Every finding on record at Marquis Plum Ridge Post Acute Rehab

Based on interview and record review it was determined the facility failed to provide SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage) notifications to 1 of 3 sampled residents (#13) reviewed for Beneficiary Notification. This placed residents and their representatives at risk for inadequate information to make financial and care decisions. Findings include:The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-10055, is issued by the facility if the beneficiary intends to continue services and the facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. Resident 13 was admitted to the facility in 12/2025 with Medicare Part A benefits.The SNF Beneficiary Notification Review form completed by the facility for Resident 13 indicated the resident's last covered day for Medicare Part A services was 2/18/26 and Resident 13 remained in the facility. Resident 13 was not provided with a SNF ABN for notification of potential financial liability for services received.On 5/21/26 at 3:57 PM, Staff 19 (Social Services Assistant) confirmed residents with Part A service termination who remain in the facility should be given a SNF ABN form in addition to a Notice of Medicare Non-Coverage. Staff 19 stated the SNF ABN was not completed for Resident 13.On 5/22/26 at 9:51 AM, Staff 1 (Administrator) acknowledged the facility failed to complete the required SNF ABN form for Resident 13.

Based on interview and record review it was determined the facility failed to clarify and follow physician orders for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for delayed treatment and unmet medication needs. Findings include:Resident 3 was admitted to the facility in 5/2024 with diagnoses including heart failure, atrial fibrillation (irregular heartbeat), and COPD (Chronic Obstructive Pulmonary Disease).The 4/2026 TAR revealed an order to obtain daily weights every day shift for Resident 3. No weights were documented on 4/16/26, 4/17/26 or 4/29/26 and weight increases exceeding two pounds were recorded as follows:-From 4/4/26 to 4/5/26: 2.2-pound increase-From 4/10/26 to 4/11/26: 3.8-pound increase-From 4/14/26 to 4/15/26: 4.8-pound increase-From 4/20/26 to 4/21/26: 2.4-pound increaseA 5/1/26 signed Medication Review Report indicated the order for daily weights every day shift was active, verbally prescribed, and had a start date of 8/1/24.The 5/2026 TAR revealed no daily weights were documented on 5/3/26, 5/9/26, 5/14/26, and 5/16/26. Resident 3 gained 10 pounds from 5/10/26 to 5/15/26.A 5/1/26 Note Text: Weight Warning identified Resident 3's weight had decreased during the week.A 5/14/26 Note Text: Weight Warning indicated Resident 3 had a small weight gain, nurses would monitor for the resident's trending weights, and notify the provider as needed.On 5/22/26 at 10:20 AM a handwritten note provided by Staff 2 (DNS) indicated Staff 7 (Doctor of Nursing Practice) expected staff to notify her when residents with orders for daily weights experienced a weight gain of two to three pounds within 24 hours or five pounds within one week. No additional documentation was found in Resident 3's clinical record. On 5/21/26 at 11:48 AM, Staff 5 (LPN) stated CNAs obtained Resident 3's daily weights. Staff 5 stated there were no documented parameters for Resident 3's daily weights and no weights were reported to Staff 7.On 5/21/26 at 12:17 PM and 4:29 PM, Staff 16 (Resident Care Manager) stated nursing staff were expected to clarify orders for Resident 3's daily weights and consistently assess weight fluctuations to ensure concerns regarding the resident's condition were addressed. Staff 16 stated staff were expected to reweigh residents when weight changes were considered significant but could not identify the specific weight parameters to address potential issues with Resident 3's weights. On 5/21/26 at 2:04 PM, Staff 7 stated there was an understanding that residents with heart failure should have daily weights according to her specified parameters. Staff 7 stated she was not notified when Resident 3's weights fell outside of those parameters.On 05/22/26 at 9:38 AM, Staff 2 acknowledged Resident 3's parameters for daily weights were not confirmed and the resident required reweighing with documentation on multiple days to monitor for potential health complications identified by the resident's weight fluctuations.

Based on observation, interview, and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 sampled resident (#2) who was reviewed for positioning and mobility. This placed residents at risk for contracture progression and joint pain. Findings include: Resident 2 admitted to the facility in 8/2024 with diagnoses including cerebral infarction (stroke), hemiplegia/hemiparesis (reduced sensation and movement with abnormal muscle tone) of the left side, and depression.The 12/23/25 Care Plan Report for Resident 2 included a restorative nursing program which included range of motion exercises for the left leg. The restorative nursing program did not include interventions for the left arm or hand.The 2/8/26 Quarterly MDS for Resident 2 indicated intact cognition and impairment of range of motion of the upper and lower extremity on one side of the body.The most recent OT Evaluation & Plan of Treatment completed on 2/16/26, reflected impaired left upper extremity range of motion in the shoulder, elbow, wrist, fingers, and thumb. This document also stated Resident 2 once had an RA program for left upper extremity range of motion. The 3/19/26 OT Discharge Summary did not reflect a left upper extremity range of motion program was established prior to discharge.On 5/18/26 at 10:07 AM, Resident 2 indicated she/he used a piece of a foam pool noodle to try to expand her/his hand, but she/he was unable to find the pool noodle on this date. Resident 2's left hand was observed to have contractures of all fingers and was fixed in a cupped position. Resident 2 stated she/he tried to do stretching of the left hand for herself/himself and indicated staff do not assist her/him with range of motion of the left arm and hand. The door leading from the resident's room to the bathroom had a photograph posted of Resident 2's left upper extremity wearing a forearm/wrist/hand splint with instructions for the application of this device. Resident 2 stated she/he no longer used the splint in the photo. On 5/19/26 at 12:35 PM Resident 2 indicated she/he had still not located the pool noodle to place in her/his left hand to stretch out the contractures of the fingers. Instead, she/he put a washcloth in her/his left hand.On 5/19/26 at 3:03 PM, Staff 25 (CNA) stated she provided no special care for Resident 2's left hand or wrist.On 5/20/26 at 10:01 AM, Staff 27 (CNA) indicated the care she offered to Resident 2 for her/his left hand was routine hand hygiene and nail care. Staff 27 did not know if Resident 2 ever had a range of motion or contracture management program for the left upper extremity.On 5/20/26 at 10:26 AM, Staff 26 (Director of Rehabilitation and Occupational Therapy Assistant) confirmed Resident 2 had no range of motion program in place for the left upper extremity.On 5/21/26 from 11:28 AM to 11:49 AM, Resident 2 was lying in bed with a pink memory foam block in her/his left hand. Resident 2 expressed feelings of sadness and cried at times during this conversation. Resident stated she/he suffered from depression and sometimes she/he just gives up on exercise programs and other things she/he knows she/he should be doing. Resident 2 expressed difficulty remaining motivated when she/he feels depressed and stated she/he needed staff to come in and remind, encourage, and assist her/him with doing stretches and exercises. Resident 2 explained therapy staff trained her/him with programs in the past for exercise and range of motion but once she/he discharged from skilled therapy, no staff regularly assisted with carrying out those programs.On 5/21/26 at 1:13 PM, Staff 16 (RCM) indicated the facility expectation was for CNA staff to provide RA programs to residents as part of their daily ADL care. Staff 16 stated the facility did not have any RA personnel on staff. Staff 16 confirmed the photo and instructions for the left arm/hand splint posted in Resident 2's room was outdated and no longer in use.On 5/22/26 at 10:22 AM, Staff 2 (DNS) stated the posted left arm/hand splint information in Resident 2's room should have been taken down, as the splint was discontinued a long time ago. Staff 2 confirmed Resident 2 needed to receive left upper extremity range of motion support to prevent decline.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident who was a trauma survivor was assessed timely and received trauma-informed care for 1 of 4 sampled residents (#3) reviewed for choices. This placed residents at risk for continued traumatization. Findings include:Resident 3 was readmitted to the facility in 5/2024 with diagnoses including heart failure and PTSD (Post-Traumatic Stress Disorder).A 5/2/22 admission: Social Services assessment revealed Resident 3 had PTSD related to military service. The assessment indicated the resident's coping mechanisms included to try not to think about it and attendance at a PTSD support group. No revised assessment related to the resident's PTSD was found in the clinical record.Resident 3 was readmitted to the facility in 2/2026.A 2/9/26 admission: Social Service assessment did not address Resident 3's PTSD diagnosis, triggers, or coping mechanisms.The 2/27/26 Quarterly MDS assessment revealed Resident 3 had a BIMS assessment score of 15 (cognitively intact).The 4/22/26 to 5/21/26 Task: Behavior Monitoring and Interventions (documentation by CNAs) revealed Resident 3 had no behaviors.A 5/15/26 revised Care Plan revealed Resident 3 experienced a sad or depressed mood related to PTSD and may be triggered by flashbacks of violent wartime events. Resident 3 attended a veteran support group with transportation provided by her/his family. The care plan did not identify loud noises as PTSD triggers.On 5/18/26 at 10:49 AM, Resident 3 was observed seated in her/his wheelchair in her/his room. Resident 3 was asked about her/his triggers related to her/his trauma. Resident 3 appeared to become agitated, developed a furrowed brow, and stated loud noises and noises from the neighbor bothered her/him as the resident pointed toward the wall shared with the neighboring room. Resident 3 stated staff were aware of the issue. Resident 3 stated she/he no longer attended her/his veterans therapy group and missed the support previously received. Resident 3 stated she/he was recently provided a bus pass to attend the veterans therapy group. On 5/19/26 at 3:46 PM, Staff 24 (CNA) stated she was aware of Resident 3's anxiety related to the noises from neighboring residents. Staff 24 stated she provided distraction techniques listed in her/his care plan to address the resident's anxiety associated with her/his PTSD several times each month.On 5/20/26 at 3:00 PM, Staff 19 (Social Service Assistant) stated Resident 3 was a long-term resident and no recent interview related to the resident's PTSD was completed. Staff 19 stated the facility was aware of concerns about Resident 3's neighbors but did not address her/his concerns because no formal complaint was submitted. Staff 19 stated Resident 3 was provided a bus pass to assist with transportation needs for attendance at the veteran support group and was not aware the resident did not attend.On 5/21/26 at 10:30 AM, Staff 18 (Social Services Assistant) stated Resident 3 was not interviewed regarding PTSD needs upon readmission. Staff 18 acknowledged the resident's care plan was updated using an outdated Social Services assessment. Staff 18 expected an annual review of Resident 3's trauma informed care needs to ensure the resident had sufficient transportation to attend the veterans support group and a potential room change related to noise concerns.On 5/21/26 at 10:51 AM, Staff 20 (Corporate Social Service Consultant) acknowledged an updated assessment for Resident 3's PTSD was not completed upon admission, staff were to assess and communicate behavioral concerns, and newly identified triggers were not incorporated into the resident's care plan. On 5/21/26 at 11:30 AM, Staff 23 (CNA) acknowledged loud noises annoyed Resident 3 and staff addressed the concerns by keeping the peace between residents. Staff 23 stated she did not consider Resident 3's responses as behaviors because the resident did not raise her/his voice. Staff 23 stated nurses were aware Resident 3 had PTSD; however, the resident's care plan did not include details about her/his triggers.On 5/21/26 at 11:36 AM, Staff 5 (LPN) stated Resident 3 complained about noise disturbances and he was informed social services staff would address the concerns with the resident. Staff 5 stated he was not aware of any triggers related to Resident 3's PTSD and acknowledged the resident's repeated complaints about noise were signs of agitation and behaviors which should be documented.On 5/21/26 at 12:02 PM, Staff 3 (CNA) stated Resident 3 reported noise concerns which were reported to nursing. Staff 3 acknowledged Resident 3 was agitated when she/he complained about the noises and acknowledged those behaviors were not documented.On 5/21/26 at 12:33 PM, Staff 16 (Resident Care Manager) stated Social Services staff were expected to address Resident 3's PTSD and acknowledged it was an interdisciplinary responsibility to ensure the resident's care plan was updated to reflect changes in triggers and psychosocial needs related to PTSD.

