Every finding on record at Monument Healthcare Taylorsville

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 41 sampled residents, one resident sustained a second-degree burn from a heat therapy treatment and will be cited at a harm level. Resident identifier: 76. Findings included:Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anterior cord syndrome at C3 level of cervical spinal cord; completed lesion at C4, C5, and C6 level of cervical spinal cord; cognitive communication deficit; spastic hemiplegia; and paresthesia of skin.On 2/2/26 at 8:31 AM, an interview was conducted with resident 76 who stated he was in the shower last Friday and the hot, hot water burned his arm. Resident 76 was observed to have a wrap on his left forearm and two blisters, approximately the size of a dime, on two of the knuckles on his left hand. Resident 76's medical record was reviewed from 1/26/26 through 2/3/26.An Alert Charting note dated 2/1/26 at 3:46 PM, indicated, Pt [patient] sent to [hospital name redacted] per on call [Medical Doctor's name redacted] orders. Pt found to have a rash with skin peeling to left arm and large blisters to knuckles on left hand.An Emergency Department document dated 2/1/26 at 5:05 PM, indicated, Findings consistent with second-degree burn to the left forearm. Scattered blistering of the skin.Isolated entirely to the left forearm. Also there are uncomplicated appearing bullae [large fluid-filled blisters] to the 3rd, 4th, and 5th digits of the left hand to the PIP [proximal interphalangeal] joints. It further indicated, In my opinion, this does not seem to be a medication reaction. This very much looks like a burn, and is isolated only to the left forearm. There is no oral involvement. There is no skin involvement anywhere else on the body. Out of an abundance of caution I elected to review this case with the on-call dermatologist. They reviewed photos. They agree that this does not seem like some sort of a systemic emergency process such as SJS [Stevens-Johnson_syndrome, a rare, serious adverse reaction, usually to a medication] or TEN [Toxic Epidermal Necrolysis, a rare, life-threatening skin reaction, usually to a medication], and again it looks like a burn. On 2/3/26 at 11:01 AM, an interview was conducted with the RNA. The RNA stated they provided heat therapy to resident 76 on 2/1/26. The RNA stated they obtained hot water from the sink in the therapy room, poured it into a basin, and submerged towels in the water. The RNA stated that they were supposed to use a thermometer to test the water but they did not test it that day. The RNA stated the temperature should have been between 105 to 115 degrees. The RNA stated they placed a dry towel on the resident's left forearm to his knuckles and then placed the hot wet towels on top of that. The RNA stated they touched the towel and it felt warm but resident 76 said it was good and that he did not express any pain through the heat therapy treatment. The RNA stated when they uncovered it they noticed it was more red than usual so they notified the nurse immediately. A Progress note dated 2/2/26 at 5:18 AM, indicated, Pt returned from [hospital name redacted] at 2000 pm [8:00 PM] after evaluation for left forearm/hand burn. Diagnosis : partial-thickness (second-degree) burn of left forearm.A Restorative Nursing Program document dated 4/24/25, indicated no heat therapy was included in the recommendations.On 2/3/26 at 9:18 AM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated Rehabilitation Services made recommendations for the Restorative Nurse Aide (RNA) program and that nursing ran the program and trained the RNAs. The DOR stated the Restorative Nursing Program document dated 4/24/25, listed the recommendations that were made for the RNA program for resident 76 and that there were no recommendations for heat therapy. The DOR stated he did not provide any heat therapy training to the RNA's. The DOR stated they did not have a hydrocollator so the facility was not equipped to provide heat therapy in an appropriate manner. The DOR stated a hydrocollator was temperature controlled and was designed to prevent burns. The DOR stated warmed or heated towels could not be heat regulated to prevent burns and that they could contain hot pockets. The DOR stated that a resident who was completely cognizant would be a better candidate to determine if a heated towel was too hot and remove it themselves. The DOR stated resident 76 had intermittent confusion.On 2/3/26 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that therapy trained the RNAs and that she thought there was a recommendation to provide heat therapy.

Based on observation and interview, the facility did not ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored in locked compartments. Specifically, observations were made of resident medications left unlocked and unattended on top of the medication cart, a multidose vial of insulin was available for use past its expiration date, and a multidose vial of tuberculin did not contain an open date for the vial. Resident identifiers: 7 and 70. Findings included:1. On 1/28/26 at 8:25 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration. LPN 1 left a blister pack of simvastatin for resident 70 on the top of the medication cart outside the resident's room. LPN 1 walked away from the medication cart to administer medication without securing the simvastatin in the locked medication cart. An immediate interview was conducted with LPN 1. LPN 1 stated that it was easier to pull all the blister packs out of the cart while dispensing medication and she forgot to put the simvastatin back inside the cart before she walked away. 2. On 1/28/26 at 9:45 AM, an observation was made of the 200 hallway medication cart with Unit Manager (UM) 1. An open multidose vial of Lantus insulin for resident 7 with an open date of 12/25/25, was observed. UM 1 stated that an open vial of insulin was good for 28 days past the open date. UM 1 stated that the insulin should be discarded. 3. On 1/28/26 at 9:59 AM, an observation was made of the medication fridge at the front of the 200/300/400 hallway. An open multidose Tuberculin vial was available for use with no open date documented on the vial or box. On 1/28/26 at 10:06 AM, an interview was conducted with UM 2. UM 2 stated that the Tuberculin vial should have an open date documented on the vial or the box. On 1/28/26 at 10:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the multidose vial of Tuberculin was good for 30 days once opened. The DON stated that the nursing staff should write the open date on the vial and on the box. The DON stated that medication blister packs should be placed back into the medication cart after dispensing the medications. The DON stated that the insulin should have been discarded as it was past the expiration date and if staff could not determine the open date they should discard the medication.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 1 out of 41 sampled residents, blood pressure medications were administered outside of parameters and professional standards of care. Resident identifier: 13. Findings included:Resident 13 was admitted to the facility on [DATE] with diagnoses which included heart failure, end stage renal disease, automatic cardiac defibrillator, pulmonary hypertension, and ventricular tachycardia.Resident 13's medical record was reviewed from 1/26/26 through 2/3/26.A Physician's Order dated 12/23/25, indicated, Metoprolol Succinate ER [extended release] Oral Tablet Extended Release 24 Hour (Metoprolol Succinate) Give 12.5 mg [milligrams] by mouth one time a day for Hypertension.A Physician's Order dated 12/23/25, indicated, Midodrine HCl [hydrochloride] Oral Tablet (Midodrine HCl) Give 5 mg by mouth two times a day for Hypotension Hold if BP [blood pressure] 110/60 or Higher .The December 2025 Medication Administration Record (MAR) was reviewed.a. Midodrine was administered for a blood pressure of 110/60 or higher, one time.b. Metoprolol Succinate was administered for a systolic blood pressure below 100, five times.c. Midodrine (a medication prescribed to treat low blood pressure) and Metoprolol Succinate (a medication prescribed to treat high blood pressure) was administered at the same time, four times.The January 2026 MAR was reviewed.a. Midodrine was administered for a blood pressure of 110/60 or higher, one time.b. Metoprolol Succinate was administered for a systolic blood pressure below 100, six times. It should be noted that on 1/7/26, resident 13 was administered Metoprolol Succinate when he had a documented blood pressure of 87/42.c. Midodrine and Metoprolol Succinate were administered at the same time, 13 times.On 2/2/26 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated that Metoprolol should be held if a resident had a systolic blood pressure under 110 because that medication could cause the resident's blood pressure to drop too low and result in a medical emergency. LPN 5 stated there usually was a parameter given in the orders for Metoprolol, but if there was not, she would use her nursing judgement and hold it if the resident had a systolic blood pressure of less than 110 and then call and clarify the order with the medical doctor. LPN 5 stated Midodrine should be held if the systolic blood pressure was over 110 because it caused the blood pressure to increase and could increase the risk of a stroke if the blood pressure went too high. LPN 5 stated Metoprolol and Midodrine should not be given at the same time.On 2/3/26 at 10:46 AM, an interview was conducted with the Director of Nursing (DON) who stated if a Metoprolol order had no parameters, it should have been held if the systolic blood pressure was less than 100 but every resident was different. The DON stated the nurse should have used clinical judgement and if the nurse had a concern about a blood pressure they should have contacted the provider. The DON stated Midodrine should have been held according to the ordered parameters and that Midodrine and Metoprolol should not have been administered at the same time.

