Every finding on record at Magnolia Creek Nursing and Rehabilitation

Based on policy review, medical record review, review of the resident trust accounts, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 1 of 1 (Resident #103) sampled residents reviewed for personal fund account statements. The findings include: 1. Review of the undated facility policy titled, .Conveyance of Funds Upon a Resident's Death., revealed .Purpose.To ensure conveyance of funds upon a resident's death are consistent with applicable legal requirements and standards of practice.Within thirty (30) days of the death of the resident, the company will convey the deceased resident's personal funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate. 2. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Diabetes Mellitus, and Dysphagia (difficulty swallowing foods or liquids). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated Resident #103 was severely cognitively impaired. Review of the medical record revealed Resident #103 expired on 1/2/2025. Review of the trust funds revealed a check was not issued until 3/12/2025, 2 months 10 days after Resident #103 expired. During an interview on 9/17/2025 at 9:52 AM, the Business Office Manager confirmed the resident's funds should have been paid out within 30 days from the date Resident #103 expired.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when unsecured sharps were in 1 of 46 (Resident #5 and #20) sampled residents' bathrooms and failed to complete fall assessment documentation for 1 of 3 (Resident #10) residents sampled for falls. The findings include: 1. Review of the facility policy titled, Accidents and Supervision, dated 6/1/2025, revealed .resident environment will remain as free of accident hazards.Environment refers to any environment or area in the facility that is frequented by or accessible to the residents, including (but not limited to) the residents' rooms, bathrooms.Hazards refers to elements of the resident environment that have the potential to cause injury. Review of the facility policy titled, Falls, dated 6/2025, revealed .Falls Management Program Guidelines .Should the Resident experience a fall the attending nurse shall complete a post fall assessment . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Bipolar Disorder, Depression, and Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #5 was cognitively intact. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Schizophrenia, Anxiety, and Major Depressive Disorder. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 9, which indicated Resident #20 was moderately cognitively impaired. Observations in Resident #5 and Resident #20's room on 9/15/2025 at 9:48 AM, 11:56 AM, and 12:42 PM, revealed 2 disposable blue razors were on the resident's bathroom sink. During an observation and interview in Resident #5 and Resident #20's room on 9/15/2025 at 1:12 PM, Licensed Practical Nurse (LPN) E confirmed that the razors should not be unsecure in the resident's bathroom. During an interview on 9/17/2025 at 8:17 AM, the Director of Nursing (DON) confirmed razors should not be left unsecured in the resident's bathroom. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Heart failure, Chronic Kidney Disease, Hypertension, and Diabetes. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #10 was moderately cognitively impaired. Review of the progress notes dated 9/2/2025, revealed .The aide came to the nurses [nurses'] station and reported that resident [Resident #10] slid off the toilet onto the floor . Review of the post fall event dated 9/2/2025, revealed pages 2-9 were incomplete. During an interview on 9/17/2025 at 12:37 PM, the DON confirmed the post fall event should have been completed.

Based on record review, observation, and interview, the facility failed to provide appropriate treatment and services when staff failed to follow physician's orders for 1 of 2 (Resident #10) sampled residents reviewed for urinary tract infections (UTIs). The findings included: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Kidney Disease, Diabetes, and Schizophrenia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #10 was moderately cognitively impaired. Review of the progress notes dated 9/9/2025, revealed .Resident [Resident #10] c/o [complains of] of burning when urinating, this nurse spoke to NP [Nurse Practitioner] about residents concern. NP ordered urine culture. Resident .temp. [temperature] 98.3. RP [Responsible Party] notified and agrees . Review of the Physician's Orders dated 9/9/2025, revealed .Culture, Urine; Urinalysis. Review of the Lab results dated 9/10/2025, revealed .Urine.DOB [DATE of birth ] does not match cup.recollect and reorder. Observation in Resident #10's room on 9/15/2025 at 3:13 PM and 4:37 PM, revealed a strong ammonia odor. During an observation and interview in Resident #10's room on 9/15/2025 at 5:04 PM, the Director of Nursing (DON) confirmed a foul odor and stated, .not sure what that smell is.maybe BM [bowel movement] .someone is going to change [Resident #10] . Observation in Resident #10's room on 9/16/2025 at 8:34 AM and 11:53 AM, revealed a strong ammonia odor. During an interview on 9/17/2025 at 9:00 AM, the Unit Manager stated, .that [urine sample] was recollected and sent across the street to the hospital. The facility was unable to provide the lab results. During an interview on 9/17/2025 at 12:32 PM, the DON confirmed staff should follow Physician Orders. During an interview on 9/17/2025 at 12:37 PM, the DON confirmed that staff should have followed up on the lab order and the results should have been documented. The DON stated, .But I think the NP said it wasn't necessary to recollect. Review of the NP Encounter Note dated 9/17/2025 and electronically signed at 2:24 PM, revealed .Order for UA [Urinalysis] and urine culture ordered on 09/09/25 [9/9/2025] discontinued.

Based on policy review, medical record review, and interview, the facility failed to ensure staff were accurately administering medications per Physician's Orders and to meet professional standards of practice for 2 of 5 (Residents #38 and #64) residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled Medication Administration, dated 2/20/2024, revealed Medications are administered .as ordered by the physician .compare the medication .to the MAR [Medication Administration Record] to verify .medication dose . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Anemia, Diabetes, and Arthritis due to other bacteria, unspecified joint. Review of the Physician Order Report dated 8/17/2025-9/17/2025, revealed .micafungin [antifungal] 100 mg [milligrams] . Review of the View Prescription Order, dated 9/10/2025, revealed Micafungin .Pharmacy Directions .INFUSE 100ML [milliliters] (100 MG DOSE) .OVER 60 MINUTES (RATE = [equals] 100 ML/HR [per hour]) . Observation in Resident #38's room on 9/17/2025 at 9:50 AM, revealed Registered Nurse (RN) C set the infusion rate of Micafungin at 200ml/hr. During an interview on 9/17/2025 at 12:32 PM, the Director of Nursing (DON) confirmed the Micafungin should be infused at a rate of 100ml over 1 hour and staff should follow Physician Orders. During an interview on 9/17/2025 at 12:45 PM, RN C confirmed that she had initially set the rate for the Micafungin at 200ml/hr, and it should have been 100ml/hr. 3. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Seizures, Congestive Heart Failure, and Anxiety. Review of the Prescription Order dated 5/19/2025, revealed .carvedilol [used to reduce blood pressure] .12.5 mg [milligram] .Hold for SBP [systolic blood pressure] < [less than] 90 or HR [heart rate] 60. Notify MD/NP [Medical Doctor or Nurse Practitioner] . Review of the Medication Administration Record (MAR) dated June 2025, revealed Carvedilol was administered when Resident #64's pulse was outside the ordered parameters on: a. 6/4/2025 with a pulse of 53 for the PM dose. b. 6/5/2025 with a pulse of 56 for the AM dose. c. 6/9/2025 with a pulse of 58 for the PM dose. d. 6/13/2025 with a pulse of 51 for the PM dose. e. 6/14/2025 with a pulse of 54 for the AM dose and 55 for the PM dose. f. 6/24/2025 with a pulse of 59 for the AM dose. g. 6/27/2025 with a pulse of 56 for the PM dose. h. 6/29/2025 with a pulse of 53 for the AM dose and 58 for the PM dose. Review of the MAR dated July 2025, revealed Carvedilol was administered when Resident #64's pulse was outside the ordered parameters on: a. 7/2/2025 with a pulse of 56 for the PM dose. b. 7/7/2025 with a pulse of 54 for the AM dose. c. 7/12/2025 with a pulse of 57 for the PM dose. d. 7/13/2025 with a pulse of 57 for the PM dose. e. 7/21/2025 with a pulse of 56 for the AM dose. f. 7/25/2025 with a pulse of 54 for the PM dose. g. 7/30/2025 with a pulse of 57 for the PM dose. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #64 was cognitively intact. Review of the MAR dated August 2025, revealed Carvedilol was administered when Resident #64's pulse was outside the ordered parameters on: a. 8/4/2025 with a pulse of 57 for the AM dose and 56 for the PM dose. b. 8/13/2025 with a pulse of 59 for the PM dose. During an interview on 9/17/2025 at 8:29 AM, the Director of Nursing confirmed medications should not be administered if vital signs are outside the ordered parameters and the provider should be notified.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when expired medications were found in 1 of 9 (Medication Cart #3) medication storage areas. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 2/2/2025, revealed .It is the facility policy to ensure all medications .will be stored in accordance to the manufacturer's recommendations.All drugs and biologicals will be stored in locked compartments.under proper temperature controls. 2. During an observation and interview at Medication Cart #3 on 9/17/2025 at 7:40 AM, revealed 5 unopened foil packs of Ipratropium (used to help breathing) 0.2 percent (%) with 5 vials in each pack with an expiration date of 7/2025. Registered Nurse (RN) B confirmed expired medication should not be in the medication cart. During an interview on 9/17/2025 at 8:17 AM, the DON confirmed expired medications should not be on the medication cart.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 5 nurses (Registered Nurse (RN) A and RN D) failed to disinfect reusable resident equipment for 2 of 8 (Resident #82 and #85) residents observed and when 2 of 5 nurses (RN D and Licensed Practical Nurse (LPN) F) failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed .Reusable resident-care equipment .Reusable multiple-resident items .are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .Multiple-resident used equipment shall be cleaned and disinfected after each use . Review of the facility policy titled, Medication Administration, dated 2/2024, revealed .Wash hands prior to administering medication . Review of the facility policy titled, Hand Hygiene, dated 6/9/2025, revealed .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Diabetes and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated Resident #82 was cognitively intact. Observation in Resident #82's room on 9/16/2025 at 2:00 PM, revealed RN D removed the stethoscope from around her neck and placed the bell on Resident #82's abdomen to check placement of the percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube inserted through the abdominal wall into the stomach for nutrition). She then placed the stethoscope back around her neck. RN D exited the room and placed the stethoscope on the medication cart. RN D failed to clean or disinfect the stethoscope after resident contact. 3. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Diabetes and Hypertension. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 2 which indicated Resident #85 was severely cognitively impaired. Observation in the Memory Care Unit on 9/17/2025 at 7:40 AM, revealed RN B gathered medications and the wrist blood pressure cuff and proceeded to check Resident #85's blood pressure. RN B administered Resident #85's medications, then returned to the medication cart, placed the wrist blood pressure cuff on the cart, and failed to clean or disinfect after use. During an interview on 9/17/2025 at 12:57 PM, the Director of Nursing (DON) was asked if reusable equipment should be cleaned in between use on residents. She stated, Yes. 4. Observation during medication administration on the Rehabilitation Unit on 9/16/2024 at 2:00 PM, revealed RN D administered medications, doffed Personal Protective Equipment (PPE), and failed to perform hand hygiene. Observation during medication administration on the Rehabilitation Unit on 9/16/2025 at 2:20 PM, revealed RN D performed hand hygiene for 10 seconds, donned gloves, and failed to perform hand hygiene after removing gloves. Observation in Resident #80's room on 9/16/2025 at 2:40 PM, revealed LPN F failed to perform hand hygiene, donned gloves, provided care, removed gloves, and performed hand hygiene at the sink for 15 seconds. During an interview on 9/17/2025 at 12:57 PM, the DON was asked if staff should perform proper hand hygiene when donning and doffing (removing) gloves. The DON stated, Yes.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and functional environment when toilets were not securely fastened to the floor in 4 of 46 occupied resident's bathrooms affecting 6 of 94 (Resident #5, #20, #29, #54, #61, #78) residents. The findings include: 1. Review of the facility policy titled, Safe and Homelike Environment, dated 6/1/2025, revealed .the facility will provide a safe, clean, comfortable and homelike environment.ensuring that the resident can receive care and services safely.maximizes resident independence and does not pose a safety risk. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Diabetes, Bipolar Disorder, Depression, and Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #5 was cognitively intact. Resident #5 required supervision or touching assistance with transfers. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Schizophrenia, Anxiety, and Major Depressive Disorder. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 9, which indicated Resident #20 was moderately cognitively impaired. Resident #20 required substantial to moderate assistance with transfers. Observation in Resident #5 and #20's shared bathroom on 9/15/2025 at 4:39 PM, revealed when gentle pressure was applied to the toilet, the toilet would move forward and backwards with movement side to side. During an observation and interview in Resident #5 and #20's shared bathroom on 9/15/2025 at 4:57 PM, the Maintenance Assistant confirmed the toilet was loose and would be an accident hazard. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension, Muscle Weakness, and Frequency of Micturition (urination). Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #29 was cognitively intact and required staff supervision or touching assistance for transfer. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #78 was cognitively intact and was independent with transferring. Observation in Resident #29 and #78's shared bathroom on 9/15/2025 at 10:06 AM and 11:35 AM, revealed the toilet was not secure to the floor and moved freely side to side with minimal effort. During an observation and interview in Resident #29 and #78's shared bathroom on 9/15/2025 at 4:03 PM, the Maintenance Assistant confirmed the toilet was unsecure and it could be an accident hazard. During an observation in Resident #29 and #78's shared bathroom on 9/16/2025 at 7:52 AM, the toilet remained unsecure to the floor and moved freely side to side with minimal effort. 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Dementia, Ataxic Gait, Lack of Coordination, and Vision Loss. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 1, which indicated Resident #54 was severely cognitively impaired. Resident #54 required supervision for toilet transfers. During an observation and interview on 9/15/2025 at 4:57 PM, the Maintenance Assistant confirmed Resident #54's the toilet was unsteady and needed a wedge placed under it to stabilize it. 5. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE], with diagnoses including Dementia, Schizophrenia, Anxiety, and Psychosis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #61 was cognitively intact. Resident #61 was independent with toilet transfers. Observation in Resident #61's bathroom on 9/15/2025 at 4:15 PM, revealed the toilet was not securely fastened to the floor and easily moved left to right with minimal effort. During an interview on 9/15/2025 at 4:45 PM, the Maintenance Assistant confirmed that Resident #61's toilet was not secure and could be an accident hazard. During an interview on 9/16/2025 at 10:39 AM, the Maintenance Director confirmed that all toilets should be secure and safe for use and that unsecured toilets can create a fall risk for residents.