Based on observation, interview, and record review it was determined the facility failed to ensure proper food temperatures were maintained during meal service for 3 of 13 sampled residents (#s 26, 52, and 70) reviewed for dining observations. This placed residents at risk for food that was not palatable or appetizing. Findings include: 1. Resident 26 was admitted to the facility in 3/2026 with diagnoses including compression fracture of the spine and respiratory failure. An 4/1/26 admission MDS revealed a BIMS assessment score of 14 (cognitively intact). Resident 70 was admitted to the facility in 5/2026 with diagnoses including kidney failure and diabetes. A 5/12/26 admission Social Services assessment revealed a BIMS score of 15 (cognitively intact). A 5/18/26 untitled document indicated Resident 70 was to receive early breakfast trays daily. On 5/18/26 at 7:25 AM an uninsulated open cart containing three covered resident meal trays was observed unattended in the hallway. On 5/18/26 at 7:40 AM, Resident 70 stated she/he ate in her/his room and the food was cold 50% of the time. Resident 70 stated meal trays were often left undelivered outside her/his room for an extended period of time. On 5/18/26 at 7:45 AM, one unidentified staff member was observed to deliver the resident meal trays from the open cart. A large, enclosed cart arrived at the same time with additional resident meal trays. On 5/18/26 at 8:06 AM, three unidentified staff members were observed to deliver meal trays to residents including Resident 26. On 5/18/26 at 8:16 AM, Resident 26 was observed eating breakfast in her/his room. The meal included fried eggs and toast. Resident 26 stated the food was barely warm. An unidentified staff member entered the room and removed the resident's plate to reheat the toast and fried eggs in the microwave. On 5/20/26 at 9:00 AM, Staff 29 (CNA) stated the breakfast meal tray delivery process involved the delivery of early trays first, then the delivery of the remaining meal trays to the dining room and resident rooms once the larger meal cart arrived. Staff 29 stated it was difficult to deliver breakfast meal trays timely when CNAs were occupied providing resident care. Staff 29 stated nurses were not available to assist with the early meal tray deliveries. On 5/20/26 at 10:09 AM, Staff 28 (Dietary Manager) stated therapy created a list of residents who required early trays in order to attend morning therapy sessions and additional residents were added to the early tray list based on dialysis schedules. Staff 28 stated early meal trays were completed daily at approximately 7:20 AM and the current meal carts were not insulated which made it difficult to maintain food temperatures without prompt delivery. Staff 28 acknowledged delayed tray delivery could result in cold food and reheated food decreased food quality. On 5/22/26 at 10:32 AM, Staff 1 (Administrator) acknowledged addressing resident concerns related to cold food remained an ongoing focus of the facility's QAPI (Quality Assurance Performance Improvement) program. 2.Resident 52 was admitted to the facility in 8/2025 with diagnoses including dialysis and diabetes. On 5/18/26 at 7:25 AM, an uninsulated open cart was observed with three covered resident meal trays on the cart. No staff were in attendance. On 5/18/26 at 8:21 AM, a meal tray for room [ROOM NUMBER] was observed in the kitchenette on the counter and not refrigerated. The resident in room [ROOM NUMBER] was not in the room On 5/18/26 at 11:25 AM, Resident 52 stated she/he was supposed to receive an early breakfast due to going out to dialysis and being an early riser, but she/he did not get her/his tray delivered early. Resident 52 stated she/he watched the meal tray sit on the meal cart undelivered. Resident 52 stated staff would warm the meal up, which made the food mushy and taste awful. Resident 52 also stated, sometimes I get my breakfast when I return from dialysis and staff warm the food up, which makes the food worse. On 5/20/26 at 9:00 AM, Staff 29 (CNA) stated she left Resident 52's meal tray in the kitchenette on the counter because there was no room in the refrigerator and she would reheat the meal for her/him once she/he returned after 10:00 AM. On 5/20/26 at 10:09 AM, Staff 28 (Dietary Manager) stated therapy created a list of residents who required early trays to attend morning therapy sessions and additional residents were added to the early tray list based on dialysis schedules. Staff 28 stated early meal trays were completed daily around 7:20 AM. Staff 28 stated the current meal carts were not insulated and it was difficult to maintain food temperatures without prompt delivery. Staff 28 acknowledged he was aware of the potential issue of cold food with late meal tray delivery and reheated food decreased food quality. 05/21/26 8:10 AM, Resident 52 stated she/he did not receive an early tray that morning. She/he sat in the tv room, observed the meal cart, and the early morning trays were not passed. On 5/22/26 at 10:32 AM, Staff 1 (Administrator) acknowledged cold food experienced by residents in the facility was an ongoing focus of the Quality Assurance Performance Improvement (QAPI) program

Based on observation, interview, and record review it was determined that the facility failed to ensure sufficient bathing was provided to a dependent resident for 1 of 1 sampled resident (#70) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings included: Resident 70 was admitted to the facility on [DATE] with diagnoses including an open wound of the left buttock and respiratory failure with hypoxia (low oxygen levels in the blood making it difficult to breathe).The 5/11/26 and 5/14/26 Task Bath/Shower log (CNA documentation) revealed Resident 70 declined bathing on both dates.Resident 70's clinical record revealed no documentation of follow-up or interventions related to the resident's bathing refusals.A 5/12/26 admission Social Services assessment revealed a BIMS score of 15 (cognitively intact) for Resident 70.A 5/12/26 Care Plan revealed Resident 70 required one staff member to provide physical assistance for care, staff were to ensure the resident's clothing remained clean and appropriate, and the resident experienced anxiety related to feelings of confined spaces.A 5/14/26 Multidisciplinary Care Conference revealed Resident 70 required supervised assistance for safety and moderate assistance with ADLs including personal care tasks.On 5/18/26 at 7:28 AM and 5/20/26 at 11:21 AM, Resident 70 was observed sitting in her/his recliner wearing a gown. Resident 70 stated only one bed bath was offered since her/his admission which the resident declined at the time. Resident 70 stated she/he was unable to receive a shower because of her/his wound and received no bathing for one week. Resident 70 stated she/he requested bathing and there was no follow-up. Resident 70 stated she/he had not been offered a clean gown since admission and therapy was aware she/he felt trapped when the resident was in bed due to her/his breathing difficulties. On 5/20/26 at 1:07 PM, Staff 12 (LPN) stated all residents are on a bathing schedule. Staff 12 stated staff were to notify nurses of resident bathing refusals to allow nursing staff to address the resident's needs individually. Staff 12 stated he was not informed Resident 70 refused bathing on 5/11/26. Staff 12 stated communication was difficult that day because Staff 12 was assigned medication administration and nursing tasks due to staffing shortages. On 5/21/26 at 3:37 PM, Staff 17 (CNA) stated she informed Staff 21 Resident 70 wanted to sleep when a shower was offered on the evening of 5/11/26. On 5/21/26 at 5:00 PM, Staff 21 (RN) stated she was not notified Resident 70 refused a shower on 5/11/26. Staff 21 stated nurses were to speak directly with the resident, reschedule or address the shower refusal, and document a progress note when notified.On 5/22/26 at 8:48 AM, Staff 14 (CNA) stated she offered Resident 70 a bed bath on 5/14/26 and the resident did not want to transfer to the bed from her/his chair. Staff 14 stated she had three scheduled showers that day and Staff 12 was informed of Resident 70's refusal.On 5/22/26 at 8:56 AM, Staff 9 (Resident Care Manager) acknowledged she became aware Resident 70 did not receive a shower for one week after her/his admission. Staff 9 stated she expected follow-up communication with the resident by nurses. Staff 9 stated bathing was necessary for Resident 70 due to the resident's wounds. Staff 9 acknowledged improved communication and interventions were necessary to address Resident 70's bathing refusals.On 5/22/26 at 9:46 AM, Staff 2 (DNS) stated following a bathing refusal, notification to nurses was expected so they could address the resident directly, reapproach bathing, and document the resident's bathing status in a progress note.

Based on observation, interview and record review it was determined the facility failed to follow proper infection control techniques during medication administration via feeding tube for 1 of 1 sampled resident (#7) reviewed for medication administration. This placed residents at risk for acquiring an infection. Findings include:The 2009 Administration of Medication via a Feeding Tube indicated, in order to administer medications via a feeding tube, staff were to gather supplies, which included: prepared medication, sterile water, towel or absorbent pad, 60ml syringe, and gloves. Staff were to perform hand hygiene and follow necessary infection control guidelines. This prevented the spread of harmful pathogens. Exposure to bodily fluids and blood would be present, so standard precautions should have been taken.Resident 7 was admitted to the facility in 5/2025 with diagnoses including quadriplegia (paralysis of all four limbs) and required the use of a feeding tube for medication administration.On 5/20/26 at 4:39 PM, Staff 13 (CMA) was observed to prepare medication to administer in Resident 7's feeding tube. Staff 13 did not place a clean barrier on the bedside table before she placed the medication cup with the medication, fluids to mix the medication before administration via the feeding tube, and a syringe which was used to administer medication into the resident's feeding tube. On 5/20/26 at 5:00 PM, Staff 13 acknowledged she did not place a clean barrier on the bedside table before she placed medication, fluids, and the syringe which were used to administer medication into the resident's feeding tube.On 5/20/26 at 5:14 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Staff 13 should have placed a clean barrier on the bedside table before she placed medication, fluids, and the syringe which were used to administer medication into Resident 7's feeding tube.

Based on interview and record review it was determined the facility failed to assess the use of a physical restraints for 3 of 4 sampled residents (#s 1, 3, and 4) reviewed for elopement. This placed residents at risk for potential abuse or neglect. Findings include:A 6/2024 revised Use of Restraints policy identified wander guards as a physical restraint. An informed consent and pre-restraining assessment was to be completed prior to use of the restraint. Restraints were only to be used if a resident had a specific medical condition that could not be addressed by another less restrictive intervention. If the resident could not remove a device in the same manner in which the staff applied it, that device was considered a restraint. 1. Resident 1 was admitted to the facility in 3/2025 with diagnoses including disorientation and peripheral vascular disease (narrow arteries). A 3/31/25 Elopement Risk Assessment identified Resident 1 was not at risk for elopement. A 3/31/25 Progress Note indicated Resident 1's wander guard (device that alarms staff and locks a door when a resident was near an exit) was in place. The 4/6/25 admission MDS indicated Resident 1 had cognitive deficits, her/his wander guard was used daily, and Witness 1 (Power of Attorney) assisted Resident 1 with decisions regarding care and housing. An 4/16/25 revised care plan indicated Resident 1's wander guard was located on her/his left ankle and behavior interventions included one on one reassurance, provide food, redirect, and provide privacy. No behaviors related to exit seeking tendencies were identified. A review of Resident 1's clinical record revealed no assessment or consent for the use of the resident's physical restraint. A 6/29/25 Nursing Note indicated Resident 1 was pacing the hallways with a suitcase in her/his hand and wanted to leave the facility. A 7/4/25 Nursing Note revealed Staff 4 (LPN) found Resident 1's wander guard strap, wander guard, and a plastic knife on the resident's vanity in her/his room. On 10/23/25 at 9:49 AM, Staff 13 (CNA) stated Resident 1 had a wander guard due to her/his exit seeking behaviors when she/he first admitted to the facility. On 10/23/25 at 11:19 AM, Witness 1 stated the facility never spoke to Resident 1 about her/his wander guard and the resident felt like a prisoner in the facility. On 10/23/25 at 3:21 PM, Staff 3 (RCM) stated a wander guard was placed on Resident 1 because the resident made a statement, she/he wanted to leave the facility, and it was unsafe after her/his surgery. Staff 3 stated she did not believe consents by residents or family members were required for the use of wander guards and acknowledged an updated assessment for the use of Resident 1's wander guard was lacking. On 10/24/25 at 9:41 AM, Staff 6 (LPN) stated she was aware paperwork was needed prior to the use of a wander guard for a resident but was unsure of the process. On 10/24/25 at 10:17 AM, Staff 2 (DNS) acknowledged there was no consent or assessment for Resident 1's wander guard and Staff 2 expected the facility to follow their own policy. 2. Resident 3 admitted to the facility in 5/2025 with diagnoses including vascular dementia. Resident 3's 6/2025 comprehensive care plan revealed she/he had cognitive impairment causing her/him to exit seek. The care plan indicated interventions of redirection and to wear the wander guard. An 10/24/25 medical record review revealed Resident 3 did not have an assessment for the use of a wander guard or consent on file. On 10/24/25 at 9:41 AM, Staff 6 (LPN) stated she was aware paperwork was needed prior to the use of a wander guard for a resident but was unsure of the process. On 10/24/25 at 10:17 AM, Staff 2 (DNS) acknowledged there was no consent or assessment for Resident 3's wander guard and Staff 2 expected the facility to follow their own policy. 3. Resident 4 admitted to the facility in 12/2024 with diagnose including right femur fracture. The 12/26/24 Annual MDS revealed Resident 4's cognition was severely impaired. Resident 4's 12/2024 comprehensive care plan revealed she/he experienced hallucinations and delusions that caused her/him to exit seek. Care plan interventions included wearing wander guard. An 10/24/25 medical record review revealed Resident 4 did not have an assessment for the use of a wander guard or consent on file. On 10/24/25 at 9:41 AM, Staff 6 (LPN) stated she was aware paperwork was needed prior to the use of a wander guard for a resident but was unsure of the process. On 10/24/25 at 10:17 AM, Staff 2 (DNS) acknowledged there was no consent or assessment for Resident 4's wander guard and Staff 2 expected the facility to follow their own policy.