Based on interview and record review, the facility did not ensure that the resident had the right to manage their financial affairs and included the right to know, in advance, what charges the facility imposed against a resident's personal funds. Specifically, for 1 out of 41 sampled residents, a resident was not informed in advance that the facility was going to charge against their personal funds the supplemental insurance premiums. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for a record of last year's account and had not heard back from her. Resident 54's medical record was reviewed on 1/26/26 through 2/3/26. Resident 54's profile listed the POA as the responsible party, POA for Care and Financial. The profile also indicated that resident 54 was their own responsible party. On 8/15/23, resident 54's POA completed an application for supplemental dental and vision insurance and the monthly premiums were $159.00 for dental and $59.00 for vision for a total of $218.00 per month. The application indicated to send the bill to the facility. Resident 54's financial statement documented insurance premium deductions that totaled $2,280.00 from their personal funds account from May 2025 through December 2025. On 1/29/26 at 10:48 AM, an interview was conducted with the BOM. The BOM stated that the facility was resident 54's representative (rep) payee. The BOM stated that resident 54's supplemental dental and vision insurance was provided through Medicaid. The BOM stated that the premiums for the insurance were supposed to be deducted from the facility's Cost of Care (COC) amount. It should be noted that the insurance premiums were not paid from the COC withdrawals but instead from resident 54's remaining account balance. The BOM stated that she became aware of the situation with resident 54's insurance in July 2025. On 1/29/26 at 12:54 PM, an interview was conducted with the Accounts Receivable Director (ARD). The ARD stated that they were not deducting the insurance premiums from the facility's COC. The ARD stated that they used resident 54's remaining account balance to pay the overdue back payment for the insurance premiums. The ARD stated that they had no documentation verifying that resident 54 or the POA authorized the facility to pay the back payment from resident 54's account balance or personal funds. On 1/29/26 at 1:23 PM, a follow-up interview was conducted with the ARD. The ARD then stated that the facility was resident 54's rep payee so they decided to deduct the back payment for the insurance premiums from resident 54's account balance. The ARD stated at one point resident 54 had an excess of funds, and they therefore took her money to pay the insurance. The ARD stated that they did not obtain authorization from resident 54 or the POA to use her excess funds to spend down her account to pay for the insurance. The ARD stated that the facility's practice was to ask the resident or POA to authorize access to the resident's personal funds. On 1/29/26 at 4:41 PM, a telephone interview was conducted with resident 54's POA. The POA stated that the facility was supposed to make the insurance payment and it was not supposed to come out of the resident's personal funds. On 2/3/26 at 9:31 AM, an interview was conducted with the ARD. The ARD stated that because they were resident 54's rep payee they did not need to notify the resident of the cost of services or any changes that were made. The ARD confirmed that they did not give resident 54 the opportunity to be informed of the changes made to her financial account. [Cross-refer F571]

Based on interview and record review, the facility did not ensure that the financial record was available to the resident through quarterly statements and upon request. Specifically, for 1 out of 41 sampled residents, a resident's quarterly statements were not provided to the resident or their personal representative and Power of Attorney (POA). Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's POA. The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for a record of last year's account and had not heard back from her. Resident 54's medical record was reviewed on 1/26/26 through 2/3/26. Resident 54's profile listed the POA as the responsible party, POA for Care and Financial. The profile also indicated that resident 54 was their own responsible party. On 1/29/26 at 10:48 AM, an interview was conducted with the BOM. The BOM stated that resident 54's POA should get a quarterly statement but she did not think it was done. On 1/29/26 at 12:54 PM, an interview was conducted with the Accounts Receivable Director (ARD). The ARD stated that they mailed statements to the POA quarterly but they had no documentation to verify that it was sent. The ARD then stated that the quarterly statements were delivered to resident 54's room and then it was shredded because they did not want to leave the documentation behind for anyone to see. The ARD then stated that the statement would not be mailed to the POA because they were resident 54's representative payee. The ARD then asked if resident 54 had a POA. [Cross-refer F571]

Based on interview and record review, the facility did not ensure that charges were not imposed against the personal funds of a resident for any item or service for which payment was made under Medicaid or Medicare. Specifically, for 1 out of 41 sampled residents, a resident's Medicaid funded insurance premiums were deducted from the resident's personal funds account and not from the facility Cost of Care (COC). Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration (SSA). The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for a record of last year's account and had not heard back from her. Resident 54's medical record was reviewed on 1/26/26 through 2/3/26. Resident 54's profile listed the POA as the responsible party, POA for Care and Financial. The profile also indicated that resident 54 was their own responsible party. On 8/15/23, resident 54's POA completed an application for supplemental dental and vision insurance and the monthly premiums were $159.00 for dental and $59.00 for vision for a total of $218.00 per month. The application indicated to send the bill to the facility. On 12/17/24, resident 54's Notice of Decision for the eligibility of benefits documented that resident 54's COC amount was $1688.00 and would begin in January 2025. This was the amount that must be given to the nursing home as resident 54's contribution towards COC. On 12/16/25, resident 54's Notice of Decision documented that the COC changed from $1688.00 to $1736.00 and would begin in January 2026. On 1/30/26, resident 54's Notice of Decision documented that the COC changed from $1736 to $1467.00 and would begin in February 2026. On 2/22/25, resident 54's Department of Health/Form 114AR Attachment D Authorization to Disclose Medical Information documented that resident 54 gave the facility the authority to Speak or act on my behalf as an authorized representative, which includes receiving Medicaid,.This authorization is effective from the date this form is signed until a written notification to revoke the authorization is received by the Department of Workforce Services. The form did not contain a signature and only had an X in the signature field and was dated 2/22/25. No other signatures were contained within the form. Resident 54's Financial Account Statement from the facility documented that resident 54's SSA monthly payment was $1733.00 per month. After the COC deduction of $1688.00, resident 54 was left with a personal funds credit of $45.00 per month. On 3/24/25, resident 54's Medical Review Complete Notice documented a countable income form Social Security of $1733.00. On 4/3/25, resident 54's starting account balance was $1733.00. On 5/1/25, resident 54's account balance was $2256.40 after a deposit of $2211.40 was credited to the account. The description is documented from PCC (abbreviation unknown). On 5/19/25, resident 54's account had a deduction of $872.00 for insurance premiums. On 6/11/25, resident 54's account had a deduction of $1935.70 for COC payment. It should be noted that the resident's COC amount was actually $1688.00 as designated on the Notice of Decision dated 12/17/24. This amounted to an additional $247.70 deducted from resident 54's account. On 6/27/25, resident 54's account had a deduction of $218.00 for insurance premiums. On 7/10/25, resident 54's account had a deduction of $436.00 for insurance premiums. On 8/28/25, resident 54's account had a deduction of $50.00 for PERSONAL NEEDS ITEMS. The payee was documented as the facility Administrator. It should be noted that no other documentation could be found to account for the expense of the $50.00. On 9/9/25, resident 54's account had a deduction of $218.00 for insurance premiums. On 10/8/25, resident 54's account had a deduction of $218.00 for insurance premiums. On 11/18/25, resident 54's account had a deduction of $218.00 for insurance premiums. On 12/12/25, resident 54's account had a deduction of $100.00 for insurance premiums. After this last deduction resident 54's account balance was $38.79. It should be noted that resident 54's insurance premium deductions totaled $2,280.00 from their personal funds account. The additional unexplained deduction of $247.70 on 6/11/25, added to the insurance premiums brings the deductions other than COC to $2527.70. On 1/29/26 at 10:48 AM, an interview was conducted with the BOM. The BOM stated that the facility was resident 54's representative (rep) payee. The BOM stated that resident 54's supplemental dental and vision insurance was provided through Medicaid. The BOM stated that the premiums for the insurance were supposed to be deducted from the facility's COC amount which would result in the facility receiving a lower monthly amount from resident 54. The BOM stated that Medicaid took resident 54 off of the supplemental insurance and the notice of this decision was sent to the POA. The BOM stated that she had been paying the supplemental insurance premiums because she was not notified of Medicaid's decision. It should be noted that the insurance premiums were not paid from the COC withdrawals but instead from resident 54's remaining account balance. The BOM stated that resident 54's POA was mad. The BOM stated that the previous BOM was behind in payment to the insurance company and they were going to cancel the plan. The BOM stated that she paid the bill from resident 54's account balance or personal funds. The BOM stated that the