Based on facility policy review, ANA's [American Nurses Association] Principles for Nursing Documentation, review, job description review, medical record review, Neuro (Neurological) Check Assessment Form review, and interviews the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive care plan and the resident's goals for care. The facility failed to promptly identify and intervene for an acute change in condition for 1 of 3 (Resident #1) sampled residents reviewed for quality of care. The facility's failure to ensure a resident received appropriate assessments and interventions resulted in Immediate Jeopardy when on [DATE] Resident #1 was noted to have a raised area on his left forehead. Nursing staff notified the contracted telehealth provider and failed to give complete, relevant, and accurate information resulting in Resident #1 remaining in the facility for 7 hours and 36 minutes before being transferred to the emergency room for evaluation of a life-threatening condition. Nursing staff also failed to notify a provider when Resident #1 had an acute change in condition from his baseline status resulting in the family requesting transfer to the hospital. Resident #1 was admitted to the hospital for a subdural hemorrhage on [DATE] and died on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), the Regional Director of Operations (RDO), the Regional Director of Clinical Services (RDCS) and the Area Director of Clinical Services (ACDS) were notified of the Immediate Jeopardy (IJ) for F-684 during the complaint investigation on [DATE] at 7:39 PM, in the conference room. The facility was cited at F-684 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from [DATE] through [DATE]. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-684 was received on [DATE]. The Removal Plan was validated onsite by the surveyors on [DATE] through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on [DATE] and was removed on [DATE]. Noncompliance at F-684 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Neurological Assessment, with a facility review date of [DATE], revealed, .It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury including Neurological Assessment.Guidelines.1. Neurological assessments are indicated.b. Following an unwitnessed fall.c. Following a fall or other accident/injury involving head trauma.d. When indicated by resident's condition.2. Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.Compliance Guidelines.Resident Neurological Assessment.a. Vital signs.b. General condition and appearance.c. Neurological evaluation for changes in: i. Level of Consciousness.ii. Resident Response.iii. Movement.iv. Hand Grasp.v. Speech.vi. Pupil Reaction.vii. Pupil Size.d. Initial Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding. e. Initial Assessment of any injuries to head.5. Notify family and document all assessments, actions, and notifications. Review of the facility policy titled, Notification of Changes, revised on 6/2025, revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies.resident's representative when there is a change requiring notification.Life-Threatening Conditions Examples-Heart Attack or Stroke.Guidelines.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.Circumstances that require a need to alter treatment. Review of the undated Charge Nurse-Registered Nurse (RN)/Licensed Practical Nurse (LPN) job description revealed, .Complete accident/incident reports, as necessary.Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care.Write nurses' notes to reflect that the care plan is being followed when administering nursing care or treatment.Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.Notify the resident's attending physician when the resident is involved in an accident or incident.Monitor seriously ill residents, as necessary. The facility was unable to provide a policy for Nursing Services. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Convulsion, Hypertension, Occlusion and stenosis of carotid artery, Difficulty in walking, Cognitive communication deficit, Anxiety disorder, and Insomnia. The facility provided Resident #1's hospital history and physical documentation which included a history of falls prior to his admission. Review of the Physician Order Report for Resident #1 revealed, XXX[DATE].carvedilol [medication given for high blood pressure] .12.5 mg [milligram].twice a day .Eliquis [anticoagulant- medication to prevent blood clots which increases the risk of bleeding] .5 mg .Twice A Day XXX[DATE] .levetiracetam [seizure medication] .750 mg .Twice A Day .Code Status: Full-Full Treatment . Review of the comprehensive care plan for Resident #1 dated [DATE], revealed .Problem .Anticoagulant .[Named Resident #1] has potential for injury/bleeding related to anticoagulant therapy .Approach .Observe for signs of active bleeding .Protect resident from injury/trauma . There was no care plan with interventions for Seizures/Anticonvulsant or Advance Directive of Full Code on Resident #1's care plan dated [DATE]. Review of the Risk Assessment Bundle for Resident #1 dated [DATE], revealed Resident #1 had a history of falls, altered gait (pattern in which a person walks) pattern and was high risk for falls. Review of the Physician Order Report for Resident #1 revealed, XXX[DATE] .aspirin [antiplatelet- medication to prevent blood clots, can increase risk of bleeding] .81 mg . Once A Day .amlodipine [blood pressure medication].10 mg.PRN [as needed] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Resident #1 required assistance with bed mobility, transfers, and walking 10 feet. Fall history on admission was marked unable to determine. Resident #1 received an anticoagulant, antiplatelet, and anticonvulsant over the 7-day look-back period for this assessment. Review of the meal intake documentation for Resident #1 dated [DATE]-[DATE], revealed meal intakes ranged between 51% to 76% except for [DATE]. On [DATE] Resident #1's meal intake was documented as none for breakfast and lunch. Review of the Progress Notes dated [DATE], [DATE], and [DATE], revealed Resident #1 was up walking around the memory care unit at various times. Review of the Medical Director's Progress Notes dated [DATE], revealed .[Resident #1].with past medical history significant for advanced dementia, hypertension, stroke and seizure disorder.[Resident #1] has history of dementia.continues with Melatonin for sleep. There are no current reported concerns of lethargy [lack of energy or excessive sleepiness] or mental status changes. There are no current reported concerns of decreased oral intake [meals and liquids].no current reported concerns of.elevated blood pressure readings.continues with Eliquis.High risk of fall.Hypercoagulable [High risk of forming blood clots] status.Continue to take.aspirin.Continue full code. Review of the Vital Signs Report dated 5/2025 revealed Resident #1's Blood Pressure (B/P-systolic top number represents pressure in your arteries when your heart beats/ diastolic bottom number the pressure inside the artery when your heart rests between beats) readings documented twice daily for 2 weeks prior to Resident #1's change in condition, averaged between 115-141 systolic and 70-90 diastolic. On [DATE], RN C documented Resident #1's BP reading of 168/97 taken at 8:58 AM. RN C did not document a follow up BP reading during her 6:00 AM-6:00 PM shift. Review of the Progress Note for Resident #1 dated [DATE] at 5:40 AM, revealed .Nurse [LPN B] was made aware by CNA [Certified Nursing Assistant A] .she noted a fluid filled raised area on LT [left] side of [Resident #1] forehead. No noted falls during the night and resident was in bed resting when CNA [CNA A] noticed area.BP 162/116.[Named Telehealth Provider] was contacted, and MD [Telehealth Provider - Medical Doctor (TMD) #1] stated to mark the area and monitor for increase in size and a cool compress could be applied. Review of TMD #1's Progress Note for Resident #1 dated [DATE] revealed, .5:40 [AM].Primary Chief Complaint.Facial Swelling.Defined area on the left side of the forehead noticed today patient denies, and there has been no recorded trauma no falls no hitting head. Patient has no tenderness and his mental status had remained at baseline area appears to look like a lipoma however, we will monitor the size. cold compress q [every] shift.Source of verification for all history: Per nurse and/or patient, Per scanned documents [scanned picture].BP Sys: [systolic]162 ./Dia: [diastolic] 116 .Exam findings per nurse and video observation.left forehead/temporal area with lipoma like mass nontender, no bruising skin intact.Diagnosis.Localized swelling, mass and lump.Please use skin marker to outline the area and evaluate for increase in size.use cool compress Q [every] shiftNotify [shift Notify] a clinician of any change in condition. Review of Resident #1's Medication Administration Record (MAR) dated [DATE], revealed there was no documented administration of amlodipine 10 mg which was ordered as needed for hypertension. There was no documented administration of Resident #1's scheduled medications which included carvedilol 12.5 mg given for hypertension (high blood pressure). Review of the Neuro Check Assessment Form dated [DATE], for Resident #1 revealed 9 neurological assessments were completed from 5:55 AM to 10:40 AM. All areas of the assessments were marked the same. Level of consciousness was marked 1 for fully conscious. Resident response was marked 1 for name. Movement was marked 1 for all 4 extremities. Hand grasp was marked 1 for equal and strong. Speech was marked 1 for clear. Pupil reaction was marked 1 for brisk (both eyes). Pupil size bilateral was marked 3 (choices were 1 for equal in size and 2 for not equal in size). There were no vital signs documented on the form. Review of the Vitals Report and the Progress Notes for Resident #1 revealed there were no vital signs documented on [DATE] after 5:40 AM (when LPN B noted the swollen area on Resident #1's forehead and a BP of 162/116) until Family Member (FM) E found Resident #1 unresponsive and requested RN C to transfer him to the hospital (approximately 7 hours later). The Neuro Check Assessment Form indicated Resident #1's neurological status findings were without change. RN C completed the assessments at 6:25 AM, 6:40 AM, and 7:10 AM. RN C confirmed Resident #1 did not wake up during the neuro check assessments and did not grasp her hand during the neuro check assessment which indicated Resident #1's change in condition. Review of the Daily Skilled Service Observation Details (Daily Skilled Note) for Resident #1 dated [DATE] at 10:07 AM, revealed .Cognition.Alert.Confused.Neurological Symptoms.None.Change in Cognitive Status.No Change.Pulmonary Status.Lungs Clear.Cardiovascular/Circulatory.N/a [Not Applicable].Integumentary Status.No new open Areas or skin issues. The daily Skilled Note was completed by RN S. Review of the Progress Note dated [DATE], revealed .12:46 [PM] .Resident [Resident #1] sent to [Named Hospital #1] ED [Emergency Department] for evaluation per family request. Review of the Discharge/Transfer with Bed Hold document for Resident #1 dated [DATE], revealed, .Blood Pressure 140/106 .Reason for Transfer .Resident or Family initiated transfer .Progress Note related to condition leading to transfer .Family requested resident be sent to ED for evaluation .Name of MD/Provider Notified . [Named NP] . Review of Resident #1's Emergency Medical Service (EMS) report dated [DATE] at 1:05 PM, revealed .dispatched and responded immediately with lights and sirens.to [Named Facility #1] for complaint of hematoma to forehead needing X-ray.Arrived to find [Named Resident #1] sitting limp in wheelchair unresponsive to verbal stimuli and sternal rub [Painful stimulus caused by firmly rubbing with knuckles across an unresponsive person's chest to cause a response]. Pt's [patient's/Resident #1] nurse [RN C] reports last known well to be approximately when she get [got] off her shift last night [[DATE] at approximately 6:30 PM] as he [Resident #1] was up and walking around. Pt's wife [FM E] had come to visit today [[DATE]] and noticed the hematoma on the forehead and requested nurse to send the patient out for evaluation. Nurse [RN C] reported that none of their staff had witnessed any fall or any other mechanism of injury over the night [[DATE]] and that the patient had been asleep all morning [[DATE]] in his wheelchair.Pt is on Eliquis blood thinner .PARAMEDIC ASSESSMENT - GCS [Glasgow Coma Scale- used to help assess acute brain injury and impaired consciousness] 7 [score] (1) eyes none, (2) verbal sounds (pt reacted to IV [catheter inserted into a vein] insertion by shouting), (4) normal flexion (when starting IVs, otherwise unresponsive to any other physical stimuli).hematoma to left forehead and right deviated gaze, pupils 4 mm [millimeter] bilaterally and sluggish reaction to light.extremities flaccid.Pt extremity lifted from wheelchair to stretcher by emt [Emergency Medical Technician] x 2 [two persons] .transported emergent with lights and sirens to [Hospital #2] ED due to neuro specialty. Pt condition remained unchanged throughout transport. Upon arrival.pt was triaged and immediately wheeled to CT [Computed Tomography imaging procedure that uses X-rays] .revealed large right subdural hemorrhage [a pool of blood between the brain and its outermost covering] . Review of Hospital #2's admission Record for Resident #1 dated [DATE], revealed .Chief Complaint Patient presents with Altered Mental Status.M [male] with a h/o [history of] afib [Atrial Fibrillation] on Eliquis, seizures.LKN [Last Known Normal] last night. Possible fall- nursing found pt [patient] this AM with a hematoma to his L [left] forehead.Vitals: BP 141/91.Neurological.Poorly responsive, R [right] gaze deviation - does not regard examiner [look at examiner] or track [follow objects with eyes], nonverbal, not withdrawing to painful stimulus at this time.ED Course.Spoke with radiology-large left sided SDH [Subdural Hematoma/Hemorrhage] 9mm midline shift [brain tissue is displaced across the brain's center line].Call out to neurosurgery, reversing Eliquis.Pt will now intermittently cross midline [moving arms or legs but not consistently], pulling at lines and clothes at times.Pt going to OR [Operating Room] with NSGY [Neurosurgery].CT evaluation of the nonvascular structures of the head and/or neck. Left hemispheric subdural hematoma again observed.There is an acute left cerebral convexity [outer surface of the brain] subdural hemorrhage with maximal thickness of 13 mm .Upon my evaluation, this pt had a high probability of clinically significant imminent or life-threatening deterioration due to subdural hemorrhage.Neuro Critical Care History and Physical.This.male.on Eliquis.seizure.presented with a change in mental status. The wife stated yesterday he was at baseline able to walk, feed himself, and talk some.NEUROSURGERY CONSULT NOTE.Presented to ER with hematoma on the left forehead above the eyebrow .Spoke with family at bedside. They wish for full neurosurgical intervention.PLAN.Unfortunately his exam continues to climb since arrival to ER. I think this is going to continue to get worse if we do not intervene.We will proceed to the OR for a [an] emergent left sided open craniotomy [surgical procedure that involves making an opening in the skull] for subdural hematoma evacuation [removal]. Review of Hospital #2's Patient Summary and Hospital Course dated [DATE], revealed Resident #1 was admitted for traumatic left acute subdural hematoma. Emergency craniotomy was performed to remove the hematoma. Resident #1's prognosis was complicated by postoperative seizures and Resident #1 required intubation (installed tube in the windpipe to maintain the airway) for respiratory failure. Further testing revealed concerns for anoxic/toxic encephalopathy (brain injury caused by a lack of oxygen and/or presence of toxins) with guarded prognosis. Discussion with family related to status resulted in the decision to switch Resident #1 to comfort care measures with Hospice. Resident #1 received Hospice care within the hospital setting and expired on [DATE]. During a telephone interview on [DATE] at 2:20 PM, FM E stated when she left Resident #1 around 6:30 PM on [DATE] he was walking, talking and smiling. FM E stated, .I was a little bit late getting to the facility that morning [[DATE]].about 10:30 [AM], [Resident #1] was not in the hallway like he often was before lunch.he was in the dining room sitting in a wheelchair with his head down.I called his name and he did not turn towards me, as he usually does.I touched him on the shoulder and he did not move or respond.the nurse [RN C] said he was like that when she got there around 6:30 [AM]. I [FM E] said he won't wake up, something is wrong, [RN C] told me he was probably just sleepy because [Resident #1] had been up during the night.[CNA D] told me he was up, dressed and in a chair when she got there.we took him to his room.[RN C] couldn't get him to wake up.I had to ask them to call an ambulance.the ambulance person called me from the ambulance and told me [Resident #1] symptoms were so severe he needed to go on to Memphis.[Facility #1] said he didn't have a fall, something happened, there was skin broke on his left arm. FM E stated the facility did not call her and tell her about the hematoma on Resident #1's forehead. FM E concluded she would have come in earlier and sent Resident #1 to the hospital. FM E then became emotional and ended the phone call. During a telephone interview on [DATE] at 4:38 PM, TMD #1 stated, .The nurse [LPN B] provided a picture.of a gentleman [Resident #1] with a raised area on his forehead.The nurse [LPN B] provided a detailed report of raised soft area and no complaint of pain or tenderness at site.the patient was at baseline cognitive level, and he did have an elevated BP.The nurse [LPN B] reported the patient had a history of hypertension and frequent episodes of elevated BP . TMD #1 confirmed LPN B did not report the patient's use of blood thinning medication, cognitive impairment, or status of fall risk. TMD #1 stated, .the nurse [LPN B] was very sure.clear the patient had not been involved in a fall or other trauma. TMD #1 acknowledged she gave the order to circle the area, monitor for increase in size, and follow up with changes. During a telephone interview on [DATE] at 11:39 PM, LPN B stated, .We [LPN B and CNA A] checked on [Resident #1] frequently all night [[DATE]-[DATE]].he was in bed asleep.a couple of times he was sitting on the side of the bed.[On [DATE]] about 5:30 [AM] [CNA A] was getting him up and she didn't see anything unusual.he [Resident #1] came down the hall and said good morning to me.he walked over to the door to answer because someone was knocking, that's when [CNA A] noticed the raised area on his forehead.his BP was 162/116, but that wasn't unusual for him, he has high blood pressure.I called [TMD #1], I sent a picture.the doctor knew his BP was high.I told her he had not fallen during the night, I told her there had not been any trauma.he was at baseline physically and cognitively.[Resident #1] didn't have any pain.[CNA A] had taken him outside for a while the evening before.I thought it [hematoma] could be an allergic reaction to a mosquito bite.area was soft and squishy.[TMD #1] told me to draw a line around the area to see if it gets bigger.I did not give her a list of medicines.don't recall telling her he was on a blood thinner, they can see his records and I assumed [TMD #1] looked at his meds. I didn't specifically tell [TMD #1] he was cognitively impaired or a high fall risk. Again, they [TMD #1] have access to the medical record, I assume they look at them.There wasn't any trauma that I know of.we watched him.we did not have him.1 on 1 every minute.I guess he could have fallen and got himself up.I know there wasn't an injury. The nurse confirmed she did not ask Resident #1 if he fell or what had happened due to his level of cognitive impairment. LPN B stated, .It is not likely [Resident #1] could tell me, he is on memory care for a reason.Dementia patients show pain in other ways, they don't always tell you. [Resident #1] wasn't scratching at the area, didn't look like bruising.on a blood thinner there would be a bruise, skin would be darker. LPN B was asked if she had opened an event/incident report in the EHR and replied, Yes. LPN B was asked if she performed neuro checks on Resident #1 and she responded, .Yes, I didn't document them [neuro check assessments] in the computer, I put them on the paper form. There is a place to put the neuro checks, it prompts you to add them for head injury.I'm not sure why I put them on paper, it's been a while since that [[DATE] the morning Resident #1 was observed with a hematoma on his left forehead] happened. During a telephone interview on [DATE] at 12:06 AM, CNA A stated, .I checked on him [Resident #1] frequently.he was either sleeping or sitting up on the side of the bed.the bed was in the lowest position, but he could get up.sometimes he did get up and wander around. CNA A confirmed she checked on Resident #1 during the night and was not always monitoring him because there were 15-16 other residents on the Memory Care Unit. CNA A stated the raised area was not present the night of [DATE] and she did not see it until the morning of [DATE]. CNA A stated, .I got him up and dressed him, the nurse [LPN B] took his vital signs and I walked with him to the common area. [Resident #1] was at baseline walking and talking.nothing unusual.didn't even notice the spot [hematoma] until he walked to the back door.it [hematoma] was small, soft, squishy.we [CNA A and LPN B] figured it was a reaction, like allergic to a mosquito bite.I had taken [Resident #1] outside for a little while the night [[DATE]] before.I don't remember asking [Resident #1] what happened to his head.[Resident #1] wasn't scratching at it [hematoma]. During an interview on [DATE] at 12:44 PM, the MD stated he would expect nursing staff to notify the provider to obtain an order for residents to be sent out for evaluation when any type of injury to the head was observed or suspected with use of anticoagulant therapy. The MD was asked about Resident #1's head injury on [DATE]. The MD replied, . [LPN B] called the [Named Telehealth Provider], and the resident was sent out for evaluation. The MD was unaware Resident #1 had remained in the facility for approximately 7 hours prior to being sent out per family request. The MD was asked to review the photo of Resident #1's raised area provided by LPN B to TMD #1. The MD responded, .[Resident #1] should have been sent to the hospital.high fall risk.anticoagulants.location of the area.not a lipoma.located on his forehead above the temple.not on his arm or leg.I am not here to judge another physician.on-call would depend on the nurse to report all risk and potential.should send out. The MD was asked if he would expect vital signs to be obtained and documented as part of the neurological assessments. The MD replied, Yes. The MD was asked if he expected nursing staff to obtain follow-up BP for abnormal readings and document the results. The MD replied, Yes. During a telephone interview on [DATE] at 3:05 PM, CNA D stated on [DATE] she received a report at 6:00 AM from CNA A related to Resident #1 having a raised area on his forehead. Resident #1 was sitting in a chair with a wheelchair beside him in the common area of the hall. CNA D described the raised area as .small, like a mosquito bite, like someone having an allergic reaction to a mosquito bite. CNA D stated at 7:00 AM Resident #1 got into the wheelchair and she pushed him to the dining room. Resident #1 went to sleep and did not eat breakfast. CNA D stated, .I woke him up and he just looked at it [breakfast].that wasn't unusual for him.[Resident #1] didn't eat lunch either, I woke him up and he looked over at the table, then went back to sleep.and like I said, that was not unusual for him.[FM E] came in and tried to wake him up.ask me to take him to his room.[Resident #1] woke up in the room when [FM E] shook him and patted his face.didn't talk, he just looked up and drifted back to sleep. CNA D concluded she had been around Resident #1 all morning in the dining room. CNA D was asked if she saw RN C do vital signs on Resident #1 in the dining room on [DATE]. CNA D replied, .not in the dining room, I saw her do vital signs one time and that was in the room.[FM E] told me to go get the nurse [RN C] because [Resident #1] would not wake up, [RN C] came in the room and did the BP at that time.[FM E] wanted [Resident #1] put in the bed.called [Named CNA R] to help me.[FM E] changed her mind, asked [RN C] to call an ambulance.left him in the chair. During a telephone interview on [DATE] at 12:24 PM, the Paramedic stated Resident #1 was sitting in a wheelchair, limp and slumped over when EMS arrived at the room. Resident #1 was not responsive to physical or verbal stimuli. RN C reported Resident #1's last known well time at the end of her shift (approximately 6:30 PM) on [DATE]. RN C reported Resident #1 was up and walking around when she left on [DATE] and sitting in wheelchair limp and nonresponsive when she arrived the morning (6:00 AM) of [DATE]. RN C reported staff had not witnessed any falls or any injury mechanism overnight. FM E came in to visit and requested to send Resident #1 out. Resident #1 had been sleeping all morning in his wheelchair. The Paramedic stated, .[Resident #1]'s feet were edematous [swollen with fluid].Resident #1] did make a sound when I started the IV.had flexion in his arm when we started the IV.never opened his eyes.GCS of 7. 1 for eyes [no eye opening], 2 for verbal sound [incomprehensible sounds], 4 for flexion [arm-withdrawal from pain].remained unresponsive for duration of care.We took him to [Named Hospital #2].because of his responses and the time he had been sitting with the head injury.being unresponsive gave me a high index of suspicion of traumatic brain injury or brain bleed or stroke.[Resident #1] had a right deviated gaze.gives suspicion of intercranial pressure.indicates brain bleed.Very large hematoma, about the size of a golf ball. The Paramedic confirmed Resident #1 did not wake or walk to the stretcher, his extremities were limp requiring two person lift to the stretcher, and he was never alert during transport. During an interview on [DATE] at 12:38 PM, CNA R stated on [DATE] CNA D asked her to assist with putting Resident #1 in bed. CNA R stated when she arrived at Resident #1's room, she observed Resident #1 sitting in his wheelchair with his head down and eyes closed. CNA R stated, .[Resident #1]'s wife [FM E] told me she didn't want him in the bed, she wanted an ambulance to come and get him.I tried to wake [Resident #1] up.I shook him and called his name, and he never responded.[RN C] came in the room as I was leaving. During an interview on [DATE] at 3:20 PM, RN M stated, .On [DATE] [Named RN C] called and asked what [Named Resident #1]'s baseline was because the wife said he wasn't at his baseline.[Resident #1] was normally alert, oriented to self and recognizes his wife. usually up and walking around, hard to get him to stay in one spot, anxious.I never actually went back to memory care and looked at [Resident #1].helped by documenting [Named Resident #1]'s vital signs, a progress note and printing off transfer paperwork. with a head injury and use of anticoagulants, even if the doctor did not order a transfer out, I would press on to get the order to send out.at times you have to press a little harder with the on-call doctors. During an interview on [DATE] at 3:56 PM, RN S stated she documented Resident #1's Skilled Observation Note on [DATE]. RN S acknowledged she had not actually observed Resident #1 on [DATE] and documented the information provided by RN C. RN S confirmed a resident with a head injury or possible head injury and on blood thinning medications would need to be sent out for evaluation for a brain bleed. RN S stated, .if the telehealth physician did not order the transfer, I would request the order due to the risk of brain bleed.getting evaluation and treatment could prevent death to the resident.I would complete neuro checks in the computer under the event note.if you are performing neuro checks there was a reason to open an event note.wouldn't document in progress note only. During an interview on [DATE] at 4:49 PM, LPN U confirmed residents who present with a raised area or swelling on the forehead need to be evaluated for head injury and if they are taking anticoagulants, they should be sent to the emergency room for evaluation. LPN U concluded she would call the on-call and request the transfer order due to risk of brain bleed. During an interview on [DATE] at 4:55 PM, LPN P was asked what steps she would take for a resident who presented with a raised area to their head, and she was unaware of how the injury occurred. LPN P stated, .the resident could have had a fall or accident.risk of blood clot or brain bleed.need to call someone and get him sent out even if the resident appeared fine, I would be more concerned if the resident was taking Eliquis.could be something more serious.neuro checks are done in the computer system, and they include a blood pressure check. During an interview on [DATE] at 5:16 PM, RN N stated when