Based on interview and record review it was determined the facility failed to ensure proper interventions were in place to ensure a resident remained free from accident hazards for 1 of 5 sampled residents (#1) reviewed for accidents. This placed residents at risk for accidents. Findings include:1. Resident 1 was admitted to the facility in 3/2025 with diagnoses including disorientation, peripheral vascular disease (narrow arteries), and diabetes.A 3/31/25 Elopement Risk Assessment identified Resident 1 was not at risk for elopement.A 3/31/25 Progress note indicated Resident 1's wander guard (device that alarms staff and locks a door when a resident was near an exit) was in place. The 4/6/25 admission MDS Psychotropic CAA indicated Resident 1 had cognitive deficits, living alone was not safe, and Witness 2 (Power of Attorney) was used to assist Resident 1 with decisions about her/his health and housing needs.An 4/15/25 Utilization Review/Discharge Planning noted Resident 1 had a SLUMS (screening tool for early signs of dementia) score of nine out of 30 which indicated dementia.An 4/16/25 revised care plan indicated Resident 1's wander guard was located on her/his left ankle and behavior interventions included one on one reassurance, provide food, redirect, and provide privacy. No behaviors related to exit seeking tendencies were identified.An 4/18/25 SLUMS Examination indicated a score of 15 out of 30 indicating dementia. A 6/29/25 Nursing Note indicated Resident 1 was pacing the hallways with a suitcase in her/his hand and wanted to leave the facility.On 7/4/25, Nursing Notes revealed the following: -At 4:24 AM, Resident 1 was provided Tylenol (pain medication) and spoke about wanting to leave the facility. Resident 1 was encouraged not to remain at the facility so wound care could be provided. -At 5:35 AM, Resident 1 was observed by Staff 4 walking with her/his cane and pulling a wheeled suitcase approximately one mile from the facility while Staff 4 drove to work. Resident 1 refused to return to the facility and continued to walk towards an open field. Staff 4 called the facility to notify them. -At 6:13 AM, Staff 4 contacted police and they transported the resident via ambulance to the hospital. -At 6:40 AM, Staff 4 found Resident 1's wander guard strap, wander guard, and a plastic knife on the resident's vanity in her/his room. On 10/21/25 at 4:38 PM, Staff 1 (Administrator) stated no investigation into Resident 1's disappearance on 7/4/25 was conducted because the resident did not elope.On 10/22/25 at 2:46 AM, Staff 11 (Social Services Director) stated information was provided about vascular dementia and memory care facilities to Witness 1 due to concerns for Resident 1. Staff 11 stated nursing staff and Staff 2 (DNS) were to be notified and work together to mitigate concerns of Resident 1's increased behavior. On 10/22/25 at 12:24 PM, Staff 4 stated the week before 7/4/25 Resident 1 had increased agitation and her/his dementia was like a see saw. Staff 4 stated he was concerned for Resident 1's safety when he observed the resident outside of the facility on 7/4/25 and the facility was unaware the resident was not in the facility until they were contacted the same day. On 10/22/25 at 3:26 PM, Staff 12 (LPN) stated he became aware Resident 1 left the building on 7/4/25 with no wander guard while Staff 12 assisted another resident. On 10/23/25 at 9:41 AM, Staff 10 (CNA) stated Resident 1 was a hard core exit seeker. Staff 10 stated late on 7/3/25, Resident 1 had not slept and was not in the common area. Staff 10 stated Resident 1 was often in the common area in the evenings.On 10/23/25 at 2:03 PM, Staff 9 (CNA) stated Resident 1 threatened to remove her/his wander guard with a plastic knife prior to 7/4/25, and Staff 9 was unsure if the nurses were informed. On 10/23/25 at 3:21 PM, Staff 3 (RCM) stated she neglected to reassess and update Resident 1's care plan in 4/2025 when the resident attempted or threatened to leave.On 10/24/25 at 11:20 AM, Staff 8 (NP) expected frequent checks on Resident 1 since staff were aware of her/his escalated behaviors and desire to leave the facility.

Based on interview and record review it was determined the facility failed to keep confidential all information contained in the resident's records, regardless of form for 1 of 3 sampled residents reviewed for discharge. This placed residents at risk for violation of their HIPPA privacy and security rights. Findings include: Resident 2 was admitted to the facility in 5/2025 with diagnoses including diabetes and a blood clot (thrombus). A 5/12/25 physician order indicated Resident 2 received Warfarin (anticoagulant) daily.On 5/30/25, Resident 2 was discharged from the facility. Staff 13 (LPN) stated she educated Resident 2 on the proper administration of her/his medications and placed the medications in a bag for her/him to take home.On 10/21/25 at 4:00 PM, Resident 2 stated when she/he returned to her/his residence from the facility, she/he reviewed the medications sent home and found another resident's anticoagulant (blood thinner) mixed within her/his bag.On 10/23/25 at 1:47 PM, Staff 2 (DNS) confirmed the photograph Resident 2 took of another resident's medication she/he received upon discharge. Staff 2 acknowledged this type of medication error should never occur.

Based on observation, and interview it was determined the facility failed to ensure proper labeling of biologicals for 3 of 6 medication carts. This placed residents at risk for reduced efficacy of medication and adverse medication side effects. Findings include: On 1/29/25 at 10:59 AM multiple bottles of OTC (over the counter) medications were observed to be opened with no open date labels on the bottles in the front hall medication cart. Two more medication carts were observed on the front hall, and the back hall with multiple bottles of OTC medications with no open date label on the bottles. Staff 17(CMA) acknowledged there were multiple OTC medications in all three medication carts with no open date labels on the bottles. On 1/29/25 at 11:59 AM Staff 2 (DNS) observed all three medication carts and acknowledged there were multiple OTC medications with no open date labels on the bottles. Staff 2 stated her expectation was for staff to label and date every medication when the medication was opened.

Based on observation, interview and record review it was determined the facility failed to ensure proper food temperatures were maintained for food trays served from 1 of 1 facility kitchens reviewed for food service and for 5 of 5 residents (#s 3, 6, 23, 37 and 266) sampled for food. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include: 1. In an interview on 1/29/25 at 7:30 AM, Staff 27 (Dietary Manager) was aware residents complaints of food being served cold and not always being palatable. On 1/29/25 at 11:02 AM, nine residents attended the resident council meeting and expressed ongoing concerns regarding meals being served cold. On 1/29/25 at 12:56 PM, a lunch test tray and an alternative test tray were provided and sampled by the survey team. The lunch tray consisted of beef stroganoff with gravy, pasta, and green beans. The alternative meal test tray consisted of a French dip sandwich with au jus, grilled cheese, and tater tots. The survey team sampled the regular and alternative meals which revealed the following: *The beef stroganoff was barely warm. *The noodles were dried out and tough to chew. *The green beans were cold. *The grilled cheese sandwich was hard around the edges and lukewarm. *The tater tots tasted freezer burnt and were cold. In an interview on 1/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of residents' complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature and palatability. 34703 2. Resident 3 was admitted to the facility in 3/2023 with diagnoses including a pressure ulcer. Observations made in the dining room on 1/27/24 from 5:06 PM through 5:53 PM revealed the following: -1/27/25 05:06 PM covers were removed from the food on the steam table and staff tempted the food. -5:23 PM multiple complaints of cold food were heard from the residents in the dining room. -5:47 PM the food on the steam table was recovered but not tempted before the dinner trays were delivered to the halls. Multiple complaints of cold food were heard from the residents. -5:53 PM Staff 24 (Assistant Kitchen Manager) stated staff did not check the temperature of the food before it was delivered to the halls. On 1/27/25 at 5:58 PM Resident 3 was observed in her/his room during dinner which included quiches, potatoes, stewed tomatoes and cake. Resident 3 stated the food was cold and undercooked. On 1/28/25 at 12:40 PM Resident 3 was observed in her/his room with lunch which consisted of chicken parmesan with pasta and overcooked veggies. Resident 3 stated the food was cold and tasted bad. On 1/29/25 at 7:30 AM, Staff 27 (Dietary Manager) stated he was aware residents had complaints of food being served cold. On 1/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of resident complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature. 3. Resident 6 was admitted to the facility in 6/2023 with diagnoses including diabetes. On 1/29/25 at 7:30 AM, Staff 27 (Dietary Manager) stated he was aware residents had food complaints, regarding food being served cold. On 01/29/25 at 10:33 AM Resident 6 stated she/he had a breakfast burrito for breakfast and it was cold. Resident 6 stated the food is always cold. On 1/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of resident complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature. 4. Resident 37 was admitted to the facility in 2/2023 with diagnoses including surgical aftercare. On 1/28/25 at 12:06 PM Resident 37 was observed in her/his room with lunch which consisted of a hamburger, cake and vegetables. Resident 37 stated the food was cold as always. On 1/29/25 at 7:30 AM, Staff 27 (Dietary Manager) stated he was aware residents had complaints of food being served cold. On 1/29/25 at 11:02 AM, nine residents attended the resident council meeting and expressed ongoing concerns regarding meals being served cold. On 1/29/25 at 12:38 PM Resident 37 was observed in her/his room with lunch which included beef stroganoff, and green beans. Resident 37 stated the food was cold and awful. On 1/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of resident complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature. 47001 5. Resident 23 was admitted to the facility in 1/2020 with diagnoses including diabetes. On 1/27/25 at 1:41 PM Resident 23 stated the food was often cold and did not consistently taste good. Resident 23 stated the grilled cheese sandwich was often hard. On 1/29/25 at 1:33 PM, Resident 23 stated she/he had the beef stroganoff for lunch. Resident 23 stated the beef was mechanical soft, chewed up texture, scratchy on the throat, and the noodles were hard and cold. On 1/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of resident complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature. 49676 6. Resident 266 was admitted to the facility in 11/2024 with a diagnoses including a hip fracture and depression. The Annual MDS 11/21/24, revealed Resident 266 had a BIMS score of 15, which indicated the resident was cognitively intact. On 1/27/25 at 2:10 PM, Resident 266 stated when she/he received her/his meals the food was often cold. On 1/29/25 at 1:12 PM, Resident 266 stated the food was warm, not hot, and the stroganoff and noodles were cold. The green beans were cold, and the resident was unsure how the green beans were prepared. In an interview on 12/30/25 at 8:50 AM, Staff 1 (Administrator) stated she was aware of resident complaints of cold food. Staff 1 stated she expected food to be served at the appropriate temperature for all residents and acknowledged food should be served at the residents' preferred temperature and palatability.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 2 sampled residents (#68)reviewed for abuse. This placed residents at risk for loss of property. Findings include: Resident 68 was admitted to the facility in 4/2022 with diagnoses including cirrhosis (scarring)of the liver. On 11/8/24 a public complaint was received which alleged Resident 68 had money stolen from her/him. A 11/13/24 witness statement indicated on 11/6/24 Resident 68's bank card was run for her/his monthly liability and declined for payment. Staff 3 (Business Office Manager) notified Resident 68's power of attorney (POA) of the declined payment. On 11/8/24 Resident 68's POA notified Staff 3 Resident 68 was missing $3300 from her/his bank account and the POA made a police report. A 11/15/24 investigation indicated the Automated Teller Machine(ATM)withdrawals were made from an ATM near the facility. Law enforcement retrieved the video recording from the ATM and the parking lot. The facility assisted law enforcement with identification of the suspect using the images from the cameras. The identified staff member was on leave until the investigation was completed, the facility reimbursed the family $3300, and the facility continued to work with law enforcement to resolve the incident. On 1/28/25 at 8:30 AM Witness 2 (Complainant) stated Resident 68 had a total of $3320 taken from her/his bank account using her/his bank card from 10/30/24 through 11/1/24. On 1/29/25 at 3:27 PM Witness 3 (Complainant) stated Staff 6 (former Activity Assistant) was identified as a suspect and arrested. Witness 3 stated the case was awaiting trial. On 1/30/25 at 9:28 AM Staff 6 stated a gentleman she thought was a family member of Resident 68,threatened her and her family due to money he said someone in Staff 6's family owed him. Staff 6 stated she paid this gentleman $1500 of her own money. Staff 6 stated on 10/30/24 this gentleman requested she assist him with withdrawing money from an ATM. Staff 6 stated she agreed to withdraw the money but stated she did not know it was Resident 68's account. Staff 6 stated she could not read the name on the ATM card. Staff 6 stated it did not sit right with her that she was an accessory to hurting Resident 68. On 1/30/25 at 12:00 PM Staff 1 (Administrator)stated Resident 68's money was taken by Staff 6.

Based on interview and record review it was determined the facility failed to conduct quarterly care conferences as required for 3 of 3 sampled residents (#s 3, 7, and 37) reviewed for care conferences. This placed residents at risk for lack of participation in care goals and unmet needs. Findings include: The 11/2017 facility Care Planning-Interdisciplinary Team Policy and Procedure indicated the resident's comprehensive care plan will be reviewed and updated at a minimal on a quarterly basis by the IDT (Interdisciplinary Team.) 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including weakness. A review of the 3/12/24 Interdisciplinary Team Care Plan Conference Form for Resident 3 revealed no quarterly care conferences were provided after 3/12/24. On 1/27/25 at 1:20 PM Resident 3 stated she/he had not had a care conference in months and had concerns she/he would like to discuss with staff. On 1/30/25 at 10:54 AM Staff 1 (Administrator) confirmed quarterly care conferences were not conducted with Resident 3 to address care plan needs quarterly. 2. Resident 7 was admitted to the facility in 3/2023 with diagnoses including weakness. A review of the 2/22/24 Interdisciplinary Team Care Plan Conference Form for Resident 7 revealed no quarterly care conferences were provided after 2/22/24. On 1/27/25 at 1:20 PM Resident 7 stated she/he had not had a care conference in months and had care concerns she/he would like to discuss with staff. On 1/30/25 at 10:54 AM Staff 1 (Administrator) confirmed quarterly care conferences were not conducted with Resident 7 to address care plan needs quarterly. 3. Resident 37 was admitted to the facility in 2/2023 with diagnoses including surgical aftercare. A review of the 9/11/24 Interdisciplinary Team Care Plan Conference Form for Resident 37 revealed no quarterly care conferences were provided after 9/11/24. On 1/28/25 at 9:23 AM Resident 37 stated she/he had not had a care conference in months and had care concerns she/he would like to discuss with staff. On 1/30/25 at 10:54 AM Staff 1 (Administrator) confirmed quarterly care conferences were not conducted with Resident 37 to address care plan needs.