facility had a change of ownership in February 2025, and during the acquisition they did not receive the financial records from the previous company. The BOM stated that resident 54's POA was also making withdrawals from the account. The BOM stated that she was responsible for the accounting and ensuring that funds were available for withdrawal. The BOM stated that she became aware of the situation with resident 54's insurance in July 2025 and she was attempting to get a refund from the insurance company and an accounting prior to the new company acquisition. The BOM stated that she was in the process of conducting a financial audit of resident 54's records. On 1/29/26 at 12:54 PM, an interview was conducted with the Accounts Receivable Director (ARD). The ARD stated that the facility had a change of ownership in February 2025 and the resident's trust was opened in March 2025. The ARD stated that they were not deducting the insurance premiums from the facility's COC. The ARD stated that they used resident 54's remaining account balance to pay the overdue back payment for the insurance premiums. The ARD stated that the insurance company was going to stop services for non-payment. The ARD stated that they had no documentation verifying that resident 54 or the POA authorized the facility to pay the back payment from resident 54's account balance or personal funds. On 1/29/26 at 1:23 PM, a follow-up interview was conducted with the ARD. The ARD stated that the PCC deposit on 5/1/25, for $2211.40 was the balance carried forward from the old trust during the change of ownership. The ARD stated that resident 54's financial statement showed the deposits, deductions for COC, and back payments to the insurance premiums. The ARD stated that the remaining account balance showed an excess of $2000.00 so her $45.00 a month was accumulating. The ARD stated that after the last deduction in December 2025 resident 54's account balance was $38.00, and we don't know where the money went. The ARD then stated that the facility was resident 54's rep payee so they decided to deduct the back payment for the insurance premiums from resident 54's account balance. The ARD stated at one point resident 54 had an excess of funds, and they therefore took her money to pay the insurance. The ARD stated that they did not obtain authorization from resident 54 or the POA to use her excess funds to spend down her account to pay for the insurance. The ARD stated that the facility's practice was to ask the resident or POA to authorize access to the resident's personal funds. On 1/29/26 at 2:28 PM, the ARD stated that resident 54's POA was only for health and not financial and she was not sure why the resident profile in the electronic medical record documented her financial POA. The ARD stated that she was not sure if resident 54's POA had been given access to her finances. The ARD again stated that the supplemental vision and dental insurance was a Medicaid provided program. The ARD stated resident 54's medical POA signed her up for the supplemental insurance, and the facility as the rep payee was allowed to distribute the funds as they saw fit. The ARD stated that Medicaid messed up on the COC for the vision and dental insurance. The ARD stated that they identified the issue with Medicaid in November 2025 when resident 54's POA started asking questions. The ARD stated that based on the bank statement they took an excess of $450.00 that would be refunded. The ARD stated that the Medicaid COC was messed up in January 2025 and resident 54 would have funds that needed to be refunded to her since that date. The ARD stated that as rep payee they should have been notified of the change from Medicaid but they never received the information. The ARD stated that it was information that should have been transferred during the change of ownership. On 1/29/26 at 3:08 PM, the ARD stated that the BOM was paying off the insurance balance. The ARD stated that they were pulling the statements for the insurance now. The ARD stated that there was a potential that they overpaid but they did not know for sure. The ARD stated that they did not know the date of cancellation for the insurance policy. The ARD stated that the withdrawal on 8/28/25, for personal needs, was the only withdrawal that they knew of and that resident 54 did not usually take money out for herself. On 1/29/26 at 4:41 PM, a telephone interview was conducted with resident 54's POA.The POA stated that resident 54's SSA benefits went directly to the facility. The POA stated that she withdrew funds from resident 54's account through the BOM when resident 54 wanted or needed anything purchased. The POA stated that she did not have financial POA for resident 54. The POA stated that she called the BOM about the missing money and the BOM told her that she was working with the insurance company about it. The POA stated that she called the insurance company herself and was informed that they had not spoken to the facility's BOM about resident 54's account but did verify that the BOM was the individual who made the payments for the insurance. The POA stated that the insurance representative told her that the facility was not supposed to deduct the premium payments from the resident funds. The POA stated that the facility was supposed to make the insurance payment and it was not supposed to come out of the resident's personal funds. The POA stated that the insurance representative told her to contact the BOM to obtain a printout of all the transactions. The POA stated that when she signed resident 54 up for the insurance she was told that the policy was to be paid by the facility and the resident would not be charged for it, and that was the only reason she agreed to the supplemental insurance. They said it wouldn't impact her social security and Medicaid. On 2/3/26 at 9:31 AM, the ARD stated that as resident 54's rep payee they had the authority to access resident 54's personal funds to make medical payments on behalf of the resident. The ARD stated that resident 54 should be able to get those funds refunded to her account one way or another. The ARD stated that they were not notified from Medicaid that the insurance was no longer covered. The ARD stated that they should have been informed but they never received the notice and the post office loses stuff all the time. The ARD stated that she had not verified the address that the Medicaid notices were sent to. The ARD stated that because they were resident 54's rep payee they did not need to notify the resident of the cost of services or any changes that were made. The ARD confirmed that they did not give resident 54 the opportunity to be informed of the changes made to her financial account.

Based on interview and record review, the facility did not inform Medicaid-eligible residents when changes were made to the items and services provided. Specifically, for 1 out of 41 sampled residents, changes were made to the residents Medicaid funded supplemental vision and dental insurance and the facility did not provide notice to the resident of the changes timely. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for a record of last year's account and had not heard back from her. Resident 54's medical record was reviewed on 1/26/26 through 2/3/26. Resident 54's profile listed the POA as the responsible party, POA for Care and Financial. The profile also indicated that resident 54 was their own responsible party.On 1/29/26 at 10:48 AM, an interview was conducted with the BOM. The BOM stated that resident 54's supplemental dental and vision insurance was provided through Medicaid. The BOM stated that Medicaid took resident 54 off the supplemental insurance and the notice of this decision was sent to the POA. On 2/3/26 at 9:31 AM, an interview was conducted with the Accounts Receivable Director (ARD). The ARD stated that they were not notified from Medicaid that the insurance was no longer covered. The ARD stated that they should have been informed but they never received the notice and the post office loses stuff all the time. The ARD stated that because they were resident 54's representative payee they did not need to notify the resident of the cost of services or any changes that were made. [Cross-refer F571]

Based on observation and interview, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 2 out of 41 sampled residents, a resident receiving medication to prevent infection and a resident receiving medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifiers: 2 and 49. Findings included:1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus (DM).A physician order dated 1/3/26, documented Dapagliflozin Propanediol Oral Tablet 5 MG [milligrams] (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day for DM.The January 2026 Medication Administration Record (MAR) was reviewed. Resident 2 had missed seven doses of the medication due to the dapagliflozin propanediol being not available from the pharmacy.2. Resident 49 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diverticulitis of large intestine without perforation or abscess without bleeding.On 1/27/26 at 8:54 AM, an interview was conducted with resident 49. Resident 49 stated she broke her tooth a week ago here at the facility. Resident 49 stated that the pain could be a little stabby. Resident 49 stated the staff had not offered her pain medications and she felt like the staff had forgotten about her. Resident 49 stated the staff told her she would see a dentist but that had not happened.A COMMUNICATION: with physician (narrative) note dated 1/23/26 at 12:41 PM, documented . Ordered peridex mouthwash BID [twice daily]. Patient notified of above and agreed. The January 2026 MAR was reviewed. Resident 49 missed the first seven doses of the medication due to the Peridex being not available from the pharmacy.On 1/29/26 at 11:37 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated the facility had issues with the pharmacy and they were switching on March 1st. LPN 2 stated that the Nurse Practitioner (NP) ordered the Peridex mouthwash until they could get resident 49 seen by the dentist. LPN 2 stated the NP ordered the Peridex to prevent the tooth from getting infected.On 2/2/26 at 11:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility was switching pharmacies in March. The DON stated there were issues with communication. The DON stated the pharmacy had been trying to be better and she was in constant communication with them. The DON stated that providers were aware.