Based on facility policy review, signed Job Description review, medical record review, and interview, the facility failed to ensure an injury of unknown origin was reported to the State Survey Agency (SSA) for 1 of 10 (Resident #1) sampled residents reviewed for abuse. The facility also failed to report the results of a thorough investigation for abuse within 5 working days to the SSA. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 5/2025, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse.includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm .Failure to implement effective communication system across all shifts for communicating necessary care and information between staff, practitioners and resident representatives.Prevention of Abuse, Neglect.The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Possible indicators of abuse include.Physical injury of a resident, of unknown source.Failure to provide care needs such as.safety.An immediate investigation is warranted when suspicion of abuse, neglect. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Convulsion, and Hypertension. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severely cognitively impaired. Record review revealed on [DATE] at approximately 5:30 AM, nursing staff observed a swollen area on Resident #1's forehead above his left eyebrow. There was no documentation Resident #1 had fallen or sustained an injury. Resident #1 was found by Family Member (FM) E unresponsive and sent to the hospital for evaluation several hours later. Resident #1 underwent emergency surgery due to bleeding in the brain and was discharged to the hospice unit in house where he died on [DATE]. The facility did not investigate the injury of unknown origin and the cause of Resident #1's injury remains unknown. During a telephone interview on [DATE] at 11:39 PM, Licensed Practical Nurse (LPN) B stated on [DATE] at approximately 5:30 AM, Certified Nursing Assistant (CNA) A noticed a raised area on Resident #1's forehead above his left eye. LPN B stated Resident # 1 had been observed sleeping in bed through the night ([DATE]-[DATE]) and did not have any falls or known trauma to his head. LPN B was asked if she had asked Resident #1 what happened to cause the swollen area on his head. LPN B stated she did not ask Resident #1 what happened due to his severe cognitive impairment. LPN B was asked if she knew how Resident #1 sustained the hematoma on his forehead. LPN B stated the raised area was soft and squishy like an allergic reaction to a mosquito bite. LPN B concluded she did not know for certain what caused the raised area due to staff was not monitoring Resident #1 at all times. LPN B confirmed she did not believe Resident #1 had fallen or caused an injury to himself. LPN B was asked if she had received training for abuse which included recognizing and reporting an injury of unknown origin. LPN B stated she had received training on abuse and did not recall reporting injuries as suspected signs of abuse. During a telephone interview on [DATE] at 12:06 AM, CNA A stated on [DATE]-[DATE] she frequently observed Resident #1 in bed sleeping, and sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 would get out of bed at times and wander around the Memory Care Unit. CNA A confirmed she was not always monitoring him during the night ([DATE]-[DATE]) because there were 15-16 other residents on the Memory Care Unit. CNA A was asked if she had received education on abuse which included recognizing and reporting an injury of unknown origin. CNA A confirmed she was not aware a head injury could be a sign of abuse. During an interview on [DATE] at 3:56 PM, Registered Nurse (RN) S stated her last abuse in-service was more than a year ago as she had just worked a minimal schedule while attending school. RN S stated she did not recall being given education related to reporting an injury of unknown origin as suspected abuse. During an interview on [DATE] at 4:49 PM, LPN U stated the last in-service training she received was within the past 3 months. LPN U did not recall specific training on injury of unknown origin being included in the reporting requirements for abuse. During an interview on [DATE] at 5:16 PM, RN N stated the last in-service on abuse was within the past year. RN N acknowledged she was not aware of the requirement to report an injury of unknown origin within a specified time frame. During a telephone interview on [DATE] at 11:00 AM, RN C stated on [DATE] she worked 6:00 AM to 6:00 PM on the Memory Care Unit. RN C stated Resident #1 did not have a raised area on his left forehead when she left work on [DATE]. RN C stated during morning (6:00 AM) report on [DATE], LPN B reported Resident #1 had a raised area on his left forehead. LPN B reported Resident #1 had not had a fall and she didn't know what caused the raised area on his forehead. RN C stated LPN B did not complete an event report and did not ask her to complete the event report for the raised area. RN C was asked if she had reported the injury to Administration. RN C replied, No. RN C was asked if she had been educated on recognizing abuse and reporting abuse. RN C acknowledged she had received abuse education, and she had provided abuse education during her employment in the facility. RN C was asked what she was required to do if a resident had an injury no one had witnessed happening and the resident was unable to explain how the injury occurred. RN C replied, .If the injury needed treatment, I would call the doctor.I would fill out an incident report and give it to the Unit Manager. During an interview on [DATE] at 1:45 PM, the Director of Nursing (DON) acknowledged she was aware Resident #1 was sent to the hospital on [DATE] for evaluation of a raised area on his left forehead and she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff. The DON was asked if the facility had determined the cause of Resident #1's injury to his forehead. The DON stated there was not an injury or fall and staff concluded the raised area was probably an allergic reaction to a mosquito bite. The DON was asked if staff provided monitoring for Resident #1 at all times during the night of [DATE]-[DATE]. The DON stated staff did not monitor at all times. The DON was asked if Resident #1's injury of unknown cause had been reported to the SSA within two hours and the facility investigation results reported to the SSA within 5 business days. The DON confirmed the injury had not been reported to the SSA and investigated. During an interview on [DATE] at 2:42 PM, the Administrator stated as the Administrator and Abuse Coordinator she was responsible to ensure allegations of abuse, known or suspected, are reported to the SSA in the required time frame. Refer to F684

Based on the facility policy review, signed Job Description review, medical record review, and interview, the facility failed to investigate an injury of unknown origin for 1 of 10 (Resident #1) sampled residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation with a revision date of 5/2025, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect.Abuse.includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.The facility will develop and implement written policies and procedures .to investigate any such allegations; and .Include training for new and existing staff on activities that constitute abuse .reporting procedures, and dementia management .Training topics will include .Identifying what constitutes abuse .Recognizing signs of abuse, neglect .Reporting process for abuse, neglect including injuries of unknown sources .Possible indicators of abuse include .Physical injury of a resident, of unknown source .Failure to provide care needs .An immediate investigation is warranted .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .Immediately, but not later than 2 hours after the allegation . Review of the Director of Nursing's (DON) job description signed on 1/2020, revealed .To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs.Management duties including.training and developing, coaching and counseling.Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required.Study.Medication Incident Reports and Resident Incident Reports for corrective action. Review of the former Administrator's job description signed on [DATE], revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and.policies . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Convulsion, Hypertension, and Difficulty in walking. Review of the admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 0, which indicated severe cognitive impairment. Record review revealed on [DATE] at approximately 5:30 AM, nursing staff observed a swollen area on Resident #1's forehead above his left eyebrow. There was no documentation Resident #1 had experienced a fall or other cause of the resident's swollen area on the forehead. Resident #1 was found by Family Member (FM) E unresponsive and sent to the hospital for evaluation several hours later. Resident #1 underwent emergency surgery due to bleeding in the brain and was discharged to the hospice unit in house where he died on [DATE]. The facility did not investigate the injury of unknown origin and the cause of Resident #1's injury remains unknown. During a telephone interview on [DATE] at 11:39 PM, Licensed Practical Nurse (LPN) B stated Resident #1 was in bed all night ([DATE]-[DATE]/ 2025). Resident #1 was observed sleeping at times and sitting up on the side of the bed at times. The morning of [DATE], Certified Nursing Assistant (CNA) A got Resident #1 up and dressed then walked him to the hall without noticing the hematoma on his forehead. LPN B spoke to Resident #1 as he passed her in the hallway, without noticing the hematoma. Minutes later, Resident #1 walked to the door and CNA A noticed the raised area when she went to assist him. LPN B notified the telehealth provider and obtained orders to outline the raised area and monitor it for changes. LPN B stated the raised area was soft and squishy like an allergic reaction to a mosquito bite. LPN B was asked if she knew how Resident #1 sustained the hematoma on his forehead. LPN B stated, .I guess I couldn't say for sure because I wasn't with him all the time that night [[DATE]-[DATE]].we did not have him 1 on 1 [monitoring] every minute. I guess he could have fallen and got himself up.I know there wasn't an injury. LPN B confirmed she did not ask Resident #1 if he fell or what had happened due to his level of cognitive impairment because it wasn't likely he could tell her what happened. LPN B confirmed she was asked to provide a statement related to the [DATE] incident on [DATE], during the complaint survey. During a telephone interview on [DATE] at 12:06 AM CNA A stated she observed Resident #1 in bed sleeping, and at times sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 could get up with the bed in the low level and would wander around the Memory Care Unit. CNA A confirmed she checked on Resident #1 during the night and was not always monitoring him, because there were 15-16 other residents on the memory care unit. CNA A stated, .I didn't see the place [hematoma] on his head the night before. CNA A was asked if she had received education on abuse which included injury of unknown origin, such as a knot on a resident's head with unknown cause. CNA A confirmed she was not aware a head injury could be a sign of abuse. CNA A confirmed she had not been asked to provide a statement about the incident with Resident #1 until [DATE]. During an interview on [DATE] at 1:45 PM, the DON stated the Staff Development Coordinator (SDC) was in the building on [DATE] and told her about Resident #1 getting sent out per family request. The DON concluded she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff. The DON was asked if Resident #1 had an injury of unknown origin which required investigation. The DON stated Resident #1's injury (hematoma) was not caused by an injury or fall and was thought to be a mosquito bite. The DON acknowledged Resident #1 was not monitored at all times during the night of [DATE]-[DATE]. The DON stated the facility started an investigation after APS (Adult Protective Services) came to the facility and told them about the investigation ([DATE]). The DON was asked if the facility was required to investigate injuries of unknown origin. The DON put her head down for a minute and then got up from the table and left the room. During an interview on [DATE] at 2:42 PM, the Administrator stated when a resident has an injury that cannot be explained the facility would be required to investigate. Refer to F684