Based on interview and record review it was determined the facility failed to provide quarterly statements in writing of Personal Incidental Funds (PIF) to the resident representative for 1 of 2 sampled residents (#1) reviewed for PIFs. This placed residents at risk of being uninformed of financial statements. Findings include: Resident 1 was admitted to the facility in 2013 with diagnoses including a stroke and depression. The 12/19/24 Quarterly MDS revealed Resident 1 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. A review of Resident 1's clinical record revealed Witness 4 (Family Member) was the resident's designated power of attorney. No evidence was found that Witness 4 received quarterly PIF statements. In an interview on 1/28/25 at 10:00 AM, Witness 4 stated he was Resident 1's designated representative and the resident's PIF account was managed by the facility. Witness 4 stated he had not received any quarterly statements from the facility regarding Resident 1's PIF account. In an interview on 1/29/25 at 3:19 PM, Staff 3 (Office Manager) stated quarterly PIF statements for Resident 1 should have been generated and sent to Witness 4. Staff 3 acknowledged Witness 4 did not receive any PIF quarterly statements for Resident 1.

Based on interviews and record review it was determined the facility failed to thoroughly investigate alleged verbal abuse from staff for 1 of 2 sampled residents (#7) reviewed for abuse. This placed residents at risk for physical and verbal abuse from staff. Findings include: The facility's 12/2020 Abuse Investigation Policy included: All reports of abuse, neglect, misappropriation of resident property, and injuries of unknown origin shall be promptly and thoroughly investigated. The investigation shall consist of: -A review of the completed Resident Incident Report Form. -An interview with the resident. -Witness reports in writing, signed and dated. Resident 7 was admitted to the facility in 8/2023 with diagnoses including respiratory failure. The 1/21/25 investigation report indicated Staff 8 (LPN) reported to Staff 28 (RNCM) Resident 7 reported an allegation of abuse. Resident 7 indicated she/he was forced out of bed and forced to take a shower by Staff 18 (RN). On 1/28/25 at 2:37 PM Resident 7 stated Staff 18 came to her/his room and stated she/he had to take a shower. Resident 7 stated she/he told staff she/he did not want to take a shower. Resident 7 stated she/he told staff, this is the last time she/he will be made to take a shower when she/he did not want to. Resident 7 stated she/he had PTSD and a trigger was someone telling her/him what to do and Staff 18 does this all the time. Resident 7 stated she/he felt verbally abused. On 1/28/25 at 2:45 PM Staff 28 (RNCM) stated Resident 7 had a shower on evening shift on 1/21/25 then reported to staff the next day that Staff 18 verbally abused her/him. Staff 28 stated she spoke with Staff 13 (CNA) and Staff 23 (CNA) who assisted Staff 18 and they indicated Resident 7 did not allege abuse while being showered. Staff 28 stated she spoke with Staff 18 and she indicated Resident 7 did not say anything during the shower. Staff 28 stated Resident 7 waited 12 hours to report the abuse incident. Staff 28 stated the investigation did not have witness statements and she did not speak to Resident 7 regarding the abuse allegation. Staff 28 stated Resident 7 had PTSD and one of her/his triggers were showers. Staff 28 stated she spoke with Staff 18 regarding Resident 7's care plan which indicated the resident prefers bed baths and will ask for a shower if she/he wanted one. Staff 28 acknowledged she should have spoken with the resident after the allegation of abuse. On 1/28/25 at 3:04 PM Staff 8 stated the day after the incident Resident 7 asked if she/he could refuse getting out of bed and taking showers. Staff 8 stated she told Resident 7 she/he could refuse any cares. Staff 8 stated Resident 7 indicated she/he told staff she/he did not want a shower but they did it anyway and she/he felt verbally abused. On 1/29/25 at 12:48 PM Staff 23 stated Resident 7 did not indicate she/he did not want a shower or say she/he was abused. On 1/29/25 at 3:56 PM Staff 13 stated Resident 7 did not refuse to take a shower but indicated she/he got nauseated when getting up out of bed. Staff 13 stated Resident 7 did not indicate she/he felt abused. On 1/30/25 at 2:41 PM Staff 18 stated she asked Resident 7 if she/he wanted to take a shower and the resident stated she/he would think about it. Staff 18 stated she asked the resident again and the resident agreed to a shower. Staff 18 stated Resident 7 did not indicate she/he was upset or felt abused. Staff 18 stated she should have looked closer at the resident's care plan regarding the resident would ask for showers if she/he wanted one, but thought the resident was fine. 1/30/25 at 3:53 PM Staff 1 Administrator stated her expectation for an allegation of abuse would be for staff to interview the resident, and have written and signed witness statements. Staff 1 acknowledged the investigation was not thourough.

Based on observation, interview and record review it was determined the facility failed to ensure pressure injury wounds were accurately assessed, and care plans were followed for 2 of 4 sampled residents (#s 3 and 31) reviewed for pressure ulcers. This placed residents at risk for inaccurate assessment and worsening of wounds. Findings include: 1. Resident 3 was admitted to the facility in 2/2023 with diagnoses including a Stage 4 (penetration of all three layers of skin exposing muscles, tendons and bones) pressure ulcer. The 12/29/24, 1/5/25, 1/14/25, and 1/19/25 Wound Evaluation Form indicated Resident 3 had a Stage 4 pressure ulcer. The wound contained slough (dead skin tissue) which indicated an unstageable (with dead tissues making it impossible to determine the depth of the wound) pressure ulcer. On 1/29/25 at 1:36 PM Staff 2 (DNS) acknowledged Resident 6's wound was not a Stage 4 pressure ulcer but an unstageable pressure ulcer due to the slough in the wound, and the Wound Evaluation Form was not accurate. 36494 2. Resident 31 was admitted to the facility in 11/2024 with diagnoses including right hip fracture and diabetes. The Admission MDS dated [DATE], revealed Resident 31 had a BIMS score of 14, which indicated the resident was cognitively intact. A 12/16/24 Skin Event revealed Resident 31 had a pressure injury to the right heel, which was a red, shiny, blanchable (the skin area turns white or pale), pea sized area. Resident 31 was not aware the wound was there but knew that it hurt. Treatment was initiated and staff were to offload the resident's right heel with a pillow or use a blue heel boot protector when in bed. A care plan revised on 12/19/24, revealed Resident 31 was at risk for skin impairments and pressure ulcers related to a right femur fracture and the resident had a closed pressure area to the right heel. Staff were to ensure Resident 31's right heel was offloaded with pillows or a blue heel boot protector to the right heel when the resident was in bed. Random observations from 1/29/25 through 1/30/25 revealed Resident 31 in bed on her/his back. Resident 31 stated her/his right foot on the bottom hurt. Resident 31 was observed with no pillow or boot protector to her/his right foot. On 1/29/25 at 8:45 AM, Resident 31 stated she/he had a wound on her/his right heel and at times the wound was painful. Resident 31 stated no one placed pillows under her/his heels when she/he was in bed. On 1/29/25 at 8:48 AM, and 1:10 PM, Staff 11 (CNA/CMA) stated he worked with Resident 31 and did not believe the resident had a wound to her/his right heel and would need to review the care plan. Staff 11 entered Resident 31's room; the resident was in bed, and Staff 11 removed her/his blankets and socks, lifted the right heel and acknowledged a small red area (approximately pencil eraser size) on the base of Resident 31's right heel. Staff 11 acknowledged the wound on the resident's right heel and acknowledged the resident's right heel was not offloaded in bed. On 1/29/25 interviews were conducted from 1:28 PM through 6:43 PM with Staff 12 (CNA), Staff 13 (CNA), Staff 14 (LPN), and Staff 21 (CNA). Staff 12, Staff 13, Staff 14, and Staff 21 stated they worked with Resident 31 and were not aware the resident had a wound to her/his right heel. Staff 12, Staff 13, and Staff 21 indicated they reviewed residents' care plans prior to the start of their shift, and if they saw any new skin issues, they would report the concern to the charge nurse. If Resident 31 had a wound to her/his heel they would offload the resident's feet with a pillow when in bed. Staff 14 stated if Resident 31 had a wound to the heel, the CNAs would offload her/his heels with a pillow or apply a heel boot protector. On 1/30/25 at 8:52 AM, Staff 16 (RNCM) stated Resident 31 had a Stage 1 (intact skin with a localized area of non-blanchable erythema [redness] pressure ulcer to her/his right heel and staff were supposed to offload the right heel with a pillow or a blue heel boot protector. Staff 16 acknowledged staff were not following the care plan and Resident 31's right heel was not being offloaded when the resident was in bed. On 1/30/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 (DNS) were present for an interview. Staff 1 and Staff 2 stated staff were expected to review the care plan prior to the start of their shift and ensure the care plan was implemented. Staff 1 and Staff 2 acknowledged Resident 31's care plan was not followed.

Based on interview and record review it was determined the facility failed to assist residents to formulate an advanced directive for 3 of 4 sampled residents (#s 3, 7, and 37) reviewed for advance directives. This placed residents at risk for healthcare decisions to conflict with resident wishes. Findings include: 1. Resident 3 was admitted to the facility in 3/2023 with diagnoses including weakness. A 3/8/24 Annual MDS revealed Resident 3 was cognitively intact. The 3/12/24 Interdisciplinary Care Conference notes revealed Resident 3 did not have an advance directive. On 1/27/25 at 2:20 PM Resident 3 stated staff did not offer her/him an advance directive and she/he would like to have her/his options reviewed. On 1/29/25 at 11:28 AM Staff 26 (Social Service Director) stated she would review options for residents regarding advance directives in their quarterly Interdisciplinary Care Conference. On 1/30/25 at 10:54 AM Staff 1 (Administrator) acknowledged staff were behind on quarterly Interdisciplinary Care Conferences, and advance directives were not being followed-up on. 2. Resident 7 was admitted to the facility in 8/2023 with diagnoses including respiratory failure. The 8/8/24 Annual MDS indicated Resident 7 was cognitively intact. The 2/24/24 Interdisciplinary Care Conference notes revealed Resident 7 did not have an advance directive. On 1/27/25 at 1:53 PM Resident 7 stated staff did not offer her/him an advance directive and she/he would like to have her/his options reviewed. On 1/29/25 at 11:28 AM Staff 26 (Social Service Director) stated she would review options for residents regarding advance directives in their quarterly Interdisciplinary Care Conference. On 1/30/25 at 10:54 AM Staff 1 (Administrator) acknowledged staff were behind on quarterly Interdisciplinary Care Conference, and advance directives were not being followed-up on. 3. Resident 37 was admitted to the facility in 2/2023 with diagnoses including surgical aftercare. The 2/16/24 Annual MDS indicated Resident 37 was cognitively intact. The 9/11/24 Interdisciplinary Care Conference notes revealed Resident 37 did not have an advance directive. On 1/28/25 at 9:23 AM Resident 37 stated staff did not offer her/him an advance directive and she/he would like to have one. On 1/29/25 at 11:28 AM Staff 26 (Social Service Director) stated she would review options for residents regarding advance directives in their quarterly Interdisciplinary Care Conference. On 1/30/25 at 10:54 AM Staff 1 (Administrator) acknowledged staff were behind on quarterly Interdisciplinary Care Conference, and advance directives were not being followed-up on.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of property for 1 of 1 facility reviewed for misappropriation of property. This failure, determined to be a past non-compliance situation, resulted from the facility failing to ensure residents were free from misappropriation of property. Findings include: A FRI report dated 6/16/23 indicated a staff member found unrecognizable signatures in the Narcotic Log Book, brought it to the attention of the Resident Care Manager and Staff 2 (DNS) and an investigation was started. Multiple forged signatures were found in the skilled unit Log Book. The FRI indicated there was no resident theft as the facility covered the cost of medications. Staff 11 (Former CMA) was identified as a suspect and was suspended pending the outcome of the investigation. A Facility Investigation document dated 6/13/23 indicated during the investigation 102 instances of forged or false signatures were found. Staff 11 worked around the times of the discovered forged signatures. No other staff schedules matched the pattern of forged signatures. Staff 11 denied any diversion of medications. Staff 11 was escorted to the local hospital for a drug screen but dropped the first urine sample into the toilet and two additional urine samples were diluted. Staff 11 then refused to provide another urine sample. Two additional narcotic pills were found missing from Staff 11's medication cart on the day she was suspended. Staff 11 was also found to have wasted medications without a licensed nurse co-signature and there were numerous instances where she signed a narcotic out of the Narcotic Log Book but did not chart it as administered on the MAR. Twenty-three resident Narcotic Log Book pages were identified with a total of 102 possible diversions. The medications diverted were identified as opioid pain medications. No evidence was found to indicate residents did not receive medications when they asked for them and there were no abnormal resident complaints about pain. On 10/5/23 at 3:12 PM Staff 1 (Administrator) and Staff 2 acknowledged the drug diversion occurred. On 6/20/23, the Past Noncompliance was corrected when the facility completed a risk analysis of the incident and determined misappropriation of property occurred. The Plan of Correction included: -Staff 1 and Staff 2 began Investigation immediately upon being informed of possible forged signatures in the Narcotic Log Book. -Staff 11 was identified as a possible suspect and suspended pending the investigation. -Staff 2 educated licensed staff and CMAs on increased medication cart security and reporting Narcotic Log Book irregularities immediately. -Drug Diversion was determined and reported to all required parties. -Full audits of the Narcotic Log Books were completed. -The facility determined no outcome to residents occurred. -Following Staff 1's investigation Staff 11 was terminated on 6/20/23 from employment. - One-hundred percent reconciliation was done of all identified potentially false signatures and Staff 11's associated narcotic documentation. -The medication diverted was identified and the facility reimbursed residents for the missing narcotics. -All licensed nurses and CMA staff were again in-serviced on narcotic shift counts and Controlled Substance policies and procedures. -An Ad Hoc Quality Assurance meeting was held to review the findings and determine further action and monitoring as needed. -Audits were to be completed by Staff 2 or a RNCM of Narcotic Log Book signatures, and observations of shift counts, at least weekly for four weeks. -Results would be reported to the Quality Assurance committee as part of an Action Plan.

