increase in weight gain, non-compliant behavior, consumption of illegal street narcotics, and lack of activity participation as potential flags to seek mental health follow up. The DON did not answer. On 6/2/17 at 3:30 p.m., during an interview, the Social Service Director (SSD) stated she was familiar with Resident 773. The SSD stated, He always smiled and he was well known. His room is centrally located near the time clock and everyone said hello to him. I knew he was diagnosed with [REDACTED]. The SSD stated she did not review the hospital records located inside Resident 773's medical record which indicated his history of suicidality and admission of 5150 on 9/9/16. The SSD stated Resident 773 stated she conducted a mood survey on a quarterly basis which addressed his depression. The SSD stated, He always denied feelings of being better off dead, but he did admit to feeling depressed and hopeless. The SSD stated Resident 773 could have been monitored for feeling depressed and hopeless instead of monitoring for sad facial expressions. The SSD stated she did not know about the time Resident 773 purchased the illegal narcotics in the street. The SSD stated she was part of the IDT and did not recall meeting with the rest of the IDT to address Resident 773's engaging in the purchase of illegal street narcotics. The SSD stated Resident 773's care plan did not address Resident 773's history of suicidal ideation, or his risky behavior of buying illegal street drugs. On 6/7/18 at 5:35 p.m., during a joint telephone interview with PCP 1 and LN 4, and concurrent record review, PCP 1 stated Resident 773's history and physical examination [REDACTED]. PCP 1 stated Resident 773 had decreased sensation of his hands and feet, he suffered from [MEDICAL CONDITION] (The build-up of fatty material inside the arteries affecting circulation), diabetes (body's abnormal metabolism of carbohydrates causing elevated levels of sugar in the blood and urine) and [MEDICAL CONDITION] (nerve damage caused from diabetes). PCP 1 stated, I was his doctor for a few years, prior to his stay at the facility. He was a young man and I lost track of him. I don't know what happened. PCP 1 stated, I think his weight contributed to his depression. PCP 1 stated he couldn't really remember if he had spoken to Resident 773's suicidal ideation's. LN 4 stated Resident 773 was on [MEDICATION NAME] 40 mg (milligram) (unit of measurement) every day. LN 4 stated Resident 773 was being monitored for sad facial expressions. PCP 1 stated Resident 773's depression entailed more manifestations and not only sad facial expressions. PCP 1 stated, (Resident 773) could be difficult and intimidating, when I would see him he would have a lot of soda cans, cookies, sandwiches. I could not come and take his food away. I would talk to him, all he would say was that they were not his. He had a lot of pain issues, he was rather complex. At one point he was on [MEDICATION NAME] (narcotic pain reliever used to treat moderate to severe pain) but he had obstructive sleep apnea (due to his obesity) and was discontinued because I was afraid this would compromise his respiratory status. The narcotics were inducing respiratory depression (decrease of respirations). PCP 1 stated Resident 773 suffered from a lot of pain due to his weight on his joints, his pressure ulcers, and his complain of burning sensation on his hands. PCP 1 stated, I think after a while he was in so much pain that this impacted his depression a lot more. PCP 1 stated Resident 773 was not referred to a pain clinic during his stay at the facility. PCP 1 stated Resident 773 was seen by a psychologist at the facility twice. PCP 1 stated Resident 773 would have benefited from more visits by the psychologist. PCP 1 stated, I always brought up his weight issue, I believe the Registered Dietician was seeing him but there were no additional external resources made. On 6/27/18 at 6:40 p.m., during a joint telephone interview with PCP 1 and LN 4, and concurrent record review, PCP 1 stated he visited Resident 773's in (MONTH) (YEAR). PCP 1 stated, He was able to stand and had less pain (in (MONTH) (YEAR)). He told me he was taking [MEDICATION NAME] (narcotic) since my visit