Based on the American Nurses Association (ANA)'s Principles for Nursing Documentation review, facility policy review, medical record review, and interview, the facility failed to ensure medical records were complete and accurately documented for 1 of 7 (Resident #1) sampled residents reviewed. The findings include: Review of the ANA's Principles for Nursing Documentation dated 2010, revealed .Nurses document their work and outcomes for a number of reasons: the most important is for the communicating within the health care team .Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential .Foremost of such electronic documentation is the electronic health record (EHR), provides an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of the patient care .Assessments .Medication records (MAR) .Nursing Documentation Principles .Principle 1. Documentation Characteristics .High quality documentation is: Accurate, relevant, and consistent. Clear, concise, and complete. Timely, contemporaneous, and sequential. Reflective of the nursing process .Principle 5. Documentation Entries .Entries into organization documents or the health record (including but not limited to provider orders) must be: Accurate, valid, and complete; Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; Dated and time-stamped by the persons who created the entry . Review of the facility policy titled, Documentation in Medical Record, with a facility review date of 1/2025, revealed .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident.information to provide a picture of he resident's progress through complete, accurate, and timely documentation.Licensed staff.shall document assessments, observations, and services provided in the resident's medical record.Documentation shall be completed at the time of service.Principles of documentation included.Documentation shall be factual.False information shall not be documented.Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care. Review of the facility policy titled, Neurological Assessment, with a facility review date of 6/19/2025, revealed .It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury including Neurological Assessment.Guidelines.When indicated by resident's condition.Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.Compliance Guidelines.Resident Neurological Assessment.a. Vital signs.b. General condition and appearance.c. Neurological evaluation for changes in: i. Level of Consciousness.ii. Resident Response.iii. Movement.iv. Hand Grasp.v. Speech.vi. Pupil Reaction.vii. Pupil Size.d. Initial Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding. e. Initial Assessment of any injuries to head.5. Notify family and document all assessments, actions, and notifications. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Convulsion, Hypertension, and Occlusion and stenosis of carotid artery. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Review of the Medication Administration Record (MAR) for Resident #1 dated 5/4/2025, revealed administration of amlodipine (medication given for hypertension/high blood pressure) 10 mg (milligram) was administered to Resident #1 for an elevated BP (Blood Pressure-the force exerted by the blood on the walls of the arteries as it flows through them) of 168/122. There was no follow-up BP reading documented in the medical record. Review of the MAR for Resident #1 dated 5/5/2025, revealed Licensed Practical Nurse (LPN) O documented administration of amlodipine 10 mg for a BP of 173/121. There was no follow-up BP reading documented in the medical record. Review of the Nurse Practitioner's (NP) Progress Note for Resident #1 dated 5/5/2025, revealed, .no current reported concerns of.elevated blood pressure readings.no current nurse concerns reported . Review of the Medical Director's (MD) Progress Note for Resident #1 dated 5/6/2025, revealed no new event, no complaints, .Advised per progress . Review of the NP's Progress Note for Resident #1 dated 5/7/2025, revealed, .no current reported concerns of.elevated blood pressure readings.no current nurse concerns reported . Review of the MAR for Resident #1 dated 5/24/2025, revealed RN C documented an administration of carvedilol (medication for hypertension) 12.5 mg and a BP reading documented at 168/97. There were no follow up BP measurements documented in the medical record. Review of the Progress Note dated 5/25/2025 at 5:40 AM, revealed Certified Nursing Assistant (CNA) A notified LPN B about a raised area on Resident #1's left forehead. LPN B documented there were no noted falls during the night of 5/24/2025 and early morning on 5/25/2025. LPN B documented Resident #1 was in bed resting when CNA A noticed the raised area to the Resident's forehead. LPN B documented Resident #1's BP reading was 162/116. LPN B contacted the Telehealth Medical Doctor (TMD) #1 and obtained orders to outline the raised area, monitor for an increase in size and apply cool compresses. Review of the TMD #1's Progress Note dated 5/25/2025, revealed notification by LPN B on 5/25/2025 at 5:40 AM related to Resident #1 having swelling on the left side of the forehead with no reported trauma or fall. TMD #1 provided orders to outline the area, evaluate for increase in size, use cool compress every shift and notify a provider of any changes in condition. Review of the Daily Skilled Service Observation Details (Daily Skilled Note) for Resident #1 dated 5/25/2025 at 10:07 AM revealed, .Cognition .Alert .Confused .Neurological Symptoms .None .Change in Cognitive Status .No Change .Pulmonary Status .Lungs Clear .Cardiovascular/Circulatory .N/A [Not Applicable] .Integumentary Status .No new open Areas or skin issues . Review of the Neuro (Neurological) Check Assessment Form dated 5/25/2025 for Resident #1 revealed nursing staff provided handwritten documentation for neurological assessments for 5:55 AM, 6:10 AM, 6:25 AM, 6:40 AM, 7:10 AM, 7:40 AM, 8:40 AM, 9:40 AM, and 10:40 AM. All entries were answered the same for the assessments as follows: level of consciousness was marked 1 for fully conscious, resident response was marked 1 for name, movement was marked 1 for all 4 extremities, hand grasp was marked 1 for equal and strong, speech was marked 1 for clear, pupil reaction was marked 1 for brisk for both eyes, pupil size bilateral was marked 3 (choices for pupil size bilateral were 1 for equal and 2 for not equal). There were no vital signs documented on the form. Resident #1's neurological assessments were documented on paper with handwritten entries including nurse's initials for completion. Registered Nurse's (RN) C) initials were marked under nurse signature for neuro checks completed on the Neuro Check Assessment Form at 6:25 AM, 6:40 AM, and 7:10 AM Review of the Discharge/Transfer with Bed Hold document for Resident #1 dated 5/25/2025, revealed .Blood Pressure 140/106 .Reason for Transfer .Resident or Family initiated transfer .Progress Note related to condition leading to transfer .Family requested resident be sent to ED for evaluation .Name of MD/Provider Notified .[Named NP] . During a telephone interview on 6/24/2025 at 2:20 PM, Family Member (FM) E stated she arrived at Facility #1 between 10:30 AM and 11:00 AM and found Resident #1 sitting in his wheelchair unresponsive to her touch and voice. FM E stated RN C suggested Resident #1 was probably just sleepy due to being up during the night of 5/24/2025. FM E stated she noticed the knot on Resident #1's left forehead and asked CNA D to take Resident #1 to his room and get the nurse. FM E stated the nurse informed her the knot had been found earlier in the morning by LPN B and the doctor had said to mark around it and see if it gets bigger. FM E stated she then demanded RN C to send Resident #1 to the emergency room because he was unresponsive. During a telephone interview on 7/21/2025 at 11:39 PM, LPN B stated on 5/25/2025 Resident #1 presented with an area of swelling above his left eye on his forehead. LPN B stated she notified the Telehealth provider and received orders to mark the perimeter of the swollen area, monitor for an increase in size of the area, use cold compress if needed, and notify the provider with any change of condition. LPN B was asked if she opened an event note in the EHR and completed neuro check assessments. LPN B confirmed she had opened an event note related to the swollen area on Resident #1's forehead and completed 2 neuro assessments before leaving the facility on 5/25/2025. LPN B was asked if the event note prompted her to complete the neuro check assessments. LPN B confirmed there was a prompt for neuro assessments and added, she wasn't sure why she had documented the neuro check assessments on the paper form. LPN B was asked if she had obtained a follow-up BP reading and documented the results. LPN B replied, .Yes, the vital signs would be documented in the computer under vital signs. LPN B stated she had applied the cold compress to Resident #1's head and he tolerated it for a few minutes then refused to keep the compress in place. LPN B was asked if she documented the refusal of treatment in the medical record. LPN B responded, .I don't recall. The facility was unable to provide an event note opened by LPN B on 5/25/2025 for Resident #1. The BP reading obtained at 5:40 AM was documented in a progress note by LPN B. There were no follow-up vital signs documented by LPN B in the vital sign section or the progress notes of Resident #1's EHR. During a telephone interview on 7/21/2025 at 12:06 AM, CNA A stated the raised area on Resident #1's forehead was not present the night of 5/24/2025 and she did not see it until the morning of 5/25/2025. CNA A stated she had taken some of the residents outside for a short time the evening of 5/24/2025. CNA A stated LPN B thought the raised area was an allergic reaction to a mosquito bite. There was no documentation related to Resident #1's activity outside the evening of 5/24/205 and no documented concern for an allergic reaction to an insect bite. During an interview on 7/21/2025 at 12:44 PM, the MD was asked about Resident #1's hematoma and what his expectations were for nursing intervention. The MD stated nursing staff notified the Telehealth Provider and received orders to send Resident #1 out to the emergency room (ER) for evaluation. The MD was asked if his expectations was to have the head injury evaluated immediately or at a later time. The MD stated a resident with a head injury, on anticoagulants, should be evaluated as quickly as possible. The MD was asked if Resident #1 was sent to the ER for evaluation in a timely manner. The MD reviewed Resident #1's EHR and confirmed Resident #1 remained in the facility approximately 7 hours before being sent to the ER. The MD confirmed there was no documentation related to monitoring Resident #1 for changes in condition and no documentation related to monitoring Resident #1's elevated BP on 5/25/2025. The MD was asked if RN C notified him on 5/25/2025 to discuss Resident #1's change in condition and FM E's request to send him to the ER. The MD confirmed RN C did not notify him on 5/25/2025 and obtain an order to send Resident #1 to the ER. During a telephone interview on 7/21/2025 at 3:05 PM, CNA D stated on 5/25/2025 Resident #1 had a small, raised area on his forehead which looked like someone having a reaction to a mosquito bite. CNA D stated Resident #1 was in the dining room all morning. CNA D stated she woke him up for breakfast and lunch and he went back to sleep without saying anything to her. CNA D was asked if she observed RN C obtaining vital signs on Resident #1 or trying to wake him up. CNA D confirmed she observed RN C obtain vital signs once on 5/25/2025 in Resident #1's room after FM E came in and requested a transfer to the hospital. During a telephone interview on 7/22/2025 at 12:24 PM, the Paramedic stated on arrival to Resident #1's room on 5/25/2025, he observed Resident #1 sitting in a wheelchair, limp and slumped over. The Paramedic stated Resident #1's feet were swollen with fluid, and he had a large hematoma on his left forehead. The Paramedic confirmed RN C reported Resident #1 had been sleeping since she arrived for work at approximately 6 AM. RN C reported the resident had no known trauma or fall to cause the hematoma on his left forehead. The Paramedic was asked if RN C provided documentation of neurological assessments with vital signs monitoring. The Paramedic replied the BP reading at 5:40 AM and the BP reading prior to the call for transport were the only readings RN C provided. The Paramedic stated RN C gave the reason for transfer as family request. The Paramedic concluded RN C did not provide documentation of any interventions or assessments completed related to Resident #1's change in condition. During an interview on 7/23/2025 at 12:38 PM CNA R stated on 5/25/2025 she went to assist CNA D in putting Resident #1 in bed. CNA R stated Resident #1 was sitting in his wheelchair with his head down and eyes closed. CNA R stated FM E said she could not wake Resident #1 up. CNA R concluded Resident #1 did not respond when she (CNA R) shook him and called his name. CNA R confirmed RN C came into Resident #1's room as she was leaving. During an interview on 7/23/2025 at 3:20 PM, RN M acknowledged on 5/25/2025 she had documented a progress note and vital signs for Resident #1 which were provided to her by RN C. RN M confirmed she did not go to Memory Care to assess Resident #1's vital signs. RN M was asked if she documented on the residents in her care every day. RN M stated nurses should document all changes in a resident's condition including pain, changes in mental status, and changes in vital signs. RN M stated a nurse should document all interventions provided to the resident and the effect of those interventions. RN M was asked what steps she would take when a resident had a BP reading of 162/116. RN M responded, .If the resident had medication scheduled or PRN [as needed] I would give the medication and recheck the BP to see if the medication was effective. RN M confirmed the follow-up BP reading would be documented in the resident's medical record. During an interview on 7/23/2025 at 3:56 PM, RN S confirmed on 5/25/2025 she had documented Resident #1's Skilled Observation note in the EHR. RN S stated she documented the information RN C provided to her and confirmed she had not been on the Memory Care Unit to observe Resident #1 on 5/25/2025. RN S stated an event note should be completed for any abnormal findings on a resident's skin. RN S was asked if neuro checks would be prompted in the computer as part of an event note for head injury. RN S replied, .Yes. RN S was asked about documentation requirements for nursing. RN S concluded nurses should document when there are changes related to a resident's condition, new orders, effectiveness of treatments, and any information related to following up on the resident's care. RN S was asked if documenting an assessment on a resident using information provided by another nurse was professional standards of practice for a nurse. RN S replied, .I don't believe it is.I didn't consider the information might not be accurate.I do now. During a telephone interview on 7/23/2025 at 7:01 PM, the Emergency Medical Technician (EMT) confirmed when she arrived at Resident #1's room on 5/25/2025, Resident #1 was in a wheelchair slumped over and limp. The EMT stated RN C reported Resident #1 had been sleeping all day and did not have any meal intake, which was unusual for him. The EMT confirmed Resident #1 was unresponsive with a minimal response to pain on the scene and remained unresponsive throughout the transport. During a telephone interview on 7/24/2025 at 11:00 AM, RN C stated she completed neurological assessments which included vital signs on Resident #1 and documented the assessments in the EHR. RN C was asked if she completed and initialed the Neuro Check Assessment form paper documentation in addition to the EHR documentation. RN C replied, .No. RN C stated Resident #1 slept in his chair on 5/25/2025 which was not unusual for him. RN C was asked if Resident #1 had awakened when she completed the neuro check assessments. RN C responded, she attempted to wake Resident #1, and he did not respond verbally, open his eyes or grasp her hands during the neuro assessments. RN C concluded Resident #1 did not want to be bothered and she didn't find that unusual. RN C acknowledged LPN B did not initiate an event note related to the hematoma on Resident #1's forehead. RN C stated Resident #1 was asymptomatic (not showing symptoms) except for sleeping a lot during the day, which was not unusual for him. RN C was asked if Resident #1 had any oral intake including foods and medications on 5/25/2025. RN C responded, .I was about to give him his meds [medication] when his wife came in and demanded me to send him out.he didn't eat breakfast but that wasn't unusual for him, and he left before lunch was served. RN C was asked if she had documented Resident #1's neuro check assessments as normal. RN C stated on the Memory Care Unit it was impossible to have a normal neuro check assessment and confirmed she had documented Resident #1's neuro check assessments as normal. During an interview on 7/25/2025 at 1:45 PM, the DON was asked if staff were required to complete an event note for abnormal skin issue findings or injuries. The DON confirmed staff were required to complete an event note if no one could explain the bruising or injury. The DON stated RN C notified the NP on 5/25/2025 and obtained an order to transfer Resident #1 to the hospital at the wife's request. The DON was asked if neuro checks should be documented as normal if the patient/resident does not wake up during the assessment and the patient/resident was unable to complete the assessment. The DON replied, .No, it would be documented as abnormal findings.the person's ability to complete the assessment could depend on their baseline. The DON was asked if she considered checking a patient's BP as part of the neuro check process was professional standards of practice. The DON replied, .yeah.BP is documented in the vital signs section of the record [EHR]. The DON confirmed nurses should not document an assessment on a resident using information provided to them by another nurse or staff member. The DON was asked to review the transfer form completed on 5/25/2025 and determine which provider was notified for orders to send Resident #1. The DON stated the nurse documented notification to the NP. The DON confirmed notification to the provider should not be documented unless the provider was notified. During a telephone interview on 7/25/2025 at 4:15 PM, LPN T stated she had worked with RN C on occasion and had to help RN C with documenting in the electronic health record. LPN T concluded, .[Named RN C] has lots of trouble on the computer.she forgets how to get in and how to complete documentation. LPN T confirmed she has documented assessments completed by RN C without performing the assessment herself. During a telephone interview on 7/25/2025 at 6:09 PM, the NP stated the facility had not called her on 5/25/2025 to discuss Resident #1's change of condition or request an order to transfer the resident to the ER. Refer to F684