Based on observation, interview and record review it was determined the facility failed to assess a resident's ability to self-administer medications for 1 of 1 sampled resident (#45) reviewed for self-administration of medications. This placed residents at risk for improper medication administration. Findings include: Resident 45 was admitted to the facility in 2023 with dysphagia (difficulty swallowing) and a feeding tube (a tube in the stomach to receive nutrition) with diagnoses including malnutrition and kidney transplant. On 10/2/23 at 8:54 AM Resident 45 was observed sitting up in bed with two medication cups containing multiple medications on the bedside table and a cup of orange liquid medication. Resident 45 stated she/he was not sure what the medications were. No assessment was located in the medical record for self-administration of medications for Resident 45. On 10/2/23 at 11:23 AM Staff 36 (LPN) stated if Resident 45 did not administer her/his medications by 11:00 AM staff were to administer the medications via her/his feeding tube. Staff 36 stated she was not aware if Resident 45 was assessed to administer her/his own medications. On 10/5/23 at 10:16 AM Staff 1 (Administrator), Staff 2 (DNS), and Staff 5 (RNCM) confirmed Resident 45 was not assessed to self-administer her/his medications.

Based on interview and record review, it was determined the facility failed to ensure residents were free from neglect. The facility failed to ensure staff did not provide care alone when two-person assistance was required for 3 of 4 sampled (#s 3, 5 and 11)residents reviewed for accidents. Resident 11 experienced a fall and sustained bilateral fractures to her/his left proximal femur (the end closest to the hip bone which includes the rounded femoral head, which is part of the hip joint) and right distal femur (long bone of the thigh). Resident 11 was transferred to the hospital. Findings include: According to the Centers for Medicare & Medicaid Services (CMS), §483.5, Neglect, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Resident 11 was admitted to the facility in 1/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 1/28/20 care plan indicated Resident 11 was a fall risk. Interventions included, bed in low position, commonly used items in reach and directed the reader to the mobility plan of care. The care plan revealed Resident 11 required assistance for mobility and to provide two person physical assist for her/his dependent transfers, with constant supervision, a mechanical lift or a transfer belt. A 2/1/21 Annual MDS indicated Resident 11 was severely impaired cognitively with short and long-term memory problems. Resident 11 required total dependence with two person physical assistance with transfers. The 5/2021 Documentation Survey Report (CNA tasks report) revealed the following assistance for Resident 11's transfers: -5/1/21 through 5/7/21 -Day shift four instances transferred with one-person assist. -Evening shift three instances transferred with one-person assist. The Facility Abuse Adverse Event Investigation dated 6/12/21 revealed Resident 11 sustained a fall with a major injury at 8:00 PM on 6/12/21. Resident 11 was transported to the hospital with bilateral femur fractures. Staff 3 (CNA) was suspended pending investigation. The Investigation summary and findings revealed on 6/12/21 at approximately 8:00 PM Staff 3 (CNA) was transferring Resident 11 to the bed using a mechanical lift alone. Resident 11 was care planned as a two person mechanical lift for transfers. Staff 3 did not request assistance. Staff 3 stated the sling was around Resident 11's shoulders and Staff 3 felt the sling under the resident's buttocks. Before Resident 11 was over the bed she/he slid out and landed between the legs of the mechanical lift. The conclusion of the investigation was Staff 3 was negligent in failing to follow the Resident 11's care plan and transferred the resident alone. A 6/13/21 Hospital Operative Report revealed Resident 11 was completely non-verbal. It was determined due to the fractures it was best to complete surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surgery was a palliative procedure and it was unlikely Resident 11 would do well medically with or without the surgery given her/his medical fragility. On 6/23/21 at 10:35 AM Staff 1 (Administrator) stated Resident 11's fall was an unfortunate event and she wondered when it became the facility culture for staff to no longer request assistance with transfers. On 7/2/21 at 8:54 AM Staff 4 (LPN) stated she was in the hallway passing medications when Staff 3 came and stated she needed assistance with Resident 11 as she/he had slipped out of transfer sling and fell . Staff 4 stated Staff 3 told her she knew Resident 11 was a two-person transfer and everyone does it meaning provide one person transfers when two are indicated. Staff 4 stated when they were rolling Resident 11 from right to left, she/he stated ow and again when they rolled her/him from left to the right. On 7/2/21 at 10:07 AM Staff 5 (RN) stated on 6/13/21 one of the aides came to her and stated to her Resident 11's leg was painful. The aide fed Resident 11 her/his breakfast and she/he vomited. Staff 5 told the aide to put Resident 11 back in bed so she could assess her/him. After the aide put Resident 11 back to bed Staff 5 noticed her/his leg was twisted internally and there was a bump on her/his upper thigh and her/his right leg was swollen. Staff 5 stated Resident 11 usually smiled when she spoke to her/him, but she/he was not smiling and was guarded. When the paramedics moved Resident 11's leg, she/he stated ouch. On 7/2/21 at 10:14 AM Staff 3 stated she was new to working by herself with the residents, and while in training it was normal to see co-workers complete one-person transfers when two were indicated. Staff 3 stated she would ask before doing anything out of the ordinary or against the rules. She was informed by other co-workers when the facility was short-staffed you could not wait for someone else to assist. Staff 3 stated she knew Resident 11 was care planned as a two-person assist with transfers, but it was the culture of the facility to complete transfers with one-person. Staff 3 stated after Resident 11 fell she/he had a look of displeasure on her/his face, and when Staff 4 touched Resident 11's right leg and she/he said ow. On 7/8/21 at 10:44 AM Staff 1 and Staff 2 (DNS) stated they expected staff to provide two person assistance if a resident was care planned for two person assistance. 2. Resident 3 was admitted to the facility in 3/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/17/21 care plan indicated Resident 3 required assistance with mobility with interventions, which included two-person assistance with transfers with her/his front wheel walker, and to provide supervision, cueing and encouragement. The 3/2021 Documentation Survey Report revealed from 3/17/21 through 3/30/21 Resident 3 was provided one person assist with transfers as follows: -Day shift: five instances -Evening shift: three instances -Night shift: one instance The 3/31/21 care plan revealed Resident 3 required two-person total assistance for the entire process to take her/him to the bathroom, transfer on and off toilet, ensure safety, provide peri care, adjust clothing, wash hands and monitor blood pressure. The 4/2021 Documentation Survey Report revealed from 4/1/21 to day shift on 4/15/21 Resident 3 was provided one person assist or supervision as follows: For Transfers -Day shift: one person assist six instances -Evening shift: supervision with setup help only one instance, one person assist three instances. For transfers for toilet Use: -Day Shift: one person assist 13 instances. -Evening shift: one person assist seven instances and supervision setup help one instance. On 7/7/21 at 11:57 AM Staff 30 (CNA) stated she had heard about the culture of CNA staff completing one-person transfers of residents when care planned for two person. On 7/8/21 at 10:44 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect staff to provide two person assistance with transfers when the resident was care planned for a two-person transfer. 3. Resident 5 was admitted in 12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 12/15/20 care plan instructed staff to provide Resident 5 with two-person, physical assist with constant supervision with a mechanical lift or transfer belt. A 12/17/20 Admission MDS and Fall CAA revealed Resident 5 had an extensive history of falls. Resident 5 required extensive assistance with two-person physical assistance with transfers. A 3/2021 Documentation Survey Report revealed from 3/1/21 through 3/30/21 Resident 5 was provided one-person assist with transfers as follows: -Day shift: 11 instances -Evening Shift: 17 instances -Night shift: three instances. On 7/8/21 at 10:44 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect staff to provide two person assistance with transfers when the resident was care planned for a two-person transfer. Refer to F689, F686, F690 and F725.

Based on interview and record review it was determined the facility failed to implement, follow, and maintain pressure ulcer treatments for 1 of 3 sampled residents (#4) reviewed for pressure ulcers. Resident 4's pressure ulcer deteriorated and required surgical intervention. Findings include: The 3/2018 Pressure Injuries/Skin Breakdown Clinical Protocol indicated the physician authorized pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Resident 4 was admitted to the facility 5/14/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/14/21 Progress Note revealed Resident 4 was alert, oriented and could verbalize her/his needs and wants. Resident 4 had an unstageable pressure area. A 5/14/21 Admission Skin Integrity assessment indicated Resident 4 had a pressure ulcer. The care plan dated 5/14/21 revealed Resident 4 was at risk for pressure ulcers, with a goal of the skin wound would resolve without complications. Interventions included pressure reducing mattress, pressure reduction on the chair, float heels, follow facility protocol/regime for wound care, treatment per physician orders, notify nurse of skin impairments, and monitor for signs and symptoms of infection. A 5/14/21 Skin and Wound Evaluation indicated Resident 4 had an unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (mass or layer of dead tissue separated from the surrounding or underlying tissue) and/or eschar (a dry, dark scab or falling away of dead skin) in the wound bed) pressure ulcer to the coccyx (a small triangular bone at the base of the spinal column) which was present on admission. The wound measured an area of 15.7 cm squared; length of 5.8 cm. and a width of 3.8 cm. The evaluation did not describe Resident 4's wound bed, if there was sign of infection, if the wound had drainage, the edges of the wound, if there was wound pain, the current treatment and the goal of care. The wound progress was documented as stable. The 5/15/21 Progress Note indicated Resident 4 had a Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) to the buttocks. Skin-prep (a liquid film-forming dressing) and [MEDICATION(S)] (used as a moisturizer) were applied. No physician orders were found in clinical records for skin prep and [MEDICATION(S)] application on 5/15/21. A 5/17/21 Skin and Wound Evaluation indicated Resident 4 had an unstageable pressure ulcer to the coccyx which was present on admission. The wound measured an area of 18.4 cm squared; 7.2 cm length by 3.3 cm width. The evaluation did not describe Resident 4's wound bed, if the wound had drainage, the edges of the wound, the surrounding tissue, if there was wound pain, or the current treatment and the goal of care. The wound progress was documented as deteriorating with new slough to the wound bed. The physician was notified, and new dressing orders were placed. A 5/18/21 Progress Note indicated Resident 4 had MASD (moisture associated skin damage) blisters and shearing over her/his inner bilateral buttocks and she/he complained of buttock pain. The 5/19/21 Skin and Wound Note revealed Resident 4 had MASD/shearing of blisters to the intergluteal cleft/coccyx. The facility requested the physician to change the wound care to covering the site with silicone foam border twice a day and PRN. A 5/20/21 Progress Note indicated Resident 4 had an unstageable pressure ulcer to the coccyx. A 5/21/21 Skin and Wound Evaluation indicated Resident 4 had an unstageable pressure ulcer present on admission. The size of the wound measured an area of 26.4 cm squared; a length of 8.6 cm by 5.2 cm wide and the wound was deteriorating. The evaluation did not describe the wound bed, if there was drainage, the edges of the wound, if there was pain in the wound, the goal of care, and the current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The 5/20/21 Admission MDS indicated Resident 4 required extensive assistance with one-person physical assist with bed mobility. A 5/22/21 Progress Note indicated Resident 4 was encouraged to offload from her/his buttocks to prevent further injury and Resident 4 stated she/he attempted to change positions frequently. The 5/2021 TAR instructed staff to complete the following: -Coccyx: MASD, shearing cleanse with wound cleanser, pat dry, apply skin barrier peri wound cover with foam border ever two days and as needed with a start date of 5/21/21 and end date of 5/25/21. -Coccyx: MASD, shearing: cleanse with wound cleanser, pat dry apply skin barrier peri wound cover with foam boarder apply [MEDICATION(S)] two times a day with a start date of 5/26/21. -Turn Resident 4 every two hours for coccyx wound with a start date of 5/26/21. No physician ordered treatment was found in clinical records for Resident 4's unstageable pressure ulcer to the coccyx. No physician ordered treatment was found in clinical records for physician ordered treatment to the coccyx from 5/14/21 through 5/20/21. A 5/24/21 Skin and Wound Evaluation indicated Resident 4 had an unstageable pressure wound to the coccyx which was present on admission and it was unknown how long the wound was present. The area of the wound measured 22.5 cm squared; 7 cm length by 4.4 cm width. There was no description of the wound bed or if the bed had drainage. The edges appeared to be flush with the wound bed or had a sloping edge, the surrounding tissue was dark reddish brown with loss of the epidermis (the outermost three layers that make up the skin) caused by exposure to urine, feces, body fluids, wound exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ) or friction. The surrounding skin was red, had superficial loss of tissue, was fragile at risk for breakdown and was wet, white, waterlogged tissue. There was no description if the wound caused pain, the goal of care for the wound, or the current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5/25/21 Progress Note indicated Resident 4's dressing was changed to the coccyx and it was fully saturated. Staff requested twice a day dressing changes to ensure the area was clean and dry. A 5/26/21 Progress Note revealed Resident 4's dressing was changed due to a saturated dressing. The wound bed was black/red, malodorous, and slough was noted to the edges. A 5/27/21 Pressure Ulcer/Injury CAA indicated Resident 4 had a bilateral gluteal and coccyx pressure area present on admission which appeared to be an evolving deep tissue injury. Resident 4 had a large pressure area on the right gluteus measuring approximately 3.35 cm by 1.95 cm open area with slough and macerated (soften or become softened by soaking in a liquid) surrounding tissue. The left gluteal pressure area was larger measuring 5.82 cm by 3.83 cm with deep purple macerated and open areas at the media/coccyx area. The lower right gluteal area was measured separately but was connected to the upper coccyx area which measured 8.55 cm by 5.16 cm and was also macerated over deep purple tissue with some sporadic areas of slough. The entire three areas measured on admission had the appearance of a suspected evolving deep tissue injury with high risk for rapid progression. Pictures indicated inclinical record dated 5/17/21 show fluid filled blisters on the right gluteal pressure area then on 5/21/21 the blisters opened. On 5/24/21 the wound was one wound encompassing the bilateral gluteal and coccyx areas with heavy drainage and odor. Resident 4 needed staff assistance with repositioning to the sides due to a left hip surgery. A standard pressure relief mattress was in place on admission and changed to an air/foam mattress on 5/22/21. On 7/2/21 at 8:33 AM Staff 18 (CNA) stated she assisted Resident 4 with incontinent care in 5/2021. Staff 18 stated she observed Resident 4's wound on her/his buttocks and the CNAs applied barrier cream. Resident 4 complained of discomfort and felt some of the discomfort was from the wound as she/he laid on her/his back. On 7/2/21 at 11:35 AM Staff 17 (LPN) stated Resident 4 could reposition herself/himself on some days but not on others. Staff 17 stated she did not remember the type of dressing Resident 4 had on her/his wound, but her/his wound deteriorated, and the facility physician was notified. A 5/31/21 through 7/7/21 Emergency Department to Hospital Admission to Post Surgical records indicated Resident 4 had a large decubitus (forms where the pressure from the body's weight presses the skin against a firm surface, such as a bed or wheelchair. Pressure cuts off the blood supply to the skin and injures tissue cells) ulcer to her/his gluteal region measuring 12 cm by 9 cm with blackened skin, and was necrotic (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) and weeping with a foul smell. The surrounding skin of the ulcer was [CONDITION(S)] (superficial reddening of the skin, usually in patches, because of injury or irritation causing dilatation of the blood capillaries) Findings were found to be consistent of [CONDITION(S)] (refers to the death of body tissue of the genitals and/or perineum) with surgery recommended. On 6/1/21 Resident 4 underwent a surgical procedure of debridement of the necrotizing soft tissue infection of the sacrum and perineal/perianal region 12 cm by 15 cm and a depth of 6 cm. On 7/8/21 at 10:39 AM Staff 1 (Administrator) and Staff 2 (DNS) stated staff sent a request for physician orders on 5/14/21 but the orders did not come back until 5/16/21 for staff to use facility protocol for wound care. No additional information was provided. Refer to F635