in (MONTH) (YEAR) and said he got it from the street .I told him he could stop breathing and die. I remember he was not happy here, he was looking to move out of the facility. He was very unhappy. His condition worsened, he gained a lot more weight, he was experiencing more pain, and we didn't do much to help. PCP 1 stated Resident 773 was referred to hospice for pain management but was told Resident was not an eligible candidate. PCP 1 stated, I wanted him to be comfortable .his pain was out of control, giving him more narcotics would have placed him in respiratory arrest. He was killing himself by eating so much, we didn't have a very good plan .we should have had him evaluated by a psychiatrist. They could have perhaps done more for him. He was not referred to a pain clinic, he was not referred to a psychologist again, and he was not referred to a psychiatrist .He could have benefited from additional help (the psychologist) could have been contacted, but was not. It looks like he declined further towards the end (of stay) with nothing much done. Review of Resident 773's clinical record titled, LICENSED NURSES PROGRESS NOTES dated 2/26/17, indicated, Called (PCP 1) for [MEDICATION NAME] 75 mg not covered by insurance MD gave (telephone order) to (discontinue) [MEDICATION NAME] and start [MEDICATION NAME] (medication used to treat depression) 30 mg . On 6/29/18 at 1:45 p.m., during a telephone interview, the Psychologist (PSY 1) stated, I am a psychologist and I go the facility when I receive referrals from the social service department. The PSY 1 stated, Typically I will do an initial evaluation and then will do a follow up visit within 30 to 60 days (following the initial visit) to see how the resident is doing. The PSY stated he visited Resident 773 for the first time on 10/6/16 and made a follow up visit on 12/16/16. The PSY 1 stated he remembered Resident 773 was an obese man, with a history of depression dating to a childhood overdose attempt in 2007/2008. The PSY 1 stated he recommended a change in the antidepressant medication (from [MEDICATION NAME] to [MEDICATION NAME] 50 mg (daily) after his first visit. The PSY 1 stated on 12/16/16, Resident 773 verbalized feeling some improvement in mood with [MEDICATION NAME]. The PSY 1 stated he recommended a higher dose of [MEDICATION NAME] to be increased to 100 mg daily. The PSY 1 stated he did not see Resident 773 again following the visit from 12/16/16. Review of police department document titled, Supplemental Report dated 6/2/17 at 4:57 a.m., indicated, .(Officer) contacted the facility director who provided .a clear plastic reseal able bag containing documents and a small box of Federal ammunition. The ammunition was located inside of (Resident 773) backpack along with the documents. (Officer) observed the documents consisted of the purchase of the firearm .receipt, dealer's record of sale, and firearms safety certificate . Review of Resident 773's Coroner Report dated, 6/2/17, indicated, SYNOPSIS Deputy dispatched to the (facility) regarding suicide coroners case .Observed a male subject .recognized as (Resident 773) sitting in a wheelchair. (There} was a large pool of blood on the cement below (Resident 773's) head .Observed some blood droplets fall for (Resident 773) head onto the cement. (Officer) advised

Based on staff and resident interview, clinical record and administrative document review, the facility failed to ensure 1 of 1 residents (Resident 1)received adequate supervision and assistance to remain free of preventable accidents when Resident 1 fell and sustained an injury when unassisted by the Certified Nursing Assistant (CNA). This failure led to an avoidable injury of Resident 1. Findings: Review of Resident 1's face sheet indicated Resident 1 had a history of [REDACTED]. Review of Resident 1's "Nursing Admission Assessment" dated 12/18/13, indicated Resident 1 had poor safety judgment, impaired balance, unsteady gait, had been at risks for falls, and required extensive assistance for toileting. Resident 1's "Minimum Data Set (MDS) assessment, (a federally mandated assessment of residents in a nursing home to identify functional abilities and health problems) dated 1/1/14...under "Functional Status," indicated, "Balance during transition and walking ...only able to stabilize with staff assistance." Resident 1's Physical Therapy notes dated 1/28/14, indicated, "Resident 1 required, "Contact Guard Assistance" (routinely requires contact with resident due to unsteadiness during transfer) to "Stand by Assistance," (close enough to reach resident if assistance needed.)