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed for 1 of 10 residents (Resident #1) reviewed for advance directives. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 was found unresponsive without respirations and staff failed to perform CPR with chest compressions and artificial respirations per the choice of Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing, Regional Director of Clinical Services, Registered Nurse (RN) #1, Area Director Clinical Services (ADCS), Regional Director of Operation (RDO), and Licensed Practical Nurse (LPN) #2 were notified of the Immediate Jeopardy (IJ) for F-678 on [DATE] at 4:47 PM, in the Conference Room. The facility was cited F-678 at a scope and severity of J, which is substandard quality of care. A partial-extended survey was completed on [DATE]. The IJ began on [DATE] through [DATE]. The surveyor validated the facility's IJ Removal Plan on [DATE], through medical record review, audit reviews, drill observation, review of education, sign in sheets, interviews with staff and administration. The last day of Immediate Jeopardy was [DATE]. The findings include: 1. Review of the facility's policy titled Emergency Code/ CPR Procedure, Revised ,d+[DATE], revealed .It is the policy of this facility to respond to medical emergencies for residents staff and visitors .The employee who first witnesses or is first on the site of a medical emergency, that are trained will initiate immediate action, including CPR as appropriate, will initiate basic first aid and summon for assistance. CPR will not be initiated if a DNR [Do Not Resituate] order is in place .A nurse will .Assess the situation and determine the severity of the emergency .Stay with the resident .Designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed .A Code Blue will be announced over the intercom system, in necessary .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services .In accordance with the resident's advance directives, or .In absence of advance directives or a Do Not Resuscitate order . 2. Review of the facility's policy titled Residents' Right Regarding Treatment and Advance Directives, Revised [DATE], revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Atrial Fibrillation, Cellulitis of Abdominal Wall, and Chronic Kidney Disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was assessed with a Brief Interview for Mental Status score (BIMs) of 15, indicating she was cognitively intact. Review of the Care Plan dated [DATE], revealed .Advance Directive .My code status is Full .Administer CPR in the event that the resident is found without pulse or respirations . Review of the Progress Notes dated [DATE], revealed .06:10 (AM) Upon making shift change rounds Resident was observed laying on right side in floor between bed and night stand table. Resident was assessed and resident was noted unresponsive to verbal or painful stimuli .No rise and fal [fall] of chest observed .911 called at 0610 . Review of the Ambulance Report dated [DATE], revealed, .ON ARRIVAL FOUND A 77 YR [year] .LYING ON RIGHT SIDE OF FLOOR BETWEEN BED, NIGHT STAND AND WALL. NO NURSE WAS AROUND AND HAD TO GET CNA [Certified Nursing Assistant] TO GET ONE. TO COME TO ROOM. WHEN NURSE CAME TO ROOM SHE TOLD ME THAT SHE WAS TRYING TO FIND OUT IF SHE [Resident #1] WAS A FULL CODE. I EXPLAINED THAT IT DID NOT MATTER DUE TO PT. [patient - Resident #1] BEING DOWN FOR SEVERAL HOURS .NURSE TOLD ME .THEY LAST CHECKED ON HER AT 6:00AM THEN THEY CHANGED THAT TIME TO 5:30 THEN AGAIN TO 4:00AM. UNKNOWN HOW LONG PT. HAD BEEN DOWN ON FLOOR. NURSE INFORMED ME THAT THEY FOUND HER WHEN THE DAY SHIFT CAME IN AND FOUND THE PT. IN BED ONE ON FLOOR WHILE TRYING TO PICK HER UP THEY FOUND THE OTHER PT [Resident #1]. AT 0616 .I PLACED MONITOR ON PT. ASYSTOLE IN 3 LEADS AT 6:20 AM. PT WAS PRONOUNCED DOA [dead on arrival] .I HAD TO GO BACK TO NURSING STATION DUE TO NURSE NOT STAYING IN ROOM WITH US . During an interview on [DATE] at 10:17 AM, Nursing Assistant (NA) #1 stated, .I peep around the curtain to check on the other lady .[Named Resident #1] and she was in the floor .she was wedged between the bed and night stand with her .her face was lying down on the floor .I told [Named Licensed Practical Nurse #1 (LPN) #1] this lady [Resident #1] was on the floor too .she [LPN #1] looked at her [Resident #1] from the foot board and said yea she [Resident #1] is gone .didn't touch her [Resident #1] or nothing .she [LPN #1] went to walk out of the room .I have never been in a situation like this and my nurse did not know what to do .I asked her [LPN #1] what are we going to do and asked if we are going to call 911 and she said go ahead and call them .I was in shock .I didn't know at that time .[if Resident #1 had died yet] .on our charting it will say full code or DNR .she [Resident #1] didn't have one .it's automatic a code .she [Resident #1] just came in a week or two and hadn't got all her stuff in the system .they [the nurses] found out after they had done some reading .that she was a full code .I walk out of the room .I call 911 .the lady [911 dispatcher] asked me was she [Resident #1] DNR .I had to go to the nurses station .and [LPN #1] was sitting down at the nurses station .I think she [LPN #1] was trying to figure out if she was a DNR .I asked her [LPN #1] .was she [Resident #1] DNR .full code .and she [LPN #1] said I don't know I'm trying to find it .she [LPN #1] tells the other nurse to take the crash cart down there [to Resident #1's room] .they [the nurses] didn't even open it .EMS [emergency medical services] was down there [in Resident #1's room] .pronounced her [Resident #1] dead at 6:20 . NA #1 confirmed an emergency procedure to perform CPR was never initiated. During an interview on [DATE] at 1:01 PM, Certified Nursing Assistant (CNA) #1 stated, .probably 6:05 [6:05 AM] .[Named NA #1] walked in there first .[Named Resident #7] was in the floor .and she [NA #1] hollered at me to come in there .I see [Named Resident #7] siting up by the door .didn't look like she [Resident #7] was hurt .she [Resident #7] was talking .she wasn't on her oxygen when we found her .[Named NA #1] went to go get the nurse .[Named LPN #1] .she came down the room and asked [Named Resident #7] how did you get in the floor .[Named NA#1] had pulled the curtain back and was saying that [Named Resident #1] .was in the floor .and bleeding .I was going to try to help get her up .she [Resident #1] wasn't moving or answering .and her arm was still in the bed .she [Resident #1] was between the night stand and the bed .I was asking are you ok .she [Named LPN #1] came in between both beds and just looked at her [Resident #1] and said she is probably gone .I couldn't see her back to see if she was breathing .I couldn't see her face .her hair was covering her face .we hadn't had her [Resident #1] long .after [LPN #1] went to the desk and sit down .she [LPN #1] didn't call a code blue [an emergency procedure to initiate CPR] .[NA#1] is on the phone with 911 .and asking if they were a code .she [referring to LPN #1] wouldn't talk to the lady on the phone .she [LPN #1] said she couldn't find what she [Resident #1] was .you are supposed to start CPR . During an interview on [DATE] at 11:16 AM, the Medical Director was asked what Resident #1's code status was. The Medical Director stated, I asked her [Resident #1] that day [day of admission] of code status .I asked her [Resident #1] specially if something was to happen what she wanted done and she said to do everything . The Medical Director was asked would you expect CPR to be initiated. The Medical Director stated, Yes .it's full code .[unless] you prove the opposite . During a telephone interview on [DATE] at 3:32 PM, LPN #1 was asked what Resident #1's code status was. LPN #1 stated, I couldn't find her code status in the system didn't know what it was at the time .might have been one in place but I couldn't find it .I think where I went wrong I left the room to check her code status .I told the graduate nurse to go get the crash cart .and [Named NA #1] asked me do I need to call 911 and I said yes . LPN #1 was asked what you did when you first walked in Resident #1's room. LPN #1 stated, .what original happened when they come in at 6:03 they were asking me to get Bed A [Resident #7] out of the floor .[Named NA #1] walked over to the side of the bed and seen she [Resident #1] was in the floor .said .she [Resident #1] is in the floor too .I immediately walked over there .I touched her .and shook her .felt for a pulse .I just looked at her for a second and it shocked me .the way her arm was up .I told [GPN #1] to get the crash cart .she was on her right side .but her right arm was up behind her .don't know how it happened . LPN #1 was asked did you call a code. LPN #1 stated, No ma'am it happened so fast .I was headed in that direction .I did tell [Named GPN #1] to call up front and tell them to come back here .I should have said page code blue .when I went to go check for code status the paramedic and police was already there .[Named Graduate Practical Nurse (GPN) #1] went back down there with the crash cart .and she couldn't get in there with the crash cart .because [Named Resident #7] was still in the floor .CNAs hadn't got her up .I don't usually get shook up .but finding her [Resident #1] like that shook me up the way her [Resident #1] arm was .it was horrible .the way it was .she [Resident #1] might have been hanging on and maybe her arm went up behind her . LPN #1 was asked how staff know if residents are a code or DNR. LPN #1 stated, It's always put in the computer .I couldn't find it that morning .I went to check her [Resident #1] code status .it just happened so fast .I told them we needed to get her [Resident #1] on her back .not trying to point fingers .the CNAs wasn't helping .not at all .I know they aren't nurses .could have got [Resident #7] out of the floor .I should have told her [GPN #1] to page up front all code blue .for some reason .I just don't know .that morning wasn't my morning threw me all the way off . LPN #1 was asked the process for code. LPN #1 stated, .to check for life .and call code blue right away .I don't know what happened .it wasn't done intentionally .I remember [Named NA #1] talking to 911 in the hallway outside of the room and I got up from the room and went to go check code status .she was on her right side .the bed was in the way .[Resident #7] would have to get up .everything was in the way . LPN #1 was asked what you should have done. LPN #1 stated, I should have stayed in that room .told the aides to call code blue and help me get [Named Resident #7] out of the floor and help me get [Named Resident #1] on her back and initiated CPR .I have been a nurse long enough to know .nothing is wrong with me .it just threw me off .I have done codes before .nurse for [AGE] years . During an interview on [DATE] at 10:34 AM, Paramedic #1 stated, .no one tried to do anything with her [Resident #1] .had not moved or anything .I'm not seeing how she fell out of bed .small side rail was up .the side she [Resident #1] was on .she was so large .she was on the right side .right arm .was behind her .wasn't touching anything .we had to flip her over .nobody had touched her .I could not put my monitor on her [Resident #1] till we moved the bed .no one could answer any questions .I don't know how long she had been down .it had been longer than 30 minutes .they [facility staff] should have cleared it [the room] out .it was the fire department that moved the bed and the body .so they could turn her [Resident #1] over so I could actually get to the front part of her .she was wedged . Paramedic #1 was asked what were you told the Resident #1's code status was. Paramedic #1 stated, .nobody told us anything .except the aides let us in and told us first room .didn't even tell us the patient [Resident's name] .I thought it was bed 1 [Resident #7] .the fire department walked in and found her [Resident #1] .I demanded a nurse to come down there .they told me she [LPN #1] was down there [at the nurse's station] looking for her [Resident #1] status .the actual aide that was supposed to be taking care of the patient [Resident #1] had actually left, it was the day shift aide that had found her [Resident #1] .but no one was in the room .even with me telling them you have got to get me a nurse now .I still didn't get anybody .to tell me something about the patient [Resident #1] .how long had she [Resident #1] been down .in the floor .when the last time someone checked on her . During a telephone interview on [DATE] at 2:19 PM, Graduate Practical Nurse (GPN) #1 was asked if she had taken the crash cart to Resident #1's room. GPN #1 stated, .nurse did asked me to bring it to her [Resident #1] room .I believe she [LPN #1] was at the desk .she [LPN #1] was looking for her [Resident #1] post status .and the other lady [Resident #7] was still in floor .we couldn't get in the room or anything .she [Resident #7] was right in front of A bed .at the end of her bed .she [LPN #1] was trying to figure out if she [Resident #1] was a full code or anything .we found her [Resident #1] right after shift change .you could tell she [LPN #1] went blank .I remember she [LPN #1] was asking for help .she [LPN #1] was saying get the other lady [Resident #7] off the floor .nobody came together to help out .I went back to the desk .was asked was anybody in the room and helping [Named Resident #7] and [Named Resident #1] .stated no . GPN #1 was asked did you see Resident #1. GPN #1 stated, .she was beside her bed by the window .she was like on her right side .kinda face down .her right arm was behind her back .her bed was kinda high .grab bar by her was up .she had on .shirt or gown .I was looking to see if her chest was raising .nobody was doing anything .I just looked at her .it didn't look like she was .she was kinda slumped over and you couldn't tell if she was . GPN #1 confirmed no code was initiated and stated, .now we know if you don't see their code status .go ahead and administered CPR . During an interview on [DATE] at 3:52 PM, the DON was asked what Resident #1 code status was. The DON stated Full Code . The DON confirmed Resident #1 didn't have an advance directive or a POST form and was asked what the protocol was if a resident is not listed to have a post form or advance direction. The DON stated, A full code . The DON was asked what the nurse or staff should do if they find a resident unresponsive and not breathing. The DON stated, .I think the nurse should be competent enough to start CPR .or the event of irreversible death .they should assess the patient and initiate CPR . The DON was asked what should have happened that morning when staff found Resident #1. The DON stated, .she should have assessed the patient and check for pulse .what she [LPN #1] told me was vital signs was unattainable .should have called code blue . The DON was asked should LPN #1 have left the room. The DON stated, No .you could understand it better if she was a new nurse .and maybe panic .but she has been a nurse for years . The DON confirmed LPN #1 did not call a code blue and CPR was not initiated. The DON was asked what the root cause of the incident was. The DON stated, .we don't know if she fell first or expired first .don't know if she had blood clot that had dislodge and was trying to get up and fell .we are waiting to see what the autopsy shows . The DON was asked if LPN #1 had initiated CPR would it have changed the outcome. The DON stated, .only God knows . During an interview on [DATE] at 4:53 PM, the Administrator was asked what a nurse or staff should do if they find a resident unresponsive and not breathing. The Administrator stated, .first make sure resident is position and do a quick assessment .get in touch 911 .do best practice . The Administrator was asked what Resident #1 code status was. The Administrator stated, .to my knowledge .full code .get in touch with 911 and start the CPR process .based on what I'm hearing she didn't start it . The Administrator was asked if you find a resident that is unresponsive and no pulse what should have been done. The Administrator stated, .CPR . During an interview on [DATE] at 7:55 AM, Regional Director of Clinical Reimbursement (RDCR) confirmed she had done Resident #1's care plan and stated, .she didn't have an advance directive .if you don't have an advance directive and a copy of the POST you have to treat them as a full code . The facility's acceptable IJ Removal Plan was validated onsite by the surveyor on [DATE] through policy review, medical record review, observation, review of education, sign in sheets and staff interviews conducted on all shifts. The Removal Plan was as follows: On [DATE] the Facility notified the Medical Director of the incident. This was verified by the surveyor though medical record review and interview with the Medical Director. On [DATE] The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy. This was verified by the surveyor though medical record review and interviews with the DON. On [DATE] The licensed nurse who did not perform CPR on the full code status resident was suspended pending investigation. This was verified by the surveyor though medical record review and interview with the licensed nurse. On [DATE] disciplinary action was taken with licensed nurse who did not initiate CPR on the full code resident and was suspended pending investigation. On [DATE] the nurse was terminated by the administrator and was reported to the Board of Nursing by the Director of Nursing. This was verified by the surveyor though medical record review and interviews with administration. Beginning on [DATE] the DON or designee Staff Development Coordinator (SDC) educated all licensed nurses on the facility's policy and procedure for initiating CPR and the exact steps to take when a resident is found non-responsive. Nurses on leave will receive education prior to their next scheduled shift. After [DATE] no licensed nurse will be permitted to work after without receiving the education. This was verified by the surveyor through review of the education, sign in sheets, interviews with nursing staff, DON and SDC. On [DATE] the SDC added to the orientation outline for all new employee's education regarding Code Status and how to respond to a full code resident and will assure that this education is complete and that return demonstration is performed during orientation. This was verified by the surveyor though interview with the SDC. On [DATE] a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) by the DON. The DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process including exactly how to respond in a code situation. Compliance checks will be conducted 2 times weekly for three months on alternating shifts. Findings will be reported at monthly QAA Committee meeting for 3 months. This was verified by the surveyor though interviews with administration. The DON or designee (SDC, Unit Manager) will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue daily and will be ongoing. The findings will be reviewed at the monthly QAA Committee meeting for 3 months. This was verified by the surveyor though audit review and interviews with staff and the DON. The Unit managers and SDC initiated a Code Blue drill on all shifts for 48 hours with licensed nursing staff. Drills will continue to be held 2 times a month for 3 months. The findings will be reviewed at the monthly QAA Committee meeting for 3 months. This was verified by the surveyor though drill observation, sign in sheets and interviews with the SDC and staff. Upon admission, change of status and quarterly code status will be reviewed with resident and/or responsible party, during resident's care plan meeting (in attendance for care plan meetings are: Social services director, MDS coordinator, Dietary manager, Activities, and Unit Manager). Clinical representative (Unit Manager or DON) will review code status and POST form with resident and/or responsible party. Any changes will be discussed with the MD (by the DON or Unit Manager) and an updated order will be obtained. Residents care plan and face sheet will be updated at that time. Residents face sheet banner in EMR will notify nursing personnel of change. A full code residents banner is GREEN and a DNR residents banner is RED. This was verified by the surveyor though medical record review and interviews with staff and DON. The facility's noncompliance of F-678 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for a pressure injury when the facility staff failed to perform pressure injury treatments as ordered for 2 of 3 sampled residents (Resident #1 and #2) reviewed for pressure injuries. The findings include: Review of the facility's policy dated October 2010 titled, Wound Care revealed .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The type of wound care given. 2. The date and time the wound care was given. 3. The name and title of the individual performing the wound care . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with dry dressing every day shift . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) dated 10/1/2021 - 10/31/2021, revealed no treatments were documented for Resident #1's pressure injury to the right ischial on 10/16/2021, 10/19/2021, 10/23/2021, and 10/30/2021. Review of the TAR dated 10/1/2021 - 10/31/2021, revealed no treatments were documented for Resident #1's wound to the right great toe amputation site on 10/16/2021, 10/19/2021, 10/23/2021, and 10/30/2021. Review of the TAR dated 11/1/2021 - 11/30/2021, revealed no treatments were documented for Resident #1's pressure injury to the right ischial on 11/13/2021 and 11/20/2021. Review of the TAR dated 11/1/2021 - 11/30/2021, revealed no treatments were documented for Resident #1's wound to the right great toe amputation site on 11/13/2021 and 11/20/2021. Review of the TAR dated 11/1/2021 - 11/30/2021, revealed no treatments were documented for Resident #1's pressure ulcer wound to the sacrum on 11/19/2021 and 11/20/2021. Review of the TAR dated 11/1/2021 - 11/30/2021, revealed no treatments were documented for Resident #1's pressure ulcer wound to the left trochanter on 11/20/2021. During an interview on 2/9/2022 at 3:00 PM, Licensed Practical Nurse (LPN) #1 was asked if the wound care was provided as ordered for Resident #1. LPN #1 reviewed the TAR and stated, .Not sure why it's not marked as done .She goes to [CONDITION(S)] on Tuesday, Thursday, and Saturday. Odd that it's those days that are missed .Looks like the treatment nurse on the weekends didn't do it . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse coccyx with dakins, pat dry, apply santyl, calcium alginate, and cover with foam dressing every day shift every Tue, Sat . Review of the TAR dated 1/1/2022 - 1/31/2022, revealed no treatments were documented for Resident #2's pressure ulcer wound to the coccyx on 1/29/2022. Observation in the resident's room on 2/9/2022 at 11:23 AM, revealed Resident #2 was alert with confusion. She required extensive assistance to total care for activities of daily living. During an interview on 2/9/2022 at 3:20 PM, the Director of Nursing (DON) confirmed the TAR did not reflect wound care was provided according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, .I see there is a problem with wound care treatments .