Based on observation, interview and record review it was determined the facility failed to execute fall risk interventions for 4 of 4 residents (#s 3, 5, 6 and 11) reviewed for accidents. This placed residents at risk for falls. Resident 11 experienced a fall, sustained bilateral fractures and was transferred to the hospital. Findings include: 1. Resident 11 was admitted to the facility in 1/2020 with diagnoses including Alzheimer's disease. A 1/28/20 care plan indicated Resident 11 was a fall risk and her/his interventions included: bed in low position, commonly used items in reach and directed the reader to the mobility plan of care. The care plan revealed Resident 11 required assistance for mobility and to provide two-person physical assist for full dependent transfers with constant supervision with a mechanical lift or transfer belt. A 2/1/21 Annual MDS indicated Resident 11 was severely impaired cognitively with short and long-term memory problems. Resident 11 was totally dependent and required two-person physical assistance with transfers. The 2/8/21 Fall CAA indicated Resident 11 was a high risk for falls due to physical and cognitive limitations. Resident 11 was dependent for all ADL cares and was unable to verbalize her/his needs. Interventions were in place to minimize the risk for falls. The 5/2021 Documentation Survey Report (CNA tasks report) revealed the following assistance provided for Resident 11's transfers: -5/1/21 through 5/7/21 -Day shift four instances transferred with one-person assist. -Evening shift three instances transferred with one-person assist. -5/8/21 through 5/31/21 -Transfers were not documented for all days and all shifts. The 6/2021 Documentation Survey Report revealed from 6/1/21 through 6/12/21 transfers were not documented for all days and all shifts. A 6/12/21 at 10:35 PM Progress Note revealed Resident 11 sustained a fall while she/he was transferred to her/his bed. When Resident 11 was moved and repositioned she/he said ouch. A Facility Abuse Adverse Event Investigation dated 6/12/21 revealed Resident 11 sustained a fall with a major injury at 8:00 PM on 6/12/21. Resident 11 was transported to the hospital with bilateral femur fractures. Staff 3 (CNA) was suspended pending investigation. The Investigation Summary and Findings revealed on 6/12/21 at approximately 8:00 PM Staff 3 (CNA) was transferring Resident 11 to the bed using a mechanical lift alone. Resident 11 was care planned as a two person mechanical lift for transfers. Staff 3 did not request assistance. Staff 3 stated Resident 11 was in a specialized wheelchair with the lift sling underneath her/him. Staff 3 stated the sling was around Resident 11's shoulders and Staff 3 felt the sling under her/his buttocks. Before Resident 11 was over the bed she/he slid out and landed between the legs of the lift. Conclusion of the investigation was Staff 3 was negligent in failing to follow the Resident 11's care plan because she transferred the resident alone. A 6/13/21 Fall/Post Fall Assessment revealed Resident 11 sustained a fall on 6/12/21 at 8:00 PM. Resident 11 had presence of pain which was new. Resident 11 could not describe where her/his pain was and continued to say ouch when repositioning her/him. Resident 11 was assessed for bruising and swelling. No swelling or bruising was found at 8:20 PM. When Resident 11 was repositioned from side to side she/he expressed pain. Her/his pain level was a 10 on a numerical pain scale of one to 10. Range of motion was within the normal resident's baseline. A 6/13/21 Nursing Note indicated Resident 11 fell on [DATE]. An assessment was completed, and Resident 11 had a hard lump to her/his right upper thigh, the leg was internally twisted and painful. Staff 5 (RN) requested Resident 11 to be transported to hospital for evaluation. A 6/13/21 Hospital Operative Report revealed Resident 11 was completely non-verbal. It was determined due to the fractures it was best to complete surgery for surgical stabilization of the fractures and allow improved pain control. The surgery was a palliative procedure and it was unlikely Resident 11 would do well medically with or without the surgery given her/his medical fragility. The 6/2021 MAR instructed staff to administer [MEDICATION(S)] (for pain) every three hours PRN for pain. Resident 11 received no [MEDICATION(S)] from 6/1/21 through 6/12/21. On 6/13/21 Resident 11's pain level was a five out of 10 and [MEDICATION(S)] was administered at 10:09 AM. A 6/16/21 Progress Note indicated Resident 11 received [MEDICATION(S)] for pain. Resident 11 was painful with facial grimacing and elevated pulse and another dose of PRN [MEDICATION(S)] was administered. On 6/23/21 at 10:35 AM Staff 1 (Administrator) stated Resident 11's fall was an unfortunate event. On 7/2/21 at 8:54 AM Staff 4 (LPN) stated she was in the hallway passing medications when Staff 3 came and stated she needed assistance with Resident 11 as she/he slipped out of the lift sling and fell . Staff 4 stated Staff 3 told her she knew Resident 11 was a two-person transfer and everyone does it meaning everyone provided one person transfers when two person assist was indicated. Staff 4 stated when they were rolling Resident 11 from right to left, she/he stated ouch and again when they rolled her/his from left to the right. On 7/2/21 at 10:07 AM Staff 5 stated on 6/13/21 one of the CNAs came to her and stated to her Resident 11's leg was painful. The CNA fed Resident 11 her/his breakfast and she/he vomited. Staff 5 told the CNA to put Resident 11 back in bed so she could assess her/him. After the CNA put Resident 11 back to bed Staff 5 noticed her/his leg was twisted internally, there was a bump on her/his upper thigh and her/his right leg was swollen. Staff 5 stated Resident 11 usually smiled when she spoke to her/him, but she/he was not smiling and was guarded. When the paramedics moved Resident 11's leg, she/he stated ouch. On 7/2/21 at 10:14 AM Staff 3 stated she was new to working by herself with the residents. Staff 3 stated while in training it was normal to see co-workers complete one-person transfers when two-person assist was indicated. Staff 3 stated she would ask before doing anything out of the ordinary or against the rules. She was informed by other co-workers when the facility was short-staffed you could not wait for someone else to assist. Staff 3 stated she knew Resident 11 was care planned as a two-person assist with transfers, but it was the culture of the facility to complete transfers with one-person. Staff 3 stated after Resident 11 fell she/he had a look of displeasure on her/his face. Staff 3 stated when Staff 4 touched Resident 11's right leg she/he said ow. On 7/8/21 at 10:44 AM Staff 1 and Staff 2 (DNS) stated they expected staff to provide two-person assistance if a resident was care planned for two-person assistance. 2. Resident 3 was admitted to the facility in 3/2021 with diagnoses including weakness and surgical after care. The 3/17/21 care plan indicated Resident 3 required assistance with mobility with interventions which included two-person assistance with transfers with her/his front wheel walker and to provide supervision, cueing and encouragement. A 3/23/21 Admission MDS revealed Resident 3 required two-person physical assistance with transfers . A 3/30/21 Fall CAA revealed Resident 3 reported no history of falling and she/he was at risk for falls due to impaired mobility, weakness, unsteady gait, and impaired balance. Resident 3's goal was to have no falls, staff to assist with transfers and mobility using front wheel walker for short distance mobility and wheelchair for longer distances. The 3/2021 Documentation Survey Report revealed from 3/17/21 through 3/30/21 Resident 3 was provided one person assist with transfers as follows: -Day shift: five instances -Evening shift: three instances -Night shift: one instance The 3/31/21 Fall Post Fall Assessment indicated Resident 3 sustained a fall in the bathroom. Resident 3 was visually observed five minutes prior to the fall and was being toileted. Staff transferred Resident 3 on a rolling commode and pushed the commode with the resident into the bathroom over the toilet. Resident 3 started to slide forward off the commode and yelled for assistance. Before staff arrived Resident 3 slid forward off the commode and landed on her/his side hitting her/his head. The 3/31/21 care plan revealed Resident 3 required two-person total assistance for the entire process take her/him to the bathroom, transfer on and off the toilet, ensure safety, provide peri care, adjust clothing, wash hands and monitor blood pressure. The 4/2021 Documentation Survey Report revealed from 4/1/21 to day shift on 4/15/21 Resident 3 was provided one person assist or supervision as follows: Transfers: -Day shift: one person assist six instances -Evening shift: supervision with setup help one instance, one person assist three instances. Toilet Use: -Day Shift: one person assist 13 instances. -Evening shift: one person assist seven instances and supervision setup help one instance. On 7/7/21 at 11:57 AM Staff 30 (CNA) stated she had heard there was a culture in the facility for staff to provide one person transfers when a resident was care planned for two-person transfers. When asked if Staff 30 completed a one person transfer of Resident 3 on 3/30/21 as documented in clinical records, Staff 30 stated she did not remember completing a one-person transfer of Resident 3 on 3/30/21 and did not remember documenting a one-person transfer. On 7/8/21 at 10:44 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they expected staff to provide two-person assistance if a resident was care planned for two-person assistance. 3. Resident 5 was admitted in 12/2020 with diagnoses including dementia and communication deficit. A 12/15/20 care plan instructed staff to provide Resident 5 with two-person, physical assist with constant supervision with a mechanical lift or transfer belt. A 12/17/20 Admission MDS and Fall CAA revealed Resident 5 had an extensive history of falls. Resident 5 required extensive assistance with two-person physical assistance of transfers. A 3/2021 Documentation Survey Report revealed from 3/1/21 through 3/30/21 Resident 5 was provided one-person assist with transfers as follows: -Day shift: 11 instances -Evening Shift: 17 instances -Night shift: three instances. On 7/8/21 at 9:10 AM when asked about one person transfers documented in clinical records completed by Staff 32 (CNA), she stated on evening shifts staff were always on the go trying to get all the required tasks completed. Staff 32 stated it may take up to a half an hour to get assistance from another CNA to provide help with a two-person transfer due to being so busy. On 7/8/21 at 10:44 AM Staff 1 and Staff 2 (DNS) stated they would expect staff to provide two-person assistance if a resident was care planned for two-person assistance. 4. Resident 6 was admitted to the facility in 5/2021 with diagnoses including falls, and cognitive communication deficit. A 5/23/21 Fall Post Fall Assessment revealed Resident 6 sustained a fall in her/his room. Resident 6 had a history of falls in the proceeding six months. Resident 6 attempted to self-transfer without calling for assistance. A new preventative plan included a toileting plan, a urinal at the bedside, pain assessment, verbal cues, visual cues, personal items within reach, diversional activities, and to seat in a high visibility area. A 6/7/21 Fall Post Fall Assessment revealed Resident 6 sustained a fall in her/his room. Resident 6 was found sitting on the floor in front of her/his wheelchair, she/he attempted to self-transfer. Resident 6's call light was on. A new preventative plan included a toileting plan, a urinal at the bedside, pain assessment, verbal cues, visual cues, personal items within reach, diversional activities, and to seat in a high visibility area. A 6/10/21 Fall Post Fall Assessment revealed Resident 6 sustained a fall in her/his room. Resident 6 attempted to self-transfer from bed and her/his call light was on. A new preventative plan included visual cues. A care plan revised on 6/15/21 indicated Resident 6 was at risk for falls with interventions which included to seat her/him in an area of high visibility for supervision, referred to the mobility plan of care and to provide Resident 6 with visual prompts to ask for help while in her/his room. The revised 6/17/21 mobility plan instructed staff to provide two person constant guidance and physical assist with a stand pivot with front wheel walker during transfers. A 6/2021 Documentation Survey Report reviewed from 6/17/21 through 6/23/21 revealed Resident 6 was provided one person physical assist on two instances on evening shift out of six opportunities. On 6/22/21 at 10:00 AM Resident 6 was in her/his wheelchair in her/his room. On 7/7/21 at 12:21 PM Staff 29 (NA) stated she was not sure if Resident 6 could be in her/his room in her/his wheelchair by herself/himself. Staff 29 stated she did not believe Resident 6's room was a high visibility area. On 7/8/21 at 9:24 AM Staff 28 (CNA) stated she did not believe Resident 6's room was a high visibility area. Staff 28 stated she heard of co-workers transferring with one-person when a resident was care planned for two-person transfer. Staff 28 stated she felt it was due to staffing issue. Staff 28 stated she was assigned up to 11 residents on an evening shift and there was no way to get everything done. On 7/8/21 at 10:44 AM Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect staff to provide two-person assistance if a resident was care planned for two-person assistance.