...when ambulating with front wheeled walker and when transferring from bed to wheelchair." Resident 1's "Care Plan....Impaired physical functioning," dated 12/26/13, indicated ambulation, transferring, and locomotion required the assistance of one to two Certified Nursing Assistants (CNAs). Review of the facility document titled, "Physical Therapy Note," dated 1/21/14, indicated, "Treatment Diagnosis: [REDACTED]. Weakness." Resident 1 required tactile cues for proper form...ambulation ...with "Contact Guard Assistance" (routinely requires contact with resident due to unsteadiness during transfer) ...with jerky starts and stops with shuffling feet." On 2/14/14 at 10 a.m., during an interview, in the conference room (with an interpreter), Resident 1 stated she remembered the night she fell . Resident 1 stated CNA 1 had been assigned to her. Resident 1 stated CNA 1 had not worked with her before. Resident 1 stated she had gone to the bathroom with the assistance of CNA 1. Resident 1 stated when she was done in the bathroom CNA 1 started to assist her back to her bed. CNA 1 had been holding on to Resident 1's arm. Resident 1 stated she was unsteady on her feet and needed someone to keep her from losing her balance. Resident 1 stated outside the bathroom CNA 1 had let go of her and instead of helping her back into bed, had turned to close the bathroom door. Resident 1 stated she fell forward and put her hands out to try and stop the fall. Resident 1 stated she fell with her full weight on her hands. Resident 1 stated she believed that CNA 1 had been careless and if CNA 1 had held on to her she would not have fallen. On 4/28/14 at 3 p.m., during a telephone interview, CNA 1 stated on the evening of 2/1/14 she had been assigned to work with Resident 1. CNA 1 stated she knew a little about Resident 1 but was not usually assigned to this resident. CNA 1 stated she had put a "Gait Belt" (a large strap wrapped around the waist of a resident in order to maintain balance) on Resident 1 to walk her to the bathroom. CNA 1 stated after Resident 1 had finished in the bathroom she got Resident 1 up and walked Resident 1 to the sink outside the bathroom and told the resident to " Hold on to the sink. " CNA 1 stated she had let go of the gait belt when she turned her back away from Resident 1 to close the bathroom door. CNA 1 stated when she turned back around Resident 1 had been on the floor. On 7/1/14 at 10:30 a.m., during a telephone interview, Resident 1 stated CNA 1 had not used a gait belt while walking her to the bathroom. Resident 1 stated when CNA 1 had begun to walk her back to the bed, CNA 1 stopped in the middle of the room. Resident 1 stated CNA 1 did not say why she stopped... CNA 1 did not ask Resident 1 to hold on to a sink, or the walker and did not ask her to "Wait." Resident 1 stated she put her arm behind herself to try and feel for CNA 1. Resident 1 stated she was standing alone in her room between the bathroom and her bed. Resident 1 stated she was not close enough to the bed to touch it, lean on it, or sit on it. Resident 1 stated she was unsteady standing alone and started to fall forward. To keep from hitting her head on the floor Resident 1 put out both her hands in front of her. Resident 1's left wrist was fractured when she hit the floor. Resident 1's MDS assessment dated [DATE], indicated, "Balance During Transitions and Walking...not steady, only able to stabilize with staff assistance...transfers. " The facility document titled, "Interdisciplinary Team Notes," dated 2/5/14, indicated on 2/1/14 Resident 1 had been taken to the bathroom by CNA 1. Resident 1 called for CNA 1 when she had finished in the bathroom. CNA 1 started to assist Resident 1 back to bed (approximately 10 feet from bathroom door to end of Resident 1's bed). Before Resident 1 and CNA 1 had reached Resident 