Based on policy review, medical record review, observation, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 3 of 27 sampled residents (Resident #11, #20, and #56). The facility's failure to revise the Care Plan with appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) to the left femur (large upper bone in the leg). Findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .Should the Resident experience a fall the attending nurse shall complete a post fall assessment. This includes .interventions to reduce the risk of repeat episodes and a review by the IDT [Interdisciplinary Team] to evaluate thoroughness of the investigation and appropriateness of the interventions .The care plan should be updated to reflect, any new or change in interventions . Review of the facility's undated policy titled, Care Planning - Interdisciplinary Team, revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive deficits, required supervision with his activities of daily living, and had no functional limitations in range of motion. Review of the Care Plan dated 7/27/2021, revealed Resident #56 was at risk for falls related to impulsiveness, poor safety awareness, and history of falling. The following interventions were identified: follow facility fall protocol, anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it, the resident needs prompt response to all requests for assistance, Physical Therapy to evaluate and treat as ordered, educate the resident/family/caregivers about safety reminders, and the resident needs a safe environment with even floors free from spills and clutter, adequate glare free light, a working reachable call light, the bed in low position at night, siderails as ordered, handrails on walls, and personal items in reach. Review of the Nursing Progress Notes dated 10/3/2021, revealed .The nurse was called to resident room at 11:00 AM due to resident having a fall in his room. Resident was noted to be sitting in the floor between the air conditioner and the bed .Denies any pain. Neuro checks were started and acceptable . There was no Post Fall Review with interventions for this fall and the Care Plan was not revised to reflect Resident #56's fall on 10/3/2021. Review of the Incident Report dated 10/9/2021, revealed .I walked in and observed the patient on his back and on the floor .He also stated that he bumped his head . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The recommendation on this form was for the resident to wear shoes but according to the documentation on the form this intervention had previously been implemented. The Care Plan was not revised to reflect the fall on 10/9/2021. Review of the quarterly MDS assessment dated [DATE], revealed Resident #56 had a BIMS score of 7, required supervision with his activities of daily living, had no functional limitations in range of motion, and had 1 fall without injury and 1 fall with minor injury since admission. Review of the Nursing Progress Notes dated 10/22/2021, revealed .Resident noted sitting on floor. Resident examined .Denies pain. Neuro intact . The Care Plan was not revised to reflect the fall on 10/22/2021. During an interview on 12/8/2021 at 10:45 AM, the Director of Nursing (DON) was asked if the interventions of wearing shoes/slippers prevented Resident #56 from falling. The DON stated, No .care plan was not updated . The DON was shown the Post Fall Review dated 10/22/2021 and the interventions documented for the resident to wear shoes or slippers and the new intervention was also shoes/slippers. The DON stated, .there are no new interventions that will prevent resident from falling . The DON was asked if the Care Plan was updated. The DON stated, No. The DON was asked if the staff should be updating the Care Plan. The DON stated, Sure. Review of the Incident Report dated 10/23/2021, revealed .I walked in the room and observed [Resident #56] sitting down on the floor beside his bed . The Care Plan was not revised to reflect the fall on 10/23/2021. During an interview on 12/8/2021 at 10:45 AM, the DON was asked if a new intervention was put into place to prevent the resident from falling after the resident had the fall on 10/23/2021. The DON stated, No .I don't see she [staff] updated the Care Plan. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident slipped while walking from bed to chair without shoes or non slip socks .List the immediate fall prevention interventions .Non slip socks, call light in reach and instructed on use . Resident #56 had severe cognitive impairment. The Care Plan was not revised to reflect the fall on 10/25/2021. During an interview on 12/8/2021 at 10:45 AM, the DON was asked if there had been any new interventions implemented after Resident #56 fell on [DATE] to prevent the resident from falling. The DON stated, No .no new interventions . Review of the Care Plan dated 10/27/2021, revealed Resident #56 had a fall on 10/27/2021. The interventions documented were .Keep phone and personal items on [in] reach Date Initiated: 10/27/2021 . This new intervention was not implemented and placed on the Care Plan until 12/8/2021. During an interview on 12/8/2021 at 10:45 AM, the DON confirmed there had been no new interventions implemented after the fall on 10/27/2021. Review of the Incident Report dated 11/8/2021, revealed .This nurse was called to the dining room on rehab [rehabilitation therapy] unit .observed resident sitting on buttocks on the floor with a dining room chair behind him .When asked resident if he was hurting anywhere, resident stated, 'My left hip hurts, I cannot move.' . Review of the Radiology Report dated 11/8/2021, revealed .Acute intertrochanteric fracture [broken hip] of the proximal left femur is noted with minimal displacement .Limited range of motion in the left hip joint . Review of the Care Plan dated 11/8/2021, revealed Resident #56 had another fall on 11/8/2021 with the intervention for staff to assist with transfers as allowed and tolerated. This Care Plan intervention was not documented until 12/8/2021 (1 month after Resident #56 fell ). The resident was transferred to the emergency room for evaluation and treatment. This intervention was documented on the Care Plan on 12/2/2021. During an interview on 12/8/2021 at 10:45 AM, the DON was asked what interventions were put in place to prevent the resident from falling. The Regional Director of Clinical Services stated, .I don't think any intervention would have kept him from missing the chair. It was an isolated incident . The DON was asked if the resident was safe to ambulate unassisted. The DON stated, .He is care planned for aggressive behaviors .he'll swing at you if he feels like it and difficult to re-direct . The DON was asked if he was agitated during the incident. The DON stated, I don't know. Review of the discharge MDS assessment dated [DATE], revealed Resident #56 was assessed to have a BIMS of 7, required supervision with his activities of daily living, had no functional limitations, had 2 or more falls without injury, 2 or more falls with minor injury, and 1 fall with major injury since the prior assessment. Review of the significant change MDS assessment dated [DATE], revealed Resident #56 now had a BIMS score of 3, which indicated severe cognitive deficits, required extensive assistance with most of his activities of daily living, and had no falls since admission or prior assessment. Review of the Nursing Progress Note dated 11/23/2021, revealed .During rounds CNA [Certified Nursing Assistant] noted resident on floor. Resident immediately notified nurse of the incident . Review of the Referral to Rehabilitation Services dated 11/23/2021, revealed .Resident stated he slipped while attempting to go to the restroom .Pt [Patient] currently on PT [Physical Therapy] /OT [Occupational Therapy]/ST [Speech Therapy] caseload for therapy. Pt's balance and safety awareness are being addressed . Review of the Care Plan dated 11/23/2021, revealed Resident #56 had a fall that day. On 12/8/2021 this fall was documented on the Care Plan with interventions to educate the resident regarding the call light (Resident #56 had severe cognitive deficits). During an interview on 12/8/2021 at 10:45 AM, the DON was asked if educating the resident about using the call light would be effective if the resident had a low BIMS score. The DON stated, .Some days he was really with it . The DON was asked if the Care Plan had been updated to reflect the interventions to prevent the resident from falling. The DON stated, .He was referred to therapy . The DON was informed Resident #56 was already in the therapy case load at the time of the fall. The DON stated, Oh. Review of the Incident Report dated 11/30/2021, revealed .I walked in room and observed patient on the floor . Review of the Care Plan dated 11/30/2021, revealed Resident #56 had a fall on 11/30/2021. Interventions to .Keep in sight as allowed and tolerated . were not documented on the Care Plan until 12/08/2021. During a telephone interview on 12/9/2021 at 8:13 AM, the physician of Resident #56 was asked about Resident #56's falls. The Physician stated, .I know he has fallen .they [facility] probably notified the Nurse Practitioner, I assumed they informed her .I saw him on 10/20/2021 for his low vitamin D labs .a vitamin D deficiency can potentially predispose the resident to fractures . The Physician was asked if Resident #56 could be educated regarding safety measures. The Physician stated, .initially it appeared that he could be educated but if you talked to him long enough, well he doesn't make much sense . The Physician was asked if the facility should have put interventions in place to prevent the falls. The Physician stated, .should have put something in place . During an interview on 12/9/2021 at 8:45 AM, the DON was asked if Resident #56's Care Plan should have been updated with new interventions. The DON stated, Yes. The DON was asked if the resident was wearing shoes, as written in the Post Fall Reviews and if shoes were an appropriate intervention. The DON stated, No. During an interview on 12/9/2021 at 10:45 AM, the Adult Gerontology Acute Care Nurse Practitioner (AGACNP) was asked if Resident #56 could be educated. The AGACNP stated, .I think there is a memory loss, but the staff should re-teach to call for assistance, but I don't think he'll remember . The AGACNP was asked if the facility should be implementing interventions. The AGACNP stated, .Yes, new interventions every time . The facility's failure to update the Care Plan with appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fractured left femur. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .List the immediate fall prevention intervention(s) put in place .place in bed after being up all night. Call light in reach . The Care Plan was not revised for Resident #11's fall on 9/17/2021. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .List the immediate fall prevention intervention (s) put in place .instructed resident to use call light to call for assistance . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Place Left foot in immobilization foot brace for 2 weeks . The Care Plan was not revised to reflect the fall on 11/1/2021 or the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/8/2021 at 4:46 PM, the DON confirmed the Care Plan was not revised timely to reflect Resident #11's falls on 9/17/2021 and 11/1/2021. Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #20 had a BIMS of 8, which indicated she was moderately cognitively impaired. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .Bed replaced with scoop mattress and matts [mats] put on floor beside bed . The Care Plan was not revised to reflect Resident #20 was to have a scoop mattress or fall mats at the bedside. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .List the immediate fall prevention intervention(s) put in place .Redirected resident and encouraged use of call light .Redirect with education the use of the call light and waiting for staff to come assist before attempting transfers . Review of the Care Plan dated 10/17/2021, revealed interventions to keep personal items within reach as allowed and tolerated, redirect resident and encourage to use call light were documented on the Care Plan on 12/9/2021. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .Non-kid socks .Fall Mat at bedside . Review of the Care Plan dated 10/18/2021 and revised on 12/9/2021 documented staff were to monitor for placement of shoes, keep them at the bedside as allowed and tolerated, and encourage to use call light for assistance with all needs. The Care Plan was not revised to reflect that Resident #20 was to have a scoop mattress or fall mats at the bedside. Review of a Fall Incident Report dated 11/7/2021, revealed .Resident was found sitting on the floor beside her bed . There was no Post Fall Review completed on 11/7/2021 and the Care Plan was not revised to reflect Resident #20's fall on 11/7/2021. Observation in the resident's room on 12/9/2021 at 12:23 PM and at 6:31 PM, revealed Resident #20 was seated in a wheelchair in the door of her room. There were no fall mats at the bedside. During an interview on 12/9/2021 at 6:56 PM, Unit Manager #2 and the DON both confirmed the Care Plan was not revised timely to reflect the resident's falls on 9/30/2021, 10/17/2021, 10/18/2021, and 11/7/2021. The DON confirmed that the intervention to educate Resident #20 was not an appropriate intervention. During an interview in the resident's room on 12/9/2021 at 7:07 PM, the DON confirmed there were no fall mats at Resident #20's bedside and stated, .she [Resident #20] was moved from room [ROOM NUMBER] to room [ROOM NUMBER] B on 10/27/2021 .they [staff] should have moved her mats with her . The DON confirmed Resident #20 should have fall mats in place at her bedside.