Based on interview and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 41 sampled residents, a resident that asked to see the dentist for a broken tooth did not have those services arranged. Resident identifier: 49. Findings included:Resident 49 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diverticulitis of large intestine without perforation or abscess without bleeding.On 1/27/26 at 8:54 AM, an interview was conducted with resident 49. Resident 49 stated she broke her tooth a week ago here at the facility. Resident 49 stated that the pain could be a little stabby. Resident 49 stated the staff had not offered her pain medications and she felt like the staff had forgotten about her. Resident 49 stated the staff told her she would see a dentist but that had not happened.On 1/23/26 at 12:41 PM, a COMMUNICATION: with physician (narrative) note documented . Ordered peridex mouthwash BID [twice daily]. Patient notified of above and agreed.On 1/29/26 at 11:25 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that herself and the Nurse Practitioner (NP) were in resident 49's room addressing some swelling that the resident had in her left arm and resident 49 mentioned that she had a broken tooth. LPN 2 stated they were working on getting the resident seen by the dentist. LPN 2 stated that Social Services would coordinate the dentist and would get the resident on the list. LPN 2 stated that the NP ordered Peridex mouthwash until they could get resident 49 seen by the dentist. LPN 2 stated the NP ordered the Peridex to prevent the tooth from getting infected. LPN 2 stated there was a standing order for the residents to see the dentist. LPN 2 stated that she would notify Social Services if a resident needed to be seen by the dentist but the NP on that day told her that she would notify Social Services because she shared an office with them. On 1/29/26 at 11:43 AM, an interview was conducted with the Resident Relations Manager (RRM). The RRM stated that she was not aware that resident 49 needed to be seen by the dentist and she would add resident 49 to the list. The RRM stated that she would make a referral to the dentist and they would come to the facility. The RRM stated the Resident Relations Assistance would ask the residents in their Interdisciplinary Team meeting if they had any dental needs. The RRM stated if the resident was receiving skilled services she would schedule the appointment with the resident's outside dentist. The RRM stated if a resident had dental needs the staff would let her know. The facility policy was reviewed Personal Care: Dental Services Policy StatementRoutine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Policy Interpretation and Implementation1. Routine and 24-hour emergency dental services are provided to our residents through:a. a contract agreement with a licensed dentist that comes to the facility monthly;b. referral to the resident's personal dentist;c. referral to community dentists; ord. referral to other health care organizations that provide dental services.6. Social services representatives will assist residents with appointments, transportationarrangements, and for reimbursement of dental services under the state plan, if eligible.This policy had an effective date of 2/1/2024.

Based on observation and interview, the facility did not store food in accordance with professional standards for food service safety. Specifically, the residents personal food fridge had two food containers that were not labeled with a date. Findings included:On 1/28/26 at 9:59 AM, an observation was made of the resident personal food fridge. On the front of the fridge was a sign that indicated, Resident Personal Food Fridge Put residents name & date on ALL items. Items must be covered and will be thrown out after 3 days from the date. Inside the refrigerator there was one large container that had a cloudy, brown, soup-like liquid in it with brown meat-like substance. Another styrofoam container was located in the fridge that contained vegetables. Both containers were not labeled with a resident name or date.A concurrent interview was conducted with Licenced Practical Nurse (LPN) 6. LPN 6 stated the two unlabeled food containers should be thrown away because they were not labeled with a resident name and date.On 2/3/26 at 10:44 AM, an interview was conducted with the Director of Nursing (DON) who stated that she was the one who checked the fridge for expired food or food not labeled with a date and discarded them. The DON stated food was supposed to be thrown away after three days of being in the fridge.

Based on observation, interview, and record review, the facility failed to provide the use of outside resources. Specifically, for 1 out of 41 sampled residents, a referral for a urology consultation was not made for a resident. Resident identifier: 70.Findings included:Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but not limited to muscle weakness, need for personal assistance, catheter use, and neurogenic bladder. A physician order dated 11/17/25, documented Refer patient to urology for suprapubic eval [evaluation] r/t [related to] frequent catheter leaking.No referral was made for resident 70 until 1/13/26. On 2/3/26 at 9:26 AM, an interview was conducted with the Director of Nursing (DON) who stated she was unsure why the referral to the urologist for resident 70 had not been made. On 2/3/26 at 9:29 AM, an interview was conducted with the Resident Relations Manager (RRM) who stated there was not an appointment for resident 70 on the calendar. RRM stated nursing makes those appointments and the RRM just sets up the transportation for the appointments. On 2/3/26 at 9:34 AM, an interview was conducted with Unit Manager (UM) 2 who stated she did not know what happened with the first referral, it was missed. UM 2 stated they started a new system last week for making appointments and following through with follow ups so this would not happen again. UM 2 stated the resident had seen the urologist recently and had another follow up scheduled.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 41 sampled residents,an assessment of the resident's condition and monitoring for complications before and after dialysis treatments were not completed. Resident identifier: 13. Findings included:Resident 13 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, automatic cardiac defibrillator, cardiomyopathies, and hypo-osmolality and hyponatremia.Resident 13's medical record was reviewed from 1/26/26 through 2/3/26.A Physician's Order dated 8/25/25, indicated, COMPLETE the Dialysis Post Assessment Form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review and follow up as indicated. Call Dialysis center if not returned with resident.A Physician's Order dated 8/22/25, indicated that resident 13 was to receive dialysis on Mondays, Wednesdays, and Fridays at 8:00 AM.Pre and post dialysis assessments were reviewed through the dates of 12/10/25 through 1/28/26. Out of 44 opportunities, 15 pre and/or post dialysis assessments were not in the medical record.On 2/2/26 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated that before a resident goes to dialysis, the nurse should have checked the fistula site and checked their blood pressure to ensure it was not too low. LPN 5 stated when a resident returned from dialysis the nurse should have obtained vital signs, checked the fistula site for the bruit and thrill to ensure it was functioning properly, look for any swelling or redness, and to monitor for bleeding.On 2/3/26 at 10:35 PM, an interview was conducted with the Director of Nursing who stated a pre and post dialysis assessment should be completed in the electronic medical record each time a resident had dialysis.