1's bed, CNA 1 turned around to go close the bathroom door. After CNA 1 closed the door she turned back around to Resident 1 when she had saw Resident 1 had fallen. The and Resident 1's wrist had been fractured in the fall. The facility administrative document titled, "Fall Prevention and Incident Management" dated 4/1/01, indicated, "It is the policy of this facility to identify residents at risk for fall and or accidents which the facility has control over by planning interventions and implementing procedures to prevent fall and or accident...to protect the safety of our residents." The facility document titled, "Interdisciplinary Team Notes, " dated 2/5/14, indicated on 2/1/14 Resident 1 had been taken to the bathroom by CNA 1. Resident 1 called for CNA 1's assistance when Resident 1 had finished toileting in the bathroom. CNA 1 began to assist Resident 1 back to bed (approximately 10 feet from bathroom door to end of Resident 1's bed). Before Resident 1 and CNA 1 had reached Resident 1's bed, CNA 1 released her hold on Resident 1, turned around in order to close the bathroom door. When CNA 1 turned back toward the resident she observed Resident 1 fall to the floor. CNA 1 stated she observed Resident 1 put out her hands in order to break the fall. Review of Resident 1's acute care hospital note indicated Resident 1 sustained a left radial and ulnar fracture (broken arm). On 2/14/14 at 10 a.m., during an interview, in the conference room assisted by a Spanish interpreter, Resident 1 stated she clearly remembered the night she had fallen and CNA 1 had been assigned to her care. Resident 1 stated she had gone to the bathroom. Resident 1 stated when she was done in the bathroom CNA 1 started to help her go back to bed and had held on to Resident 1's arm. Resident 1 stated she was unsteady on her feet and needed someone to keep her from losing her balance. Resident 1 stated outside the bathroom CNA 1 "let go" of her and turned around to close the bathroom door. Resident 1 stated she then fell forward and put her hands out to try and stop the fall. Resident 1 stated she fell with her full weight on her hands. Resident 1 stated she believed CNA 1 had been "careless" and if CNA 1 had held on to her she would not have fallen. On 4/28/14 at 3 p.m., during a telephone interview, CNA 1 stated on the evening of 2/1/14 she had been assigned to work with Resident 1. CNA 1 stated she had put a "Gait Belt" (a large strap wrapped around the waist of a resident in order to assist with transfer) on Resident 1 to help assist Resident 1 into the bathroom. CNA 1 stated after Resident 1 had finished in the bathroom she got Resident 1 up and walked Resident 1 to the sink outside the bathroom and told Resident 1 to "Hold on to the sink." CNA 1 stated she had let go of the gait belt when she turned her back away from Resident 1 to close the bathroom door. CNA 1 stated when she turned back around to Resident 1, Resident 1 then fell to the floor. On 7/1/14 at 10:30 a.m., during a telephone interview, Resident 1 stated CNA 1 had not used a gait belt while walking her (Resident 1) to the bathroom. Resident 1 stated when CNA 1 walked her back to the bed, CNA 1 stopped in the middle of the room. Resident 1 stated CNA 1 did not say why she stopped... CNA 1 did not ask Resident 1 to hold on to a sink, or the walker and had not asked her to wait. Resident 1 stated she put her arm behind herself to try and feel for CNA 1. Resident 1 stated she was standing alone in her room between the bathroom and the bed. Resident 1 stated she was not close enough to the bed to touch it, lean on it, or sit on it. Resident 1 stated she was unsteady standing alone and started to fall forward. To keep from hitting her head on the floor Resident 1 stated she put out both hands in front of her. Resident 1 stated when she hit the floor she hurt her arm. The facility administrative document titled, "Fall Prevention and Incident Management," dated 4/1/01, indicated, "It is the policy of this facility to identify residents at risk for fall and or accidents which the facility has control over by planning interventions and implementing procedures to prevent fall and or accident...to protect the safety of our residents."