Based on policy review, medical record review, observation, and interview, the facility failed to implement appropriate interventions to prevent falls and injury for 1 of 7 sampled residents (Resident #56) reviewed for accidents. The facility's failure to provide appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) of the left femur (large upper bone of the leg). The findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure .recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury .DEFINITION: A fall is considered to be .an unintentionally coming to rest on the ground, floor, or lower level, but not as a result of an overwhelming external force .An episode where a resident lost his/her balance .would have fallen, if not for staff intervention, is considered a fall .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Should the Resident experience a fall the attending nurse shall complete a post fall assessment. This includes .interventions to reduce the risk of a repeat episode and a review by the IDT [Interdisciplinary Team] to evaluate thoroughness of the investigation and appropriateness of the interventions .The care plan should be updated to reflect, any new or change in interventions . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Hypertension, Depression, and Anxiety Disorder. Review of the Fall Risk Scale dated 7/6/2021, revealed Resident #56 was not at risk for falling. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive deficits, required supervision with his activities of daily living, and had no functional limitations in range of motion. Review of the Care Plan dated 7/27/2021, revealed Resident #56 was at risk for falls related to impulsiveness, poor safety awareness, and history of falling. The following interventions were identified: follow facility fall protocol, anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it, the resident needs prompt response to all requests for assistance, Physical Therapy to evaluate and treat as ordered, educate the resident/family/caregivers about safety reminders, and the resident needs a safe environment with even floors free from spills and clutter, adequate glare free light, a working reachable call light, the bed in low position at night, siderails as ordered, handrails on walls, and personal items in reach. Review of the Nursing Progress Notes dated 10/3/2021, revealed .The nurse was called to resident room at 11:00 AM due to resident having a fall in his room. Resident was noted to be sitting in the floor between the air conditioner and the bed .Denies any pain. Neuro checks were started and acceptable . Review of the Incident Report dated 10/3/2021, revealed .This nurse was called to resident room by CNA [Certified Nursing Assistant] who was alerted by a housekeeper that resident was sitting in the floor between the air conditioner and the bed . There was no Post Fall Review with interventions for this fall and the Care Plan was not revised to reflect this fall. Review of the Fall Risk Scale dated 10/8/2021, revealed Resident #56 was at low risk for falling. Review of the Incident Report dated 10/9/2021, revealed .I walked in and observed the patient on his back and on the floor .He also stated that he bumped his head . Review of the Post Fall Review dated 10/9/2021, revealed the footwear, assistive devices, and safety interventions used at the time of the fall were shoes and slippers. The recommendation on this form was for the resident to wear shoes but according to the documentation on the form this intervention had previously been implemented. The Post Fall Review is the facility's investigation and the resident's caregivers do not refer to this form for interventions. The Care Plan was not revised to reflect this fall. Review of the quarterly MDS assessment dated [DATE], revealed Resident #56 still had a BIMs of 7, required supervision with his activities of daily living, had no functional limitations in range of motion, and had 1 fall without injury and 1 fall with minor injury since admission. Review of the Fall Risk Scale dated 10/22/2021, revealed Resident #56 was at high risk for falling. Review of the Nursing Progress Note dated 10/22/2021, revealed .Resident noted sitting on floor. Resident examined .Denies pain. Neuro [neurological status] intact . Review of the Incident Report dated 10/22/2021, revealed .Resident noted sitting on floor .Floor cleared of liquids . Review of the Post Fall Review dated 10/22/2021, revealed the footwear, assistive devices, and safety interventions used at the time of the fall were shoes. The intervention/recommendation was shoes which had been in place prior to this fall. The Care Plan was not revised to reflect this fall. During an interview on 12/8/2021 at 10:45 AM, the Director of Nursing (DON) was asked if the intervention of wearing shoes/slippers prevented Resident #56 from falling. The DON stated, No .care plan was not updated . The DON was asked if the Care Plan was updated. The DON stated, No. The DON was asked if the staff should update the Care Plan with new interventions after a fall. The DON stated, Sure. Review of the Incident Report dated 10/23/2021, revealed .I walked in the room and observed [Resident #56] sitting down on the floor beside his bed . Review of the Post Fall Review dated 10/23/2021, revealed the resident was wearing shoes and the intervention for this fall was for the resident to have footwear. This intervention was already in place. The Care Plan was not revised to reflect new interventions after this fall. Review of the Fall Risk Scale dated 10/23/2021, revealed Resident #56 was at high risk for falling. During an interview on 12/8/2021 at 10:45 AM, the DON was asked if a new Care Plan intervention was implemented on 10/22/2021 to prevent any further falls. No .I don't see she [staff] updated the Care Plan. Review of the Incident Report dated 10/25/2021, revealed .Resident was noted to be sitting in the floor at the foot of the bed by the chair. Legs curled to the side. Bare feet no shoes or non skid socks . Review of the Post Fall Review dated 10/25/2021, revealed .Resident slipped while walking from bed to chair without shoes or non slip socks .List the immediate fall prevention interventions .Non slip socks, call light in reach and instructed on use [Resident #56 had severe cognitive impairments] . Review of Resident #56's Care Plan dated 10/25/2021, revealed .10/25/2021 Fall noted. Apply non-skid socks Date Initiated: 10/25/2021 . but the intervention was not placed on the Care Plan until 12/8/2021. During an interview on 12/8/2021 at 10:45 AM, the DON was asked if there had been any new interventions implemented on the Care Plan to prevent the resident from falling after the fall on 10/25/2021. The DON stated, No .no new interventions . Review of the Care Plan dated 10/27/2021, revealed Resident #56 had another fall on 10/27/2021. The interventions documented were .Keep phone and personal items on [in] reach Date Initiated: 10/27/2021 . This new intervention was not implemented and placed on the Care Plan until 12/8/2021. During an interview on 12/8/2021 at 10:45 AM, the DON confirmed there had been no new interventions implemented after the fall on 10/27/2021. Review of the Fall Risk Scale dated 10/27/2021, revealed Resident #56 was at high risk for falling. Review of the Incident Report dated 11/8/2021, revealed .This nurse was called to the dining room on rehab [rehabilitation therapy] unit .observed resident sitting on buttocks on the floor with a dining room chair behind him .When asked resident if he was hurting anywhere, resident stated, 'My left hip hurts, I cannot move.' . Review of the Post Fall Review dated 11/8/2021, revealed the resident was wearing shoes at the time of the fall and the intervention was Physical Therapy and Restorative Nursing. Review of the Radiology Report dated 11/8/2021, revealed .Acute intertrochanteric fracture [broken hip] of the proximal left femur is noted with minimal displacement .Limited range of motion in the left hip joint . Review of the Fall Risk Scale dated 11/8/2021, revealed Resident #56 was at high risk for falling. Review of the Care Plan dated 11/8/2021, revealed Resident #56 had another fall on 11/8/2021 with the intervention for staff to assist with transfers as allowed and tolerated. This Care Plan intervention was not documented until 12/8/2021 (1 month after Resident #56 fell ). The resident was transferred to the emergency room for evaluation and treatment. This intervention was documented on the Care Plan on 12/2/2021. During an interview on 12/8/2021 at 10:45 AM, the DON was asked why Resident #56 had been in the Rehabilitation Dining Room by himself. The DON stated, .it wasn't dinner time .he walked down the hall from his room unassisted. There is a big television in there . The DON was asked what interventions were implemented to prevent the resident from falling. The Regional Director of Clinical Services stated, .I don't think any intervention would have kept him from missing the chair. It was an isolated incident . The DON was asked if the resident was safe to ambulate unassisted. The DON stated, .He is care planned for aggressive behaviors .he'll swing at you if he feels like it and difficult to re-direct . The DON was asked if he was agitated during the incident. The DON stated, I don't know. Review of the discharge MDS assessment dated [DATE], revealed Resident #56 still had a BIMS score of 7, required supervision with his activities of daily living, had no functional limitations, had 2 or more falls without injury, 2 or more falls with minor injury, and 1 fall with major injury since the prior assessment. Review of the significant change MDS assessment dated [DATE], revealed Resident #56 had a BIMS score of 3, which indicated severe cognitive deficits, required extensive assistance with most of his activities of daily living, and had no falls since admission or prior assessment. Review of the Nursing Progress Note dated 11/23/2021, revealed .During rounds CNA [Certified Nursing Assistant] noted resident on floor. Resident immediately notified nurse of the incident . Review of the Post Fall Review dated 11/23/2021, revealed the resident was wearing socks at the time of the fall and the fall prevention intervention for this fall was to educate the resident to use the call light when attempting to transfer even though the resident had severe cognitive deficits. Review of the Referral to Rehabilitation Services dated 11/23/2021, revealed .Resident stated he slipped while attempting to go to the restroom .Pt [Patient] currently on PT [Physical Therapy] /OT [Occupational Therapy]/ST [Speech Therapy] caseload for therapy. Pt's balance and safety awareness are being addressed . Review of the Care Plan dated 11/23/2021, revealed Resident #56 had an actual fall on 11/23/2021 and the staff were to increase room rounds to assist with toileting. This intervention was not placed on the Care Plan until 12/8/2021. Review of the Fall Risk Scale dated 11/23/2021, revealed Resident #56 was a high risk for falling. During an interview on 12/8/2021 at 10:45 AM, the DON was asked if educating the resident about using the call light could be effective if the resident had a BIMS score of 3. The DON stated, .Some days he was really with it . The DON was asked if the Care Plan had been updated to reflect interventions to prevent the resident from falling. The DON stated, .He was referred to therapy . The DON was informed Resident #56 was in the therapy case load at this time. The DON stated, Oh. Review of the Nursing Progress Notes dated 11/28/2021, revealed .12:10 PM this nurse was called to resident room to evaluate resident and assist to bed per request of his brother .had attempted to assist resident to the rollator seat beside his bed but was unable to do this .both advised he did not fall he sat him down . Review of the Post Fall Review dated 11/28/2021, revealed .Resident was sitting upright on his buttocks in the floor beside his bed with knees flexed and was laughing when I walked in the room. He said I'm in trouble .Resident was attempting to get to his rollator walker with the assistance of his brother . wearing non skid socks. The resident and his brother were .cautioned against transfer without staff assistance . Review of the Care Plan dated 11/28/2021, revealed the resident had another fall on 11/28/2021 with interventions to .Encourage Family to ask for assistance when assisting Resident with transfers-Mats to bedside . This intervention was not placed on the Care Plan until 12/8/2021. Review of the Fall Risk Scale dated 11/28/2021, revealed Resident #56 was high risk for falling. Review of the Referral to Rehab Services dated 11/29/2021, revealed .Brother tried to assist with walker and sat resident on floor .Pt is currently receiving skilled OT/PT/ST services at this time to address strength, balance, & safety. Resident is not safe to use walker/rollator at this time. Recommend removal [of walker/rollator] . Review of the Incident Report dated 11/30/2021, revealed .I walked in room and observed patient on the floor . Review of the Post Fall Review dated 11/30/2021, revealed the resident was wearing shoes and slippers. The immediate fall prevention interventions implemented were a .fall mat and call assessment . Review of the Care Plan dated 11/30/2021, revealed Resident #56 had another fall on 11/30/2021 with interventions to .Keep in sight of staff as allowed and tolerated . The interventions were placed on the Care Plan on 12/8/2021. Review of the Fall Risk Scale dated 11/30/2021, revealed Resident #56 was at high risk for falling. Observation in the resident's room on 12/6/2021 at 2:45 PM, revealed Resident #56 lying in the B bed (by the window) with a sheet covering his bottom area. A rollator walker was at the foot of his bed next to the wall. Resident #56 was confused and alert to his name only. Observation in the resident's room on 12/7/2021 at 8:55 AM and 3:30 PM, revealed Resident #56 lying in the B bed sleeping with the head of his bed raised. His roommate had his television on, and fall mats were on each side of the roommate's bed. Observation in the resident's room on 12/8/2021 at 10:45 AM, revealed Resident #56 seated on the side of the B bed. His wheelchair was at the bedside. During an interview on 12/8/2021 at 6:52 PM, Licensed Practical Nurse (LPN) #12 was asked which bed was Resident #56's bed. LPN #12 stated, B bed. Observation in the resident's room on 12/9/2021 at 8:08 AM, revealed Resident #56 was seated in his wheelchair with a blanket wrapped around him. The rollator remained at the foot of his bed against the wall. The rollator had been recommended to be removed on 11/29/2021 by therapy. During a telephone interview on 12/9/2021 at 8:13 AM, Resident #56's Physician was asked about Resident #56's fall record. The Physician stated, .I know he has fallen .they [facility] probably notified the Nurse Practitioner, I assumed they informed her .I saw him on 10/20/2021 for his low vitamin D labs .a vitamin D deficiency can potentially predispose the resident to fractures . The Physician was asked if Resident #56 had the cognitive ability to be educated. The Physician stated, .initially it appeared that he could be educated but if you talked to him long enough, well he doesn't make much sense . The Physician was asked if the facility should have put interventions in place to prevent the falls. The Physician stated, .should have put something in place . During an interview on 12/9/2021 at 8:45 AM, the DON was asked if Resident #56's Care Plan should have been updated with new interventions. The DON stated, Yes. The DON was asked if the resident was wearing shoes, as documented in the Post Fall Reviews and if shoes were an appropriate intervention. The DON stated, No. During an interview on 12/9/2021 beginning at 8:50 AM, in Resident #56's room, the DON was asked to identify Resident #56. The DON was informed Resident #56 had been observed on 12/6/2021, 12/7/2021, and 12/8/2021 in the bed by the window. The DON stated, .The resident was moved to the A bed [bed by the door] on Saturday. I guess they [staff] are not communicating because it hasn't been changed in the computer either. The DON was asked if the rollator walker should be in the resident's room if the therapist had recommended it to be removed. The DON stated, It should be removed. The DON was asked if the fall mats would be effective if they were on each side of the A bed when Resident #56 was in the B bed. The DON stated, No. The DON was asked if staff should be with Resident #56 when he was ambulating down the hall. The DON stated, .we can't stop him from ambulating .if staff try to assist him, he will go irate, swing at you, and curse you .staff may not see him . The DON was asked if she felt the interventions were implemented after each fall. The DON stated, No. During an interview on 12/9/2021 at 10:45 AM, the Adult Gerontology Acute Care Nurse Practitioner (AGACNP) was asked if Resident #56 could be educated. The AGACNP stated, .I think there is a memory loss, but the staff should re-teach to call for assistance, but I don't think he'll remember . The AGACNP was asked if the facility should be implementing interventions. The AGACNP stated, .Yes, new interventions every time . During an interview on 12/9/2021 at 9:15 AM, CNA #18 was asked which bed was Resident #56's bed. CNA #18 stated, .he was changed to the A bed .we are moving him today . Observation in the resident's room on 12/9/2021 at 11:44 AM, revealed Resident #56 lying in the A bed wearing nonskid socks. There were floor mats noted on each side of his bed. The facility's failure to provide appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fractured left femur.

Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner which resulted in delayed mealtimes on 5 of 5 halls (100 Hall, 200 Hall, 300 Hall, 400 Hall, and the Rehabilitation Hall). This failure had the potential to affect 98 of the 100 residents who received a meal tray. The findings include: Review of the facility's policy titled, Frequency of Meals, dated 7/2017, revealed .Meals will be served .to help assure that residents receive nutritional requirements. The following meal times have been established by our facility for residents: Breakfast 7 AM [7:00 AM] Start .Lunch 11 AM [11:00 AM] Start .Dinner 5 PM [5:00 PM] Start . Observation of the Rehabilitation Hall meal cart revealed the cart was delivered to the unit on 12/6/2021 at 6:19 PM (1 hour and 19 minutes late). Observation of the 300 Hall meal cart revealed the cart was delivered to the 300 Hall on 12/6/2021 at 6:30 PM (1 hour and 30 minutes late). Observation of the 100/400 Hall meal cart revealed the cart was delivered to the 100/400 Hall on 12/6/2021 at 6:40 PM (1 hour and 40 minutes late). Observation of the 200 Hall meal cart revealed the cart was delivered to the 200 Hall on 12/6/2021 at 6:45 PM (1 hour and 45 minutes late). During an interview on 12/6/2021 at 6:50 PM, the Dietary Manager confirmed the dinner trays on 12/6/2021 were scheduled to be served at 5:00 PM. The Dietary Manager stated, .time got away from me .we started supper over an hour late .the dinner trays should have been served at 5 [5:00] PM, with the last cart served at 5:30 PM .the dinner trays were over an hour late .

Based on Centers for Medicare and Medicaid Services (CMS) guidelines, policy review, Staff Screening Tool review, Daily Schedule Report review, and Timecard Detail review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 3 of 7 nurses (Licensed Practical Nurse (LPN) #4 and #8, and Unit Manger #2) failed to perform proper hand hygiene during medication administration and discarded a needle into the trash for 3 of 8 sampled residents (Resident #2, #67, and #252) reviewed for medication pass observations and failed to follow Centers for Disease Control (CDC) Infection Control guidelines to ensure all staff who enter the facility completed the screening process for the prevention and potential spread of COVID 19 when 28 of 108 staff members (Registered Nurse (RN) #1 and #2, LPN #1, #2, #3, #4, #5, #6, #7, #8, Certified Nurse Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15, Housekeeper #1 and #2, and Laundry Technician #2) failed to complete the screening log prior to working on 7 of 14 days (11/21/2021, 11/22/2021, 11/23/2021, 11/24/2021, 11/25/2021, 11/26/2021, and 12/4/2021) reviewed. This had the potential to affect the 100 residents residing in the facility. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidelines titled, Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed .1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility . Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 8/2015, revealed .Vigorously lather hands with soap and rub them together .for a minimum of 20 seconds .Rinse hands thoroughly under running water .Dry hands thoroughly under running water .Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel . Review of the facility's policy titled, COVID-19 Standard of Practice (SOP), revised 8/16/2021, revealed, .Complete infection control education and screening questionnaires for all employees, visitors, outpatients, contractors who attempt to enter facility. The screening will include temperature and other possible symptoms of COVID19 .Have designated facility employee at main entrance providing screening and offering education handouts, if possible . Observation in the resident's room on 12/8/2021 at 7:10 AM, revealed LPN #4 performed medication administration on Resident #67 through a percutaneous endoscopic gastrostomy (peg tube) tube. LPN #4 placed medications on the overbed table, washed her hands and turned the faucet off using the same paper towel. LPN #4 donned new gloves, poured water into each medication cup, then went to the medication cart, obtained her stethoscope, and cleaned it with a bleach wipe. LPN #4 washed her hands, turned the faucet off using the same paper towel and donned new gloves. LPN #4 administered medications, removed her gloves, washed her hands, and turned off the faucet using the same paper towel. Observation in the resident's room on 12/8/2021 at 8:13 AM, revealed Unit Manger #2 gathered Intravenous (IV) line supplies and placed them on Resident #252's overbed table which appeared dirty. The Unit Manger went into the bathroom, washed her hands, and turned off the faucet with the same paper towel. Unit Manger #1 placed the medication on the IV pole, donned gloves, wiped the overbed table with a disinfectant wipe, removed her gloves, washed her hands, and turned off the faucet with the same paper towel. During an interview on 12/8/2021 at 10:17 AM, Unit Manager #2 was asked if the resident's medications should have been placed on the resident's dirty over bed table. Unit Manager #2 stated, No, should have wiped the table off . Unit Manager #2 was asked if she should use the same paper towel, she had dried her hands with to turn off the faucet. Unit Manager #2 stated, No. Observation in the resident's room on 12/8/2021 at 8:50 AM, revealed LPN #8 washed her hands prior to medication administration and turned the faucet off using the same paper towel she had used to dry her hands. After injecting Resident #2 with her prescribed insulin, LPN #8 placed the needle from the insulin pen into the resident's trash. During an interview on 12/8/2021 at 8:55 AM, LPN #8 was asked if the syringe should have been discarded in the resident's trash. LPN #8 stated, .no, I should not have . During an interview on 12/9/2021 at 9:25 AM, the Director of Nursing (DON) was asked how staff should wash their hands. The DON stated, They should turn on faucet and let the water run, scrub hand 20-30 seconds .dry hands with paper towel and use a dry towel to turn off the faucet. The DON confirmed staff should not use the same paper towel to dry their hands. Review of the facility's Staff Screening Tool, Daily Schedule Report, and Timecard Detail Report from 11/21/2021-12/4/2021, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19. a. 11/21/2021 - LPN #1 and LPN #2; CNA #1, #2, #3, #4, and #5. b. 11/22/2021 - LPN #3 and #4; CNA #13 and #14. c. 11/23/2021 - LPN #5 and CNA #15. d. 11/24/2021 - LPN #1, #6, and #8; CNA #2, #6, #8, and #9; Housekeeper #1; and Laundry Technician #2. e. 11/25/2021 - RN #2; CNA #2, #3, #10, and #11 f. 11/26/2021 - LPN #2; CNA #12 and #13; and Housekeeper #2 g. 12/4/2021 - RN #1; LPN #1, #6 and #7; CNA #2, #3, and #7. During an interview on 12/7/2021 at 3:50 PM, Unit Manager #2 and the Infection Preventionist were asked who audited the screening logs to make sure all staff were screening for COVID-19 prior to entering the building. Unit Manager #2 stated, .I audit the screening logs every 3 weeks or so . During an interview on 12/8/2021 at 8:25 AM, the Business Office Manager (BOM) was asked whose responsibility it was to make sure staff screens for COVID-19 prior to entering the facility. The BOM stated, .it's my responsibility to make sure everyone screens. I have 2 receptionist that know they are to make sure everyone that enters the building screens .