Based on observation, interview and record review it was determined the facility failed to ensure a resident did not develop an avoidable pressure ulcer for 1 of 1 sampled resident (# 28) reviewed for pressure ulcers. Resident 28 developed multiple Stage 2 (partial-thickness skin loss) pressure ulcers. Findings include: Resident 28 was admitted to the facility in 7/2019 with [DIAGNOSES REDACTED]. The resident's 7/30/19 care plan indicated the resident required total assistance for mobility and additionally indicated characterized by the following: -Contractures of: Bilateral hands and footdrop (inability to raise the toes or foot) -Pull the resident up in bed every two hours and PRN to keep toes from pressing against the footboard -Use foot cradle on foot of the bed to keep covers from rubbing against the resident's feet. Pressure Ulcer: -actual impairment related to cognitive impairment, immobility, incontinence, lack of sensation related to [MEDICAL CONDITION] and contractures of hands and feet. Pressure Reduction mattress on bed: -pressure reducing mattress with extension due to the resident's laying height of seven feet. A Licensed Nurse Skin Event assessment dated [DATE] indicated the resident slid down in bed and acquired three Stage 2 pressure ulcers to the right second and third toes due to the right foot pressed against the footboard. A Licensed Nurse Skin Event assessment dated [DATE] indicated the resident was tall, slid down in bed with toes against the cushion/footboard and experienced pressure on her/his toes causing the left third, fourth and fifth toes and the base of the fifth toe to develop blisters (Stage 2 pressure ulcers). A Licensed Nurse Skin Event assessment dated [DATE] indicated the resident had a Stage 2 pressure ulcer to the left foot on the fourth toe. Staff were to ensure toes were not in proximity to the footboard and were protected at all times. Random observations on 9/16/19 through 9/19/19 on day and evening shifts revealed Resident 28 lying in bed with toes against the footboard. Resident 28 was observed with two Stage 2 pressure ulcers to the left two end toes and right two end toes. On 9/17/19 at 10:18 AM Witness 1 (Family) stated she had requested a longer bed for the resident since admission but nobody had responded. Witness 1 confirmed the pressure ulcers were from the footboard which was why she requested a longer bed for the resident. On 9/19/19 at 11:29 AM Staff 3 (RNCM) stated she notified housekeeping and maintenance regarding a longer bed but they were unable to locate one. Staff 3 acknowledged the resident developed four Stage 2 pressure ulcers in total to both feet from the resident scooting down in the bed with her/his toes pressed against the footboard.

Based on interview and record review it was determined the facility failed to provide adequate supervision after a shower for 1 of 3 sampled residents (#81) reviewed for accidents. Resident 81 fell which resulted in a hip fracture. Findings include: Resident 81 was admitted to the facility on 2015 with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE] revealed the resident was non-verbal and cognitive ability was unable to be determined. The resident had a [DIAGNOSES REDACTED]. The assessment indicated the resident was to be kept in an area of observation and monitored for safety. Review of an initial care plan dated 7/27/15 revealed the resident was at risk for falls related to weakness, inability to recover body position and a cognitive impairment. Staff interventions included visual checks to see of the resident was restless or needed assistance. Review of a Fall CAA dated 8/4/15 revealed the resident was dependent for all care and did not have awareness of body positioning. The CAA indicated the resident was not able to sit or stand without support due to weakness, poor balance and lack of awareness of needs. Review of a incident report dated 8/18/15 revealed the resident was found on the shower floor in the resident's bathroom. The report indicated the resident had just received a shower and the resident had fallen after an attempted self transfer from a shower chair. Review of a incident investigation dated 8/19/15 revealed Staff 14 (CNA) had given the resident a shower at the request of the charge nurse. Staff 14 had stepped out of the resident's bathroom to get the charge nurse in order to apply a rash medication. When Staff 14 returned to the bathroom the resident was found on the floor of the shower. The charge nurse was called to the resident's bathroom, assessed the resident and the resident was sent to the emergency room for evaluation. The fall resulted in a left hip fracture and a new fall intervention was to be put in place not to leave the resident unattended in the shower. Review of a hospital consultation note dated 8/18/15 revealed the resident was diagnosed with [REDACTED]. In an interview on 10/28/15 at 10:33 am Staff 3 (RNCM) said on 8/18/15 the resident was in the bathroom getting a shower from Staff 14 so the nurse could apply lotion to a rash. Staff 14 left the resident in the shower to get the nurse and when Staff 14 returned the resident was on the floor of the shower. Staff 3 said it was not good practice to leave the resident alone in the shower because of the resident's risk for falls and staff did not leave residents in the shower unless the resident was independent. Staff 3 said the resident suffered a hip fracture which required surgery. In an interview on 10/28/15 at 11:24 am Staff 14 said on 8/18/15 she was instructed by the charge nurse to shower the resident in order for lotion to be applied to a rash on the resident. Staff 14 said she left the resident in the shower in a shower chair in order to get the charge nurse. Staff 14 said she was only gone for two minutes and when she returned the resident had fallen out of the shower chair onto the shower floor. Staff 14 said she did not use the call light in the bathroom because she thought it would be quicker to get the nurse herself. Staff 14 said the resident was sent to the hospital after the resident was assessed by the nurse. In an interview on 10/28/15 at 12:15 pm Staff 2 (DNS) indicated Staff 14 should not have left the resident in the shower alone. Staff 2 acknowledged the resident's fall and hip fracture was a result of poor judgement by Staff 14.

Based on interviews and record review it was determined the facility failed to thoroughly investigate multiple fall incidents and report alleged violations involving possible neglect to the appropriate State agency for 1 of 3 sampled residents (#1). Findings include: Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress Note (IDP) dated 7/13/10 at 10:22 pm revealed the resident fell in the bathroom which resulted in a "bump top of head." Review of an undated Fall Assessment revealed the resident fell in the resident's bathroom during an unassisted transfer on 7/13/10 at 9:00 pm. The assessment indicated the resident suffered a "bump" to the head, had pain rated zero out of ten and was alert and confused. The assessment did not include an assessment of the circumstances surrounding the incident, the time and date the resident's physician and family were notified and what intervention or corrective action was taken to prevent further falls. Review of an IDP dated 8/21/10 at 6:40 pm revealed the resident was found sitting on the floor in the bathroom next to the resident's toilet. The note indicated the resident had a "large bump" on the back of the resident's head and no complaints of pain. Review of a Fall assessment dated [DATE] revealed the resident fell in the resident's bathroom during an unassisted transfer on 8/21/10 at 6:40 pm. The assessment indicated the resident suffered a "lump on right scalp," complained of pain rated four out of ten and was alert and oriented. The assessment did not address the circumstances and effectiveness of current fall interventions surrounding the incident which included the use of a personal alarm (PA), padded fall mat and motion detector indicated on the resident's care plan. The assessment also indicated no abuse or neglect was suspected. In an interview on 1/13/11 at 2:46 pm Staff 1 (RNCM) said the incident report was "not clear" if a PA was in place at the time of the resident's fall on 8/21/10. Staff 1 said it was expected and the responsibility of the facility CNAs to have the resident's PA on the resident. No documentation could be located to indicate the resident's care plan was followed prior to the resident's fall on 8/21/10 which would rule out possible neglect and reporting to the appropriate State agency. Review of an IDP dated 8/31/10 at 2:15 pm revealed the resident was found on the floor in the resident's room and complained of pain in the left leg. Review of an unsigned and undated Post Fall Assessment revealed the resident was found on the floor in the resident's room complaining of left leg pain on 8/31/10 at 4:15 pm. The assessment did not address the circumstances and effectiveness of the current fall interventions which included the use of a PA, padded fall mat and a motion detector indicated on the resident's care plan. In an interview on 1/14/11 at 10:07 am Staff 10 (Housekeeping) indicated on 8/31/10 Staff 10 saw the resident lying on the floor in the resident's room. Staff 10 did not hear the resident's PA sounding. No documentation could be located to indicate the resident's care plan was followed prior to the resident's fall on 8/31/10 which would rule out possible neglect of care and reporting to the appropriate State agency. Review of an IDP dated 10/27/10 at 11:20 pm revealed the resident was found on the floor in the resident's room after an attempted self transfer. Review of a Post Fall assessment dated [DATE] revealed the resident was found on the floor in the resident's room from an attempted self transfer on 10/27/10 at 10:20 pm. The assessment did not address the circumstances of the current fall interventions which included the use of a PA, padded fall mat and a motion detector indicated on the resident's care plan. No documentation could be located to indicate the resident's family was informed of the resident's fall and if the resident's care plan was followed prior to the resident's fall on 10/27/10 which would rule out possible neglect of care. Review of an IDP dated 11/5/10 at 11:00 pm revealed the resident was found on the floor in the resident's room after an attempted self transfer. Review of a Post Fall assessment dated [DATE] revealed the resident suffered a non-injury fall after an attempted self transfer on 11/5/10 at 10:00 pm. The assessment did not address the circumstances of the current fall interventions which included the use of a PA, padded fall mat and a motion detector indicated on the residents care plan. No documentation could be located to indicate the resident's care plan was followed prior to the resident's fall on 11/8/10 which would rule out possible neglect of care. Review of an IDP dated 12/4/10 at 11:40 pm revealed the resident fell in the hallway by the nurses station after an attempt to self transfer from a wheelchair. Review of a Post Fall Assessment 12/6/10 revealed the resident had a witnessed fall from a wheelchair on 12/4/10 at 11:40 pm and suffered a "hematoma." The assessment did not address the circumstances of the fall which included the use of a PA while the resident was in a wheelchair and whether the resident's responsible party was notified of the fall. No documentation could be located to indicate the resident's care plan was followed prior to the resident's fall on 12/4/10 which would rule out possible neglect of care. In an interview on 1/21/11 at 11:00 am Staff 2 (DNS) indicated all accidents/incidents are reported to the facility's administrator immediately using the Accident/Incident form and post fall assessment. Staff 2 indicated facility staff were expected to follow the facility's policy for investigations of an resident accident/incident. Review of the facility's policy and procedures regarding accidents or incidents revealed the policies and procedures were not followed. Refer to F-323