Based on interview and record review, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the health or safety of an individual in the facility is endangered; the licensee ceases to operate the facility; the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Specifically, for 2 out of 41 sampled residents, two residents were inappropriately discharged from the facility after going on leave of absence. Resident identifiers: 115 and 137. Findings included: 1. Resident 115 was admitted to the facility on [DATE] and discharged on 11/24/25. Resident 115 had diagnoses which included, but were not limited to, congestive heart failure, respiratory failure, muscle weakness, Crohn's disease, type II diabetes and chronic obstructive pulmonary disease. Resident 115's medical record was reviewed. A Brief Interview for Mental Status (BIMS) was conducted on 11/20/25, and resident 115 scored a 15 out of 15 which indicated resident 115 was cognitively intact. A safety evaluation dated 11/19/25, documented resident 115 was alert and oriented and required minimal assistance with mobility. On 11/24/25 at 8:09 PM, a Progress note documented Came back to facility with partner at side. Resident was told he had to leave the building for leaving AMA [against medical advice] previously. Resident left with belongings. Officer [name omitted] with local pd [police department] came and walked the building to make sure resident left. On 11/24/25 at 11:34 AM, a late entry Progress note documented [Resident 115] came back to the facility after an outing. [Resident 115] did not follow the LOA [leave of absence] process and had been considered AMA. [Resident 115] left the building with his partner. On 11/24/25 at 8:37 PM, a Medication Administration Note documented left AMA. On 11/25/25 at 9:51 AM, a Provider discharge evaluation note documented . It was reported that patient left later in the day AMA. Please note: the provider did not document rationale why the resident was discharged AMA. On 11/25/25 at 11:27 AM, an Interdisciplinary note documented Resident left the facility AMA without notifying staff. Upon review, resident had signed the LOA sign-out book; however, per prior education, resident is required to be supervised for all LOAs due to history of psychoactive substance use, impaired judgment, and prior unsafe exits. Resident did not request staff assistance or supervision and did not inform nursing of his departure from the building. Staff noted resident missing during routine safety rounds. Multiple attempts were made by nursing staff to contact the resident via phone to determine his whereabouts; all attempts were unsuccessful. Resident remained unreachable for an extended period. Resident returned to the facility at 7:00 PM. Nursing staff assessed resident upon return. Resident was alert and oriented but was advised to seek emergency evaluation at the hospital due to his history of psychoactive substance abuse, unsafe behaviors, and the risk associated with leaving the facility unsupervised. Due to safety concerns, police were contacted to ensure the resident vacated the premises after being instructed to proceed to the hospital. Resident left the building under police supervision without incident. The facility LOA absence sign out book was reviewed. It was documented resident 115 had signed out both times he left the facility. The LOA paperwork did not indicate that resident 115 required supervision. On 1/29/26 at 9:27 AM, an interview was conducted with the Director of Nursing (DON) and Unit Manager (UM) 3 who stated the safety evaluation done on admission determines whether a resident requires supervision on LOA. The DON stated resident 115 was not compliant with being supervised and he did not let the nurses know where he had gone, they could not get ahold of him, and he left with IV (intravenous) access. The DON stated resident 115 was aware of the LOA policy and what happened if he broke it. The facility was unable to provide a LOA policy when requested. On 1/29/26 at 10:58 AM, an interview was conducted with UM 2 who stated the resident did not have IV access when he left the day of his AMA discharge. On 1/29/26 at 11:59 AM, an interview was conducted with the Resident Relations Manager (RRM) who stated she was over resident discharges and resident 115 was not a planned discharge. On 1/29/26 at 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 4 who stated when the resident returned to the facility after his LOA visit that he was no longer a resident of the facility and had to leave. LPN 4 stated she was not exactly sure why, other than he had been gone longer than four hours from the facility. LPN 4 stated resident 115 did return and she called the police to assist with him not staying at the facility. LPN 4 stated the resident was not taken for medical treatment; the police were just present to protect the staff and keep the resident out of the facility. LPN 4 stated resident 115 did not sign an AMA form. On 1/29/26 at 1:22 PM, an interview was conducted with LPN 3 who stated the LOA process was confusing and resident 115 did not need supervision, he was alert and oriented. On 2/2/26 at 2:45 PM, a telephone interview was conducted with Registered Nurse (RN) 2 who stated resident 115 was alert and oriented and did not need supervision. RN 2 stated she noticed the resident was gone during her shift but was unsure how long he had been gone. RN 2 stated she called the Administrator and was told to discharge the resident AMA for being gone too long. RN 2 stated she was not told to call the authorities at any time to look for the resident, she was only told to discharge the resident and not allow him back into the facility. RN 2 stated resident 115 still had belongings in the facility. 2. Resident 137 was admitted to the facility on [DATE] and discharged on 8/4/25 with diagnoses which included, but were not limited to, fracture of one rib on the left side. A BIMS was conducted on 7/31/25, and resident 137 scored an 8 out of 15 which indicated resident 137 was moderately cognitively impaired. On 8/4/25 at 1:55 PM, an Interdisciplinary Team (IDT) Progress Note documented a late entry discharge: [resident 137] went on LOA and never returned. Attempted to contact with no success. No nomnc [Notice of Medicare Non-Coverage] issued due to left AMA. It should be noted that AMA signed paperwork was unable to be located in the medical record. On 8/4/25 at 6:26 PM, a Skilled Needs Review note documented . IDT Determination: [resident 137] Reviewed by IDT on 07/29/2025 07/29/2025 DC [discharge] Planning/Barriers : Resident expects to be discharged to the community. Overall discharge goal details: Plans to discharge to the community. Has not decided if he goes back to the streets or to his sisters; Highest level of function goal: Independent as possible; Potential barriers to discharge/functional goals: Unhoused; Discharge planned in the next week. Discharge driven by IDT determination. Resident will be discharged to community. On 8/5/25 at 8:53 AM, a Medication Administration Note documented Patient left ama. On 8/5/25 at 10:13 AM, a Follow up Note documented . ADDENDEM: it was reported by nursing that he left LOA and never returned to the facility and is discharged as AMA. Disposition: discharged from facility AMA. signed out as 'Sis' in LOA book and never returned. Discharge Information: RN/CNA [Certified Nursing Assistant]/PT [Physical Therapy]/OT [Occupational Therapy] to evaluate and treat needs and cares. Follow up: SS [Social Services] will attemptto [sic] set up appointment unclear if he has PCP [Primary Care Physician]. On 2/2/26 at 3:16 PM, an interview was conducted with LPN 2. LPN 2 stated the evening before resident 137 left the facility for the period of time the residents were allowed. LPN 2 stated the residents were allowed to leave for four hours maximum and it could not interrupt therapy time or major medications. LPN 2 stated that she would ask the resident if they want to take their medications on LOA and it would depend on what the medications were. LPN 2 stated that 137 tried to come back to the facility the next day and talk with the Administrator. LPN 2 stated resident 137 did not have any lines but resident 137 was mentally unstable. LPN 2 stated that because resident 137 did not come back to the facility he was discharged . LPN 2 stated if a resident left the facility for more than four hours, we would try to reach out to them and if we could not reach them it was an AMA. LPN 2 stated if the resident was not alert and oriented she would call the police. LPN 2 stated that resident 137 was very alert and came back the next day wanting to know why he could not come back to the facility. LPN 2 stated that she remembered that day because the lobby smelled like marijuana. On 2/2/26 at 3:25 PM, an interview was conducted with the Administrator (ADM). The ADM stated that resident 137 left the faciity on LOA and was independent. The ADM stated that staff attempted to call resident 137 with no answer. The ADM stated that resident 137 did not attempt to come back to the facility. On 2/3/26 at 9:55 AM, an interview was conducted with the ADM. The ADM stated the facility did not have a determination on a time frame that the residents could leave the facility. The ADM stated he would typically have communication with the resident and if they were supervised. The ADM stated that the only time lines given for LOA were with the insurance and Medicare who stated the residents could only be gone for four hours. The ADM stated that insurance would set an allotted number of days that the residents could leave in a year. The ADM stated that right before resident 137 left LOA the staff discussed the discharge plan with him. The ADM stated that resident 137 did not notify the staff and did not sign out. The ADM stated an AMA determination would have been put in the medical record from the signing of the form. The ADM stated that on the day resident 137 left the facility staff did not communicate AMA with resident 137, but the day before they did. The ADM stated the provider would have been notified of the discharge. The ADM stated in both situations when the staff did not have any communication with the residents and they did not return to the facility, at some point the staff needed to have a conversation with the Provider.

Based on interview and record review, the facility did not provide the necessary care and services to ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, for 1 out of 41 sampled residents, a resident was not provided assistance with showers per their preferences and as outlined in their shower schedule. Resident identifier: 116. Findings included:Resident 116 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, bacterial meningoencephalitis, nontraumatic intracranial hemorrhage, ataxia, dysphagia, and cognitive communication deficits.On 1/26/26 at 9:08 AM, an interview was conducted with resident 116. Resident 116 stated she only had two showers since admission and would like to receive more. Resident 116's medical record was reviewed on 1/26/26 through 2/3/26. Resident 116's bathing task documented that the resident was scheduled for showers on Wednesday and Saturday during the day shift. Resident 116's bathing task for the last 30 days documented that resident 116 required substantial/maximal assistance to dependent assistance for bathing. The task documented that resident 116 received a shower or bed bath on 1/7/26, 1/12/26, 1/19/26, and 1/28/26. Resident 116's medical record did not have any documented refusals for showers. According to the shower schedule resident 116 should have received a shower on 12/24/25, 12/26/25, 12/31/25, 1/3/26, 1/10/26, 1/14/26, 1/17/26, 1/21/26, and 1/24/26. On 1/28/26 at 2:18 PM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 116's shower schedule was a morning shower on Wednesday and Saturday. CNA 1 stated that they documented the shower on a skin observation shower form and then in the electronic medical record under the bathing task. CNA 1 stated that resident 116 required supervision for bathing to ensure she did not fall. On 1/28/26 at 2:38 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents were provided showers two days a week per the shower schedule. The DON stated that she would expect to see documentation that the resident either received the shower or refused the shower. The DON confirmed that based on the resident's shower schedule she did not receive two showers per week as scheduled.

Based on observation, interview, and record review it was determined that for 2 of 7 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident transported to a dialysis appointment was properly secured with a seatbelt, and subsequently sustained fractures of both of his legs. In addition, the facility did not ensure that a resident's call light was within reach and the resident reached for the call light, fell out of bed, and fractured his hip. This will be cited at a HARM. Resident Identifiers: 4, 7. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnosis which included encephalopathy, end stage renal disease, spinal stenosis, weakness, limitation of activities due to disability, need for assistance with personal care, and adult failure to thrive. On 3/12/24 at 9:38 AM, an interview was conducted with resident 7. Resident 7 stated that on 12/28/23 he was going to be transported to dialysis. He stated that the van driver was new and it was the van drivers 3rd or 4th day. Resident 7 stated that the van driver strapped him in the van ok, with two straps at the front of his chair and two in the back. When resident 7 was asked about a lap and shoulder seat belt, he stated he did not have one on and did not remember the van diver attempting to put a shoulder or lap seat belt on him. He stated that he did not refuse to have the seatbelts put on. Resident 7 stated that they were on the freeway, the van driver was using a GPS [Global Positioning System] map to drive to the location, the van driver said that the exit should be coming up soon. Resident 7 stated he was looking out the window and told the van driver that they were about to miss the exit, and the van driver braked had but not so hard the van squealed and darted over to the emergency lane. He stated the braking did pull him out of his chair feet first and he slammed into the back of the van drivers chair and could tell his legs were broken. Resident 7 stated he was then taken to the hospital and was told his femur bones were shattered. On 11/30/23 a quarterly Minimum Data Set (MDS) assessment documented, resident 7 had a Brief Interview for Mental Status (BIMS) of 15. The MDS also documented, resident 7 required extensive two person assistance with bed mobility, transfers, and toileting. On 9/14/21, a care plan documented resident 7 was at risk for falls related to deconditioning, gait/balance problems. Interventions included, ensure that resident 7 was wearing appropriate footwear when ambulating or mobilizing in w/c[wheelchair]. On 12/29/23 at 6:30 AM, an incident report documented, Van driver came back to facility saying [resident 7] did not make it to dialysis. Van dirvier[sic] stated that he did not fasten the safety belt because [resident 7] declined and stated he didn't need it. He stated while on highway, the driver had missed the turn off so [resident 7] shouted out and startled him so he braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. Van driver called 911 and he was taken to [a local hospital]. Can driver called dialysis and updated dialysis center that he would not be at dialysis today due to hospital admission . Resident unable to give description. The document stated No injuries observed at time of incident. On 12/29/23 at 9:51 AM, a nursing note documented, Van driver came back to facility saying [resident 7] did not make it to Dialysis. He stated while on highway, he had missed the turn off, [resident 7] yelled at him and then he suddenly braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. 911 was called and he was taken to [a local hospital]. Van driver called Dialysis and stated he would not be at dialysis today. On 12/29/23 at 4:33 PM, a nursing note documented, Contacted [local hospital] to see if res [resident] had been admitted to hospital. He is in the ICU [Intensive Care Unit], is receiving dialysis there, bilat [bilateral] LE [lower extremities] were affected and they both will be needing surgery. His stay will be awhile. On 1/1/24 at 8:35 AM, an administration note documented, in hospitalized [sic] A review of resident 7's hospital history and physical reports dated 12/29/23 documented, the patient is found to have bilateral femur fractures and other associated soft tissue injuries . On 3/12/24 at 10:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she had not worked with resident 7, but knew that he was a full assist and required 2 people with transfers. On 3/12/24 at 10:43 AM, interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 7 was preferably a 2 person assist with transfers and that he did not have much leg strength. She stated that he was typically transferred into a geri chair and transferred in that to dialysis. She stated she was unsure how he was typically strapped into the van. On 3/12/24 at 11:08 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she had worked with resident 7 and that he was extremely difficult in a lot of incidences. She stated that he had depression and was frustrated and he would lash out at care givers and would refuse to cooperate. She stated that she was not present at the time he was being transported and can not say what happened. On 3/12/24 at 1:22 PM, an interview was conducted with the Van Driver (VD). The VD stated that he was new and had not received training, the only training received was to ride with another driver a couple of times. He stated that the other driver showed him how to strap a wheelchair into the van but never a geri chair. The VD stated that he arrived at the facility and a nurse brought resident 7 out to the van in the geri chair. The VD stated he thought resident 7 should not be transported like that but that he was new and was not sure. The VD stated he loaded resident 7 into the van and tied his chair down, then tried to put a shoulder strap and waist belt on resident 7, but that resident 7 refused the shoulder and waist belt. The VD stated he did not know the policy and was told that the customer was always right, and decided to transport the resident. The VD stated that on the freeway he was in the wrong land and the exit was difficult to get to. The VD stated that resident 7 told him they missed the exit. He stated he panicked and that resident 7 slid out of his chair onto the van floor. The VD stated he tried to help resident 7 back into his chair but that resident 7 refused and said to call 911 stating his legs were broken. The VD stated that the geri chair did not move, it was strapped to the van and the brakes were on. The VD stated he tried to call his supervisor and could not get a hold of him, then called dispatch to inform them of the incident. The VD stated that during his training no one said that it was mandatory to be strapped by the shoulder and lap belt and no one had informed him of the policy. The VD stated that he wanted to put the seatbelts on the resident but that the resident refused. The VD then terminated the interview. On 3/12/24 at 2:26 PM, an follow up interview was conducted with the RNC. The RNC stated that best practice was for a resident to be buckled when being transported. The RNC stated that if a resident refused, they must look at the things that were important, the residents have the right to choose. The RNC stated that with this situation the driver did attempt to do what he could with a reasonable attempt to buckle, and opted not to per resident 7's request. The RNC stated that for resident 7 dialysis was vital and that he had complications due to refusing dialysis. The RNC stated that ultimately it was best practice to secure residents in transport. On 3/13/24 at 9:22 AM, a follow up interview was conducted via telephone with the VD. The VD again stated that when he picked up resident 7, resident 7 was in a geri chair. The VD stated that technically you're not supposed to transport people in a geri chair. The VD stated that he loaded the resident in the geri chair into the van, and secured the wheels of the chair, making sure it didn't move. The VD stated that the resident refused to wear the shoulder lap belt. The VD stated that resident 7's exact words were 'I don't need it and I don't want it.' The VD stated that he had never transported someone without securing them completely. The VD stated that it was 5:00 in the morning, and I couldn't get a hold of my supervisor. The VD stated that the only training he had received prior to working alone was riding along with other van drivers. The VD stated that he was not trained on what to do if a resident refused to be secured, and was unsure if there was a specific company policy. The VD stated that he was terminated for transporting the resident without properly securing the resident. The VD stated that during the drive, resident 7 yelled out, and I reacted to his yelling, and he slid out when I hit the brakes. The VD stated that after he braked, the resident began screaming. The VD stated that he pulled over, and checked on the resident. The VD stated that the resident had slid out of the geri chair completely, and was sitting with his legs crossed in the space between the drivers seat and the geri chair, behind the driver. The VD stated that resident 7 told him to call 911. 47432 2. Resident 4 was admitted [DATE], readmitted [DATE] with diagnoses including: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, anterior cord syndrome at c [cervical] 3 level of cervical spinal cord subsequent encounter, complete lesion at c4 level of cervical spinal cord subsequent encounter, complete lesion at c5 level of cervical spinal cord subsequent encounter, complete lesion at c6 level of cervical spinal cord subsequent encounter, unspecified intracranial injury without loss of consciousness subsequent encounter, and major depressive disorder recurrent in partial remission. Resident 4's medical record was reviewed from 3/11/24 through 3/12/24. Resident 4's most recent Brief Interview for Mental Status (BIMS) score on 2/18/24 from his significant change Minimum Data Set (MDS) assessment was a 10, indicating a moderate cognitive impairment. Prior to this, a quarterly assessment had been completed on 1/22/24. Resident 4's BIMS score from this assessment was a 9, indicating a moderate cognitive impairment Resident 4's nursing care plan was reviewed. A care plan dated 6/5/20 revealed a focus area of, FALL RISK [Resident 4] is at risk for falls r/t [related to] deconditioning, gait/balance problems, psychoactive drug use and paraplegia in all extremities. This focus was revised on 9/15/20 The goal documented for this focus area was, [Resident 4] will have no unaddressed falls. This goal was initiated on 6/5/20 and was revised on 2/26/24. The interventions for this care area were documented as: a. Anticipate and meet [Resident 4]'s needs. b. Be sure [Resident 4]'s call light is within reach and encourage [Resident 4] to use it for assistance as needed. c. Encourage the [Resident 4] to participate in activities that promote exercise, physical activity for strengthening and improved mobility. d.Encourage/remind [Resident 4] to use mobility aides [sic] (walker, cane, crutches, etc.) when ambulating/transferring to aide with fall prevention. e. Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room. A care plan dated 6/5/20 revealed a focus area of, ACTUAL FALL [Resident 4] has had an actual fall with no [sic] r/t [related to] poor balance, unsteady gait and hemiplegia in all extremities. This focus was revised on 11/17/23. The goal documented for this focus area was,[Resident 4] will resume usual activities without further incident within 90 days. This goal was initiated on 6/15/20 and revised on 2/26/24. The interventions for this care area were documented as: a. 1/15/24 fall Therapy to room eval [evalute] with OT [occupational therapy] r/t [related to] room transfer. b. 2/9/24 offered room change resident refused loves room [ROOM NUMBER]/9/24 fall education with staff 2/9/24 call light also attached to dresser. c. FALL 2/20/24 asked resident to move closer to nursing station refused again educated use of call light and using and NWB [non-weight bearing] status talked to sister he is very adamant to maintain independence. d. Fall 6/4/22 - OT [occupational therapy] to eval [evaluate] and treat for safety awareness. e. Fall 9/13/22- PT [physical therapy] to eval [evaluate] and treat for leg strength for safety and positioning when in wheelchair. Staff education provided to encourage [Resident 4] to use leg rests when in wheelchair. f. [Resident 4] will not be left unattended in bathroom (pt [patient] at times toilets self) d/t [due to] safety awareness. g. Monitor/document/report PRN [as needed] x 72h [hours] to MD [doctor of medicine] for s/sx [signs/symptoms]: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. h. OT [occupational therapy] to eval [evaluate] and treat for use of self releasing seat belt to assist with autonomy. i. Provide activities that promote exercise and strength building where possible. Provide 1:1 [one on one] activities if bedbound. An incident report dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right] hip. Nurse was called to evaluate, res was in grimacing pain and guardian R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic] ordered. Dr notified, Sister [name redacted] called but left message. The incident report also noted that at the time of Resident 4's fall, his pain was rated as a 4 out of 10. A nursing progress note dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right hip]. Nurse was called to evaluate, res was in grimacing pain and guarding R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic] ordered. Dr notified, Sister [name redacted] called but left message. A nursing progress note dated 2/9/24 revealed, Xray [sic]results reviewed, orders rec'd [recommend] to send res to hospital to more [sic] evaluation on the femual [sic] head Fx [fracture]. Res does not want any family called r/t [related to] his mother being in the hospital right now and doesn't want to [NAME] [sic] out his family further. Res took no personalitems [sic] with him. [Ambulance company redacted] transported to [hospital named redacted]. At 4:45 PM, ER called. An interdisciplinary team progress note dated 2/15/24 revealed, Event: Fall with hip injury 2/9/24 Resident status prior to event: Sleeping in bed reached for call light fell and slipped out of bed fell with hip pain Risk factors: Epilepsy, Hemiplegia, C3-C6 spinal cord injury, language barrier, immobility, Bipolar disorder Preventive measures prior to event: Bed to be placed in lowest position for safety r/t to seizure hx [history] and mattress to be placed next to his bead. Medications routinely reviewed with pharmacy Care plan risk factors and interventions: [resident 4] is atrisk [sic] for fall r/t Deconditioning, Gait/balance problems, Psychoactive drug use and paraplegia in all extremities; Anticipate and meet [Resident 4]'s needs. Be sure [Resident 4]'s call light is within reach and encourage [Resident 4] to use it for assistance as needed. New device to hook to [Resident 4] [sic] dresser to help hold call light. The following areas reviewed - -Medication Review Regimen: Senna, Miralax, Flomax, Phenobarbital, Melatonin, Carbamazepine, Tylenol - Weight Loss: no weight loss - Dehydration: Average fluid intake 1500ml (millileter)/day -Pain: Resident reported pain to hip after fall. Sent out to ER -ADL [activities of daily living]: Requires one person extensive assistance with bed mobility, transfers and toileting. Set up and supervision for meals. Resident insist [sic] on transferring self often to toilet. -Decline in mobility: Dependent on w/c [wheelchair] for mobility -Psychotropic Drug Use: Sertraline Root Cause Analysis. After further investigation this incident has been reasonably r/t call light falling and resident reaching for. Offered resident to movecloser [sic] to nursing station on main hall 100 and resident declined. Offered to hook call light to dresser also as a back up and resident liked this idea. New interventions implemented: Continue working with therapy, sat with resident on ideas to help and came up with new way to help hook cord to dresser and than [sic] bed. Attendees: ED [executive director], DON [director of nursing], ADON [assistant director of nursing], Therapy, MDS [minimum data set], Resident Advocate. A pain assessment dated [DATE] revealed that at the time of Resident 4's fall, his pain was rated as a 6 out of 10. A change in condition evaluation dated 2/9/24 revealed that at the time of assessment that Resident 4's pain was rated as a 7 out of 10. A grievance filed 1/16/24 revealed, [Resident 4] was told, [sic] in order to eat meals in the dining area, [sic] that he would have to wheel himself down. [Resident 4] is unable to do this safely, he is a fall risk. [Resident 4] stated this happened two weeks ago with the CNA's [sic] in 200 hall as well as the nurse in 200. The corrective action for the grievance dated 1/18/24 revealed, Coaching and teaching staff - (CNA's [sic]) about when the resident needs something they need to do it in a timely manner. The findings of the investigation of the grievance dated 1/18/24 revealed, The resident did indeed ask for help down to the dining room, but was told he could wheel himself down to go eat. The recommendation for corrective action for the grievance dated 1/18/24 revealed, When residents ask certain things (tasks) to be done and they need help, staff members need to act accordingly in a timely respectful manner. The results of the action taken for the grievance dated 1/18/24 revealed, Staff members (cna's [sic], nurses) know to help the resident down to the dining room when they ask for help. On 2/10/24, the facility provided an in-service on fall safety for Resident 4. The training stated, [Resident 4] Fall Training C.N.A updated reminders 1. Bed to be placed in low position at all times r/t safety and seizures 2. Floor mat next to bed 3. Seat Belt is safely in place 4. Call light placement (prefers on pillow) education on new clips if needed. (can get from maintenance) 5. Encourage [Resident 4] when rounding to let you help toilet him if needed. Management Side 1. Review chart of all previous care plan items noted in past 2. Do education with staff regarding the care plan item in place 3. Speak with [Resident 4] regarding how we can better team up with him to prevent falls 4. Follow up on seat belt orders, can be released, being used, still needs to be used 5. Offer change in room to 101 busy hall with lots of eyes on resident. On 2/24/24, the facility provided an in-service with topics including, Fall prevention: call lights close, bed side tables close, ask if we can do anything else to help, anticipate needs, ask questions, non skid socks, talk to managers if you see a risk. The training summary revealed, Falls training prevention 1. Ensure call lights are always next to resident 2. Bed side tables are close to residents 3. Anticipate needs 4. Non ski socks for resident getting up and out of bed. 5. Always say before leaving a room is there anything else I can get you 6. If you suspect some one has a change in condition or is a high fall risk please notify nurse, if no change happens notify Nurse manager. If a fall happens you are required to Nurse 1. Complete incident report, get a set of ortho static [sic] vitals and record in Progress note (updated 3/11) 3. Complete fall and pain assessment 4. Start neuro (all falls not witnessed BY STAFF 5. PN [progress note] what happened, what you did to keep resident safe, notification family, MD, Text on call manager 6. Any wound orders if required 7. Notify your abuse coordinator ASAP [name redacted] administrator if you suspect fracture or abuse in any way. C.N.A. 1. Get a nurse to assess patient 2. Start Vital signs on Neuro sheet 3. Get a set or [sic] ortho static [sic] vitals with nurse if your [sic] not trained on this please see nurse or ADON [assistant director of nursing]. The facility conducted fall audits. The audit form revealed, DON/designee will conduct random audits on 5 residents and fall preventions interventions in place weekly x 4 weeks, then monthly x 3 months or until substantial compliance has been maintained to ensure decrease in falls. For the week of 2/19/24 through 2/25/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, seatbelt, call light. For the week of 2/26/24 through 3/3/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, low bed, call light pillow. For the week of 3/4/24 through 3/10/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment, seatbelt/safety reminder. For the week of 3/11/24 through 3/17/24, Resident 4 was selected to be audited. The audit form stated that Resident 4 had his fall precautions in place when facility staff entered his room. Per the audit form, Resident 4 had the comment fall mat - behind bed pt [patient] up [sic]. On 3/11/24 at 12:39 PM, an interview was conducted with Resident 4. Resident 4 stated that he remembered his fall that resulted in his hip fracture. Resident 4 stated that the night of the fall, his call light had dropped onto the floor and that the remote control for his bed had also dropped onto the floor. Resident 4 stated that he was unable to lower his bed further. Resident 4 stated that he tried to reach for his call light and fell out of bed. On 3/11/24 at 12:39 PM, an observation was made of Resident 4's room. The call light was taped to the side of his nightstand and clipped to the right side of his pillow. On 3/12/24 at 1:17 PM, an additional observation was made of Resident 4's room. Resident 4's bed was in the low position and his fall mat was behind his bed. On 3/12/24 at 1:17 PM, an interview was conducted with Resident 4. Resident 4 stated that staff stopped putting the fall mat on the floor at bedtime when he was moved from the 200 hall to the 400 hall. A review of Resident 4's room history revealed that Resident 4 was moved from the 200 hall to the 400 hall on 1/15/24. On 3/12/24 at 9:31 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that residents should be checked on every 2 hours. CNA 1 stated that he should check a resident's call light position every time he enters their room. CNA 1 stated that Resident 4 was not a high fall risk. CNA 1 stated that he has never heard of Resident 4 having experienced a fall. CNA 1 stated that he can see what fall interventions a resident had in place by looking at notes in the Resident's electronic medical record. On 3/12/24 at 1:23 PM, an additional interview was conducted with CNA 1. CNA 1 stated that to his knowledge, Resident 4 did not use a fall mat at night. CNA 1 stated that Resident 4's bed should have been in the low position. On 3/12/24 at 9:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that CNAs should check on residents every 2 hours. LPN 1 stated that each time a CNA completed their rounds they should check the position of each resident's call light. LPN 1 stated that Resident 4 was a high fall risk. LPN 1 stated that information about a resident's fall interventions could be found in the electronic medical record. LPN 1 stated that Resident 4 needed to be checked on more frequently due to him having an independent mindset and that he frequently tried to self transfer. On 3/12/24 at 11:28 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 was the nurse on duty the day Resident 4 fell . RN 2 stated that another staff member called her into Resident 4's room. RN 2 stated that she examined the resident and lifted him onto his bed. RN 2 stated that she notified Resident 4's physician and facility administration. RN 2 stated that an x-ray was ordered and that the x-ray staff confirmed that Resident 4 had a hip fracture. RN 2 stated she could not recall what Resident 4's fall interventions were at the time of the fall. RN 2 stated that she could not recall the location of Resident 4's call light when she entered his room. RN 2 stated that CNAs should check on residents at least every 2 hours and that anytime a CNA enters a resident's room they should check the positioning of the resident's call light. On 3/12/24 at 2:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should check on residents at least every 2 hours. The DON stated that staff should check the position of a resident's call light each time they enter a resident's room. The DON stated that staff can check to see what a resident's fall interventions were by looking at the Kardex in the electronic medical record. The DON stated that Resident 4 was a fall risk due to him wanting to maintain his independence. The DON stated that Resident 4 used a fall mat at night. The DON stated that Resident 4's fall mat should have been on his care plan. (Note: the usage of a fall mat was not documented on Resident 4's care plan). The DON stated that she had interviewed Resident 4 and Resident 4 had stated that he was not sure if he had knocked his call light out of place. On 3/12/24 at 2:24 PM, an interview was conducted with the facility administrator (ADM). The ADM stated that the facility does not track exact times that facility staff exit and enter a resident's room. The ADM stated that Resident 4's call light had been attached to the bar on Resident 4's bed and had fallen onto the ground prior to Resident 4's fall.

Based on interview and record review, it was determined, that for 2 of 7 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hour if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Specifically, the facility did not report two instances of potential neglect related to serious bodily injury to the State Survey Agency (SSA). Resident Identifiers: 4,7. Findings Included: 1. Resident 4 was admitted [DATE], readmitted [DATE] with diagnoses including: fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, anterior cord syndrome at c (cervical) 3 level of cervical spinal cord subsequent encounter, complete lesion at c4 level of cervical spinal cord subsequent encounter, complete lesion at c5 level of cervical spinal cord subsequent encounter, complete lesion at c6 level of cervical spinal cord subsequent encounter, unspecified intracranial injury without loss of consciousness subsequent encounter, and major depressive disorder recurrent in partial remission. Resident 4's medical record was reviewed from 3/11/24 through 3/12/24. Resident 4's most recent Brief Interview for Mental Status (BIMS) score on 2/13/24 from his significant change Minimum Data Set (MDS) assessment was a 10, indicating a moderate cognitive impairment. Prior to this