Based on resident personal funds accounts review, policy review, medical record review, and interview, the facility failed to notify the family and/or resident when the amount in the resident's account exceeded the eligibility limit for 7 of 64 residents (Resident #6, #12, #34, #38, #48, #53, and #75) personal fund account statements reviewed. The findings include: Review of the facility's policy titled, Resident Personal Funds,dated 3/21/2021, revealed .The facility must notify each resident that receives Medicaid benefits: a. When the amount in the resident's account reaches $200 less than the SSI [Social Security Income] resource limit for one person b. If the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI . Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape (resident personal fund account) revealed Resident #6 had the following balances in the personal funds account: a. On 7/2/2021 Resident #6 had a closing balance of $6,851.14. b. On 8/4/2021 Resident #6 had a closing balance of $6,742.42. c. On 9/9/2021 Resident #6 had a closing balance of $6,792.72. During an interview on 12/9/2021 at 5:45 PM, the Business Office Manager (BOM) stated, .we are in the process of getting him new stuff . Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape revealed the following: a. On 7/30/2021 Resident #12 had a closing balance of $3,479.25. b. On 8/17/2021 Resident #12 had a closing balance of $3,460.98. c. On 9/24/2021 Resident #12 had a closing balance of $3,430.15. During an interview on 12/9/2021 at 5:45 PM, the BOM stated, .the Social Worker is supposed to be getting him a burial policy . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape revealed the following: a. On 7/20/2021 Resident #34 had a closing balance of $3,355.61. b. On 8/30/2021 Resident #34 had a closing balance of $3,656.08. c. On 9/3/2021 Resident #34 had a closing balance of $3,992.23. During an interview on 12/9/2021 at 5:45 PM, the BOM stated, .we [facility] are trying to get conservatorship over him so we can get a burial set up . Review of the medical record, revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident Statement Landscape revealed the following: a. On 7/30/2021 Resident #38 had a closing balance of $3,444.23. b. On 8/31/2021 Resident #38 had a closing balance of $3,289.38. c. On 9/28/2021 Resident #38 had a closing balance of $3,100.96. During an interview conducted on 12/9/2021 at 5:45 PM, the BOM stated, .the family knows what the balance is and doesn't want to spend down . Review of the medical record, revealed Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape revealed the following: a. On 7/2/2021 Resident #48 had a closing balance of $5,951.36. b. On 8/13/2021 Resident #48 had a closing balance of $5,976.59. c. On 9/10/2021 Resident #48 had a closing balance of $6,015.56. During an interview on 12/9/2021 at 5:45 PM, the BOM stated, .On April 21, 2021 we spoke with the daughter about putting money towards a burial policy . Review of the medical record, revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape revealed the following: a. On 7/2/2021 Resident #53 had a closing balance of $5,156.39. b. On 8/3/2021 Resident #53 had a closing balance of $5,206.61. c. On 9/3/2021 Resident #53 had a closing balance of $5,256.83. During an interview on 12/9/2021 at 5:45 PM, the BOM stated, .the family is supposed to be getting her a burial policy . Review of the medical record, revealed Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident Statement Landscape revealed the following: a. On 7/30/2021 Resident #75 had a closing balance of $2,869.49. b. On 8/9/2021 Resident #75 had a closing balance of $2,749.47. c. On 9/3/2021 Resident #75 had a closing balance of $2,622.40. During an interview on 12/9/2021 at 6:35 PM, the BOM was asked if she was aware and educated the residents' families on the outcome if the resident's funds exceed the resource limit. The BOM stated, .they could lose their Medicaid benefits .I spoke with the Social Worker and she doesn't have any notes either that documented the conversations she had with the family members encouraging them to spend down the resident accounts . During an interview on 12/9/2021 at 7:54 PM, the Administrator was asked what monetary limit of funds the residents can have in their accounts without risking losing their Medicaid. The Administrator stated, Anything close to 1800 hundred that is our bench mark .have to call family members to make authorization to spend it . The facility failed to provide documentation that the residents and/or families were notified when the resident personal funds accounts reached $200.00 less than the SSI resource limit.

Based on policy review, observation, and interview, the facility failed to ensure the environment was clean, comfortable, and sanitary when overbed tables were in disrepair in 8 of 80 resident rooms (Room #4, #18, #204, #208, #209, #211, #212, and #213) observed. The findings include: Review of the facility's policy titled, Maintenance Service, revised 12/2009, revealed .Maintaining the building in good repair and free from hazards . Observation during initial tour on 12/6/2021 beginning at 9:05 AM, revealed the following: a. Room #204 A-an overbed table with peeling vinyl and the wood was visible. b. Room #208 A and B-the overbed tables had peeling vinyl. c. Room #209 A and B-the overbed tables had peeling vinyl and the wood was visible. d. Room #211 A and B-the overbed tables were missing part of the vinyl and the wood was visible. e. Room #212 B-overbed table with peeling vinyl and the wood was visible. f. Room #213 A and B-the overbed tables had portions of the vinyl missing and the wood was visible. Observation in Room #4 A on 12/6/2021 at 10:19 AM, revealed the vinyl around the edges of the table were missing. Observation in Room #18 A on 12/7/2021 at 2:25 PM, revealed an overbed table in disrepair and the brown plastic top coating of polyethylene (vinyl) was peeled off on three fourths of the sides of the overbed table. During an interview on 12/7/2021 at 1:30 PM, Resident #89 (in Room #209 B) confirmed she had put orange tape on her overbed table due to it .scratches my fingers and hands . During interview on 12/7/2021 at 4:00 PM, the Maintenance Director was shown the overbed tables in the residents' rooms, and he stated, They do look bad .I will try to do better .

Based on review of the Medications with Shortened Expiration Dates, policy review, observation, and interview, the facility failed to ensure medications were stored properly in 5 of 11 medication carts (Rehab (Rehabilitation) Unit Medication Cart #5, Rehab Unit Medication Cart #6, Heritage Way Medication Cart #2, Heritage Way Medication Cart #1, and Memory Care Unit Medication Cart #3) and 1 of 6 nurses (Unit Manager #2) failed to ensure medications were not left unattended and out of sight during medication pass observations. The findings include: Review of the MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by MED PASS, revealed [MEDICATION(S)]/salmeterol ([MEDICATION(S)]) expires 30 days after removing from the protective wrap, [MEDICATION(S)] expires 3 months after the first actuation, Incruse expires 6 weeks after opening the foil tray, [MEDICATION(S)] expires 6 weeks after removal from the moisture protective overwrap, [MEDICATION(S)] expires 6 weeks after removal from the aluminum pouch, [MEDICATION(S)] expires 3 months after the first use, [MEDICATION(S)] and [MEDICATION(S)] expires 28 days after the first use or removal from the refrigerator, whichever comes first. Review of the facility's policy titled, Medication Storage, dated [DATE], revealed .During a medication pass, medication must be under the direct observation or locked in the medication storage area/cart .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defected, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed . Review of the facility's policy titled Medication Administration, dated [DATE], revealed .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .identify expiration date and ensure medication is not expired . Observation of the Rehab Unit Medication Cart #5 on [DATE] at 9:52 AM, revealed the following: a. One open and undated [MEDICATION(S)] [MEDICATION(S)] insulin pen b. One open and undated [MEDICATION(S)] Diskus Observation of the Rehab Unit Medication Cart #6 on [DATE] at 10:05 AM, revealed the following: a. One open and undated [MEDICATION(S)] insulin [MEDICATION(S)] pen b. One open and undated [MEDICATION(S)] insulin [MEDICATION(S)] pen c. One open and undated [MEDICATION(S)] insulin pen d. One open and undated [MEDICATION(S)]/salmeterol inhaler Observation of the Heritage Way Medication Cart #2 on [DATE] at 10:47 AM, revealed the following: a. One open and undated [MEDICATION(S)] insulin pen b. One [MEDICATION(S)] insulin [MEDICATION(S)] pen with an open date of [DATE] c. One [MEDICATION(S)] insulin pen with an open date of [DATE] Observation of the Heritage Way Medication Cart #1 on [DATE] at 11:04 AM, revealed the following: a. Two Novolog insulin pens with an open date of [DATE] b. Three open and undated [MEDICATION(S)] Insulin pens c. Two open and undated [MEDICATION(S)] pens d. Two open and undated [MEDICATION(S)] ,d+[DATE] pens e. One open and undated [MEDICATION(S)] insulin pens f. One open and undated vial of [MEDICATION(S)] g. One open and undated [MEDICATION(S)] KwikPen h. One [MEDICATION(S)] insulin [MEDICATION(S)] with an open date of [DATE] i. One open and undated Incruse Ellipta inhaler j. One open and undated [MEDICATION(S)]/salmeterol inhaler k. One open and undated [MEDICATION(S)] inhaler Observation of the Memory Unit Medication Cart #3 on [DATE] 05:49 PM, revealed the following: a. One Amelog insulin pen with and open date of [DATE] b. One open and undated [MEDICATION(S)] inhaler c. One open and undated [MEDICATION(S)] inhaler Observation in the resident's room on [DATE] at 8:13 AM, revealed Unit Manager #2 entered Resident #252's room and placed a bag of intravenous antibiotic and the supplies on the resident's over bed table. Unit Manager #2 went into the resident's bathroom, washed her hands, and left the medication out sight and unattended. During an interview on [DATE] at 11:04 AM, LPN #9 confirmed that the insulin and inhalers should have an open date when opened. During an interview on [DATE] at 6:02 PM, the Director of Nursing (DON) confirmed that the Pharmacist comes to check the medication cart monthly. The DON confirmed that insulin without an open date or medications that have expired past their open date should not be in the medication carts. The DON confirmed that inhalers should be dated when opened. During an interview on [DATE] at 10:17 AM, Unit Manager #2 confirmed that she should not have left the resident's medication on the overbed table out of sight when she went into the bathroom and washed her hands.

Based on review of the facility's certified nursing assistants (CNA) specific job responsibilities for days, policy review, medical record review, observation and interview, it was determined the facility failed to ensure pain management was provided for 1 of 4 (Resident #16) sampled residents reviewed for pain management of the 31 residents included in the stage 2 review. The failure of the facility's staff to provide timely pain management, resulted in actual harm to Resident #16. The findings included: Review of the facility's certified nursing assistants specific job responsibilities for days documented, "...Do pericare after every incontinent episode.. .Report to charge nurse any problems..." Review of the facility's pain assessment and management policy documented, "...POLICY... Patients with complaints of pain or signs and symptoms of pain are assessed and managed based on the assessment... PROCEDURE... The facility ensures this policy is met by assessing each patient for pain on admission, readmission, and anytime the patient verbalizes or displays signs and symptoms of pain or discomfort... Patients experiencing pain are evaluated periodically to ensure that methods used to alleviate pain are effective and changes are made as needed..." Medical record review for Resident #16 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive status score was 12 out of a possible score of 15 indicating the resident was moderately impaired. The resident was totally dependent on the staff for personal hygiene and bathing. Pain assessment documented the resident had pain of moderate intensity and received pain medications and non pharmacological interventions as needed for pain. Review of the care plan dated 9/20/13 last reviewed 6/11/14 documented, "...Totally dependent on staff for bathing-bathe/shower daily... always incontinent of bowel and bladder... apply moisture barrier to buttocks... pain management as needed..." Review of the physician's orders [REDACTED]. Observations in Resident #16's room on 7/23/14 beginning at 9:40 AM, revealed CNA #1 and CNA #2 provided a bed bath for Resident #16. After the CNAs prepared for the bed bath and before beginning, the resident complained of a headache, she needed her medicine. Resident #16 stated, "Don't know why she (nurse) can't give it to me." The CNAs continued with the resident's bath, not responding to the resident's complaint and request. Resident #16's adult brief was removed. The resident was soiled with a large amount of semi-liquid stool. Redness between the skin folds of the buttocks and rectal area was noted. Resident #16 was crying and yelling out during the bathing of these areas, and requesting cream for the "raw" areas. More redness was noted to the groin area and the resident continued to cry and yell out and ask for cream when the reddened areas were touched during the bath. Resident #16 asked CNA #1 to apply powder to the reddened and raw perineal areas. CNA #2 told the resident the nurse would get her cream for that. During an interview at the 400 hall nurse's station on 7/23/14 at 10:52 AM, Nurse #2 was asked if Resident #16 had been given pain medication. Nurse #2 stated, "No, could have had the medicine at 9:30 AM because it is prn (as needed)." Nurse #2 was then asked about the treatment for [REDACTED]. Nurse #2 stated she usually does hers after lunch, but that she would go ahead and take it to her now. Nurse #2 had not been informed of the pain the resident had experienced during the bath given by CNA #1 and CNA #2. During an interview in the conference room on 7/23/14 at 11:15 AM, the Director of Nursing (DON) was asked what was expected of the CNAs if a resident requested pain medication during the bath. The DON stated, "The staff should cover the resident and immediately report the request to the charge nurse." The DON was asked what is the acceptable timeframe for reporting the resident's complaint of pain and request for pain medication. The DON stated, "Immediately, within 5 or 10 minutes unless they have an emergency." The DON was asked what if a resident requests cream or Zinc for redness to her bottom. The DON stated the staff should report this to the charge nurse and she would handle it. During an interview in the conference room on 7/24/14 at 1:49 PM, Resident #16's physician was asked about pain management for Resident #16. The physician stated, "If she is on a particular regimen, then they (staff) should follow that regimen. I'll go deal with that right now." The failure of the CNAs to stop and report Resident #16's complaint of pain and request for pain medication at the beginning of the bath on 7/23/14 at 9:40 AM, and to continue bathing, as the resident was yelling and crying out in pain without notifying the nurse, resulted in actual harm to Resident #16. Resident #16's pain medication and zinc ointment were not provided until 10:52 AM.

Based on review of the "National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", medical record review, observation and interview, it was determined the facility failed to identify and prevent the development of pressure ulcers and failed to accurately assess a pressure ulcer for 2 of 8 (Residents #1 and 5) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #1. The findings included: 1. Review of the "National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...p.9... Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... p. 12... 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." 2. Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the"Daily Skilled Nurse's Note" checklist dated 6/14/11 documented, "...Skin - WNL (within normal limits)..." Review of the "Daily Skilled Nurse's Note" dated 6/15/11 documented, "... Skin - WNL... *Pressure Ulcer... Services Provided... treatment of [REDACTED]./11 documented, "...Location: Sacral area Date of Onset: 6/15/11... Stage UNS (unstageable)... Size: (in cm (centimeters)) L (length) 7.5 W (width) 7 D (depth) UTD (unable to determine)... Necrotic/Eschar Periwound: Red Exudate: Serosanguineous Undermining / Tunneling: UTD... necrotic 10% (percent) slough, hypogranulation..." Observations in Resident #1's room on 7/18/11 at 5:38 PM and on 7/20/11 at 6:08 PM, revealed Resident #1 lying on his back in bed with an air mattress on the bed. During an interview at the Rehabiltation Unit nurses' station on 7/19/11 at 5:28 PM, Nurse #9 was asked when Resident #1's sacral wound was discovered. Nurse #9 stated, "June 15th (2011)." Nurse #9 was asked what stage the wound was upon discovery. Nurse #9 stated, "...unstageable..." When asked how often Resident #1's skin was being assessed Nurse #9 stated, "Weekly... but skilled patients should be assessed daily by the nurse." During an interview in the conference room on 7/19/11 at 5:55 PM, the Assistant Director of Nursing (ADON) was asked how often skin assessments are to be performed on residents. The ADON stated, "...nurses should do a head to toe skin assessment daily... should be done every day by the nurse on skilled patients..." The ADON was asked if she would expect a wound to be discovered before becoming unstageable. The ADON stated, "I would have expected them (nurses) to find something, even if just some softness on the skin..." During an interview in the conference room on 7/20/11 at 8:15 PM, Resident #1's physician was asked if he would have expected a wound to be discovered before becoming unstageable. Resident #1's physician stated, "I would have expected them to find something... clearly someone wasn't paying attention..." The failure to identify and prevent skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #1. 3. Medical record review for Resident #5 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's admission and readmission assessment dated [DATE] documented, "...feet heels dry & (and) scaley..." There was no documentation of any pressure ulcers. Review of the "Daily Skilled Nurse's Note" checklists dated 5/17/11 and 5/18/11 documented, "...Skin-WNL..." Review of the nurse's notes dated 5/18/11 documented, "...1125AM (11:25 AM)... Upon careful assessment was noted Stage III to (Lt) (left) lateral ankle..." Review of the weekly wound progress note dated 5/18/11 documented, "...Date of Onset 5/14/11... Stage III... Size: (in cm) L 2 W 1.5 D UTD Tissue Type: Slough... Periwound: dark Exudate: serosanguineous... Undermining/Tunneling: sloughy..." Review of the monthly summary dated 5/21/11 documented, ".. Skin Condition No problems noted..." Review of the weekly wound progress note dated 5/26/11 documented, "...Closed 5/26/11..." indicating that the wound was healed. During an interview in the conference room on 7/19/11 at 2:35 PM, Nurse #9 was asked who performed the initial wound assessment on Resident #5. Nurse #9 stated, "I did on 5/18/11." Nurse #9 was asked what stage the wound was when it was found. Nurse #9 confirmed that it was documented as a Stage III and stated, "I overstaged it..." During an interview in the conference room on 7/19/11 at 3:40 PM, the ADON was asked who is responsible for performing the skin assessment on residents upon admission or readmission. The ADON confirmed that the admitting nurse is responsible for performing a head to toe assessment when a resident is admitted or readmitted . The ADON was asked if there was any documentation of a wound on Resident #5 upon return to the facility on [DATE]. The ADON stated, "...I don't see any documentation of a wound..." The ADON stated, "...we have a bad problem (with pressure ulcers)..." During a telephone interview in the conference room on 7/19/11 at 3:45 PM, the Family Nurse Practitioner (FNP) was asked if he would expect a Stage III pressure ulcer to heal in 8 days. The FNP stated, "No."