Based on interviews and record review it was determined the facility failed to follow the care plan for 1 of 3 sampled residents (#1) resulting in multiple falls which caused a hip fracture and a traumatic brain injury. Findings include: Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 7/13/10 revealed the resident was discharged to the facility and received physical therapy for gait training secondary to weakness. Review of a Fall Risk assessment dated [DATE] revealed the resident had a history of [REDACTED]. Review of an Interdisciplinary Progress Note (IDP) dated 7/13/10 at 10:22 pm revealed "Res (resident) walked to BR (bathroom) reach toilet chair fell to floor between toilet and wall." The note indicated the resident was confused and had a "bump top of head." The resident was assessed and monitored through the night. Review of an IDP dated 7/14/10 revealed "RCM f/u (follow up) investigation res (resident) fall 7/13/10." The note indicated the resident had been complaining of light headedness and dizziness and ambulated with a walker and one person assistance. The resident had gotten out of bed unassisted and did not call for help to use the bathroom. The note also indicated the resident had a history of [REDACTED]. The resident's care plan was was updated "for fall risk" and no abuse or neglect was suspected. Review of a care plan dated 7/14/10 revealed the resident was a fall risk due to weakness, history of falls, gait disturbance and cognition. The care plan interventions included non-skid shoes and socks, to encourage the resident to call for assistance and have personal items within reach. Review of an undated post Fall Assessment revealed the resident suffered a fall in the resident's bathroom on 7/13/10. The form indicated the resident had a "bump top head" caused by an unassisted self transfer. The report indicated the resident was in bed prior to the fall and needed to use the bathroom. In an interview on 1/13/11 at 2:05 pm Staff 4 (CNA) indicated the resident was found on the floor in the resident's bathroom on 7/13/10. Staff 4 said the resident had not used the call light for assistance. Staff 4 said a personal alarm (PA) was used after the fall as a safety intervention. In an interview on 1/13/11 at 2:46 pm Staff 1 (RNCM) said the resident was at risk for falls on admission and fall interventions included non-skid socks and shoes, to encourage the resident to call for assistance and to have personal items in reach. Staff 1 said a PA was not used as a fall intervention after the resident's fall on 7/13/10. In an interview on 1/14/11 at 12:10 pm Staff 1 (RNCM) said a PA was not a fall intervention for the resident on admission and prior to the resident's fall on 7/13/10 because the resident was not active and had no signs of getting out of bed without assistance. Review of a hospital note dated 7/23/10 revealed the resident was admitted due to altered mental status and "not feeling well." The resident was re-admitted to the facility on [DATE]. Review of a Fall Risk assessment dated [DATE] revealed the resident had a history of [REDACTED]. Assistive device needs included a personal alarm (PA) on at all times, non-skid socks and shoes and personal items within reach. Review of the care plan updated 8/17/10 revealed the resident was at risk for falls due to a history of falls, gait disturbance, cognition, impulse control, mobility and a decreased sense of safety. Care plan interventions included non-skid socks and shoes, non-skid mat nest to bed, PA on the resident's bed and wheelchair, personal items within reach, motion detector and a padded mat at bedside. Review of an IDP dated 8/21/10 at 6:40 pm revealed the resident was found sitting on the floor next to the resident's toilet. The note indicated the resident had a "large bump" on the back of the resident's head and no complaints of pain. Review of an Incident/Accident Report dated 8/21/10 revealed the resident was found on the bathroom floor with an injury. The report did not indicate a PA was in use or sounding at the time of the fall, what contributing factors may have contributed to the resident's fall and where and what the resident was doing prior to the fall. Review of a Witness Statement dated 8/21/10 revealed the resident was found on the floor in the resident's bathroom. The statement indicated the area looked "normal" and the safety device in use at the time of the resident's fall was a four wheeled walker. The statement did not indicate what the resident was doing prior to the fall or if the resident's PA was in use, sounding, properly functioning or had been removed by the resident at the time of the resident's fall. In an interview on 1/13/11 at 2:46 pm Staff 1 (RNCM) said the incident report was "not clear" if a PA was in place at the time of the resident's fall on 8/21/10. Staff 1 said it was expected and the responsibility of the facility CNAs to have the resident's PA on the resident. In an interview on 1/18/11 at 12:29 pm Staff 8 (CNA) indicated being asked by another CNA on 8/21/10 to assist the resident who had fallen in the bathroom. Staff 8 said the resident had a tendency to get out of bed without calling for assistance. Staff 8 did not hear the resident's PA sounding and thought the resident may have removed the PA. In an interview on 1/14/11 at 9:16 am Staff 9 (RN) said on 8/21/10 the resident was found on the floor in the resident's bathroom. Staff 9 said the resident had attempted to use the toilet without calling for assistance. Staff 9 said the resident was care planned to have a PA on while in bed or in a wheelchair but did not hear the resident's PA sounding at the time of the fall. Staff 9 did not remember seeing a PA in the resident's room and said the resident was able to remove the PA. Staff 9 indicated the resident did not use a motion detector as a fall intervention as directed in the resident's care plan. Review of a post Fall assessment dated [DATE] revealed the resident slipped while attempting to use the toilet and was found on the floor in the resident's bathroom. The resident suffered a bump on the head and causative factors included the urge to void, failure to call for assistance and failure to use a walker. The assessment did not indicate if the resident's PA was in use, sounding, properly functioning or been removed by the resident at the time of the resident's fall. The assessment indicated no abuse or neglect was suspected and the prevention plan was to "reinforce call for assistance." Review of a fall Resident Assessment Protocol (RAP) dated 8/24/10 revealed the resident had a history of [REDACTED]. The RAP indicated the resident was at risk for additional falls and "Resident continues at risk for falls per all of the above. She desires to be independent, but is usually cooperative with calling for assistance. She does, however, have intermittent periods of confusion." The RAP did not indicate whether prior fall interventions were effective in reducing the potential for falls and did not indicate any changes to the resident's care plan. Review of an IDP dated 8/31/10 at 2:15 pm revealed the resident was found in the resident's room on the floor complaining of pain in the left leg. The resident was assessed and sent to the ER for evaluation. Review of a unsigned and undated Post Fall Assessment revealed the resident was found on the floor in the resident's room complaining of left leg pain. The resident was alert and indicated to staff "Don't know how I got on the floor." The assessment indicated the resident was last seen in bed at 4:00 pm, toileted at 2:15 pm and was medicated at 7:00 am. The assessment did not indicate whether the PA was in use, sounding, properly functioning or had been removed by the resident at the time of the resident's fall. The assessment concluded the resident fell while attempting to use the bathroom and did not call for assistance. The preventative plan was for a PA to be used at all times. Review of a Witness Statement form by Staff 5 (CNA) dated 8/31/10 at 4:00 pm revealed "Did the resident use safety devices (state type) and were they in place and working?" and Staff 5 wrote "non-skid rug." No additional fall interventions were documented on the Witness Statement such as a padded fall mat, PA or a motion detector. Review of a Witness Statement form by Staff 4 (CNA) dated 8/31/10 at 4:15 pm revealed "Did the resident use safety devices (state type) and were they in place and working?" and Staff 4 wrote "tried to use her walker, but didn't unfold it." No additional fall interventions were documented on the Witness Statement such as a padded fall mat, PA or a motion detector. Review of a hospital note dated 8/31/10 revealed the resident was diagnosed with [REDACTED]. The note indicated the resident was to have surgery on 9/1/10 and the resident was readmitted to the facility on [DATE]. In an interview on 1/13/11 at 3:55 pm Staff 6 (Activities) said on 8/31/10 as she walked past the resident's room, she was informed by Staff 10 (Housekeeping) the resident was "down." Staff 6 informed nursing and did not remember hearing the resident's PA sounding. In an interview on 1/14/11 at 10:07 am Staff 10 (Housekeeping) indicated on 8/31/10 Staff 10 saw the resident lying on the floor in the resident's room. Staff 10 did not hear the resident's PA sounding. In an interview on 1/13/11 at 2:05 pm Staff 4 (CNA) indicated on 8/31/10 the resident was found on the floor in the resident's room. Staff 4 did not remember hearing a PA sounding at the time the resident was found on the floor and stated the resident was care planned to have a PA on at all times. Staff 4 said the resident was capable of removing the PA. Staff 4 said the resident was assessed by the nurse and sent to a local hospital for evaluation. In an interview on 1/13/11 at 2:46 pm Staff 1 (RNCM) said the care plan was being followed regarding the resident's fall on 8/31/10 but there was no documentation the resident's PA was in use prior to the resident's fall. In an interview on 1/19/11 at 10:43 Staff 13 (LPN) indicated completing a post fall assessment on the resident after the resident fell on [DATE]. Staff 13 was at the nurses station and the resident was in bed prior to the fall. Staff 13 said the resident's PA sounded and the resident was found on the floor in the resident's room. When asked why the safety alarm section of the post fall assessment was marked "N/A" instead of marked "sounding" Staff 13 said it was because she had turned the alarm off after the resident fell . Staff 13 did not remember if the resident's fall mat was in place at the time of the fall and said the resident did not use a motion detector. Staff 13 revealed seeing Staff 6 (Activities) in the hallway on the way to the resident's room. In an interview on 1/19/11 at 2:20 pm Staff 4 (CNA) said the resident did not have a motion detector and did not know the resident was care planned to have a motion detector. Staff 4 could not remember if a fall mat was in place at the time of the resident's fall on 8/31/10 and said the resident was care planned to have a fall mat. In an interview on 1/19/11 at 2:25 pm Staff 5 (CNA) said there was no fall mat or motion detector in place at the time of the resident's fall. Review of an IDP dated 10/27/10 at 11:20 pm revealed "Res (resident) attempted to transfer self from her bed, then slipped - in her bare feet - and fell to the floor landing on her fanny There are no injuries, denies pain. Fax sent to MD (physician) There are no (sic) behavior issues this shift, no Ativan (anti anxiety medication) given." Review of an Incident/Accident Report dated 10/27/10 revealed the resident was found on the floor in the resident's room after an attempted self transfer. The report indicated the resident was not injured. The report did not indicate if a personal alarm, padded fall mat and motion detector was in use at the time of the fall. Review of a Post Fall assessment dated [DATE] revealed the resident was found sitting on the floor in the resident's room on 10/27/10 at 10:20 pm after an attempt to get out of bed. The assessment indicated effective fall interventions included a PA and a bedside commode at night and non effective interventions included a toileting plan. The assessment did not indicate a PA was in use, sounding, properly functioning or been removed by the resident at the time of the resident's fall. The assessment concluded the resident fell while attempting to get out of bed barefoot and slipped on the floor. The plan was for a PA to be used at all times, non-skid footwear, toileting plan commode at bedside, pain assessment, verbal cues, personal items within reach, diversional activities and a social service referral. Review of an IDP dated 11/5/10 at 11:00 pm revealed "Res (resident) attempted to get up out of bed without using her call lgt (light). She was naked and barefoot, stood up, fell to the floor, landing on her right side." The note also indicated the resident got out of bed because the resident was hungry, the resident was not exhibiting any behaviors and was pleasant and cooperative with care. Review of an Incident/Accident Report dated 11/5/10 revealed the resident fell in the resident's room after an attempted self transfer. The report indicated the resident was not injured. The report did not indicate if a personal alarm was in use, padded fall mat, motion detector at the time of the fall. Review of a Post Fall assessment dated [DATE] revealed the resident suffered a fall in the resident's room after an attempted self transfer from bed. The report indicated the resident was barefoot. Interventions in use at the time of the fall were a low bed and a non-skid mat. The assessment did not indicate the PA was in use, sounding, properly functioning or had been removed by the resident at the time of the resident's fall. Current effective interventions were listed as a walk to dine program and the use of a PA. Current non-effective interventions were listed as diversional activities, talking one on one with staff and dining room for meals. The assessment also indicated the resident continued "to self transfer et is unable to correctly use call light" and the recommendations were to use a PA at all times, non-skid socks and shoes, pain assessment, personal items in reach, diversional activities, adjust bed height and a walk to dine program. In an interview on 1/19/11 at 2:25 pm Staff 5 (CNA) said the resident had a PA on at all times and could not remember if the resident's PA sounded when the resident fell on [DATE]. Review of the care plan updated 11/8/10 revealed a padded fall mat and a floor pressure alarm were added next to the resident's bed as a fall intervention. In an interview on 1/13/11 at 3:30 pm Staff 1 (RNCM) said the resident's care plan was updated on 11/8/10 to reflect additional fall interventions which included a fall mat and a floor pressure alarm. In an interview on 1/18/11 at 12:29 pm Staff 8 (CNA) said the resident's floor alarm has been effective in keeping the resident from getting out of bed without assistance. Review of an IDP dated 12/4/10 at 11:40 pm revealed "Resident getting up from w/c (wheelchair) in hallway by TV room, had a witnessed fall to floor, w/c rolled backward and away from resident as she was standing she lost balance and fell to her face and front to the floor." The note indicated the resident's physician was notified, was taken back to bed and monitored. Review of an Incident/Accident Report dated 12/4/10 revealed the resident was found on the floor in the hall after an attempt to stand from a chair. The report indicated the resident suffered a hematoma (head injury). The report did not indicate a personal alarm was in use at the time of the fall. Review of a Witness Statement form by Staff 4 (CNA) dated 12/4/10 at 11:40 pm revealed the resident had been sitting in the hallway in a wheelchair talking to another resident and fell to the floor after an attempt to get out of a wheelchair. The form also revealed "Did the resident use safety devices (state type) and were they in place and working?" and Staff 4 indicated "N/A." Review of a Witness Statement form by Staff 11 (CNA) dated 12/4/10 at 11:40 pm revealed the resident had been sitting in the hallway in a wheelchair talking to another resident and fell to the floor after an attempt to get out of a wheelchair. The statement indicated the resident was walking prior to the fall and Staff 11 had asked a nurse to get a wheelchair for the resident. The form also revealed "Did the resident use safety devices (state type) and were they in place and working?" and Staff 11 indicated "no." Review of a Witness Statement form by Staff 12 (CNA) dated 12/4/10 at 11:40 pm revealed the resident had been sitting in the hallway in a wheelchair talking to another resident and fell to the floor after an attempt to get out of a wheelchair. The form also revealed "Did the resident use safety devices (state type) and were they in place and working?" and Staff 11 indicated "nope." Review of a Post Fall assessment dated [DATE] revealed the resident suffered a witnessed fall on 12/4/10 at 11:40 pm. The assessment indicated suffered a "potential head injury" and a hematoma was noted to the right front forehead. Preventative measures in place at the time of the fall was noted to be "N/A." Review of an IDP note dated 12/6/10 at 5:35 am revealed the resident complained of a headache, vomiting and dizziness. the resident physician was notified and a physician order [REDACTED]. Review of a hospital discharge note dated 12/7/10 revealed the resident was diagnosed with [REDACTED]. In an interview on 1/19/11 at 9:15 am Staff 3 (CNA) said on 12/4/10 around 10:00 pm the resident had become agitated and wanted to contact family. Staff 3 took the resident in a wheelchair down to the nurses station and positioned her so staff could monitor the resident. Staff 3 did not remember if the resident had a PA in place. In an interview on 1/20/11 at 7:00 am Staff 12 (CNA) said on 12/4/10 the resident was sitting in a wheelchair at the nurses station visiting with another resident. Staff 12 said the resident had been sitting there for about 30 minutes prior to the fall and did not have a PA in place. Staff 12 said the resident attempted to stand up from the wheelchair and fell to the floor. Staff 12 said the resident was assessed and monitored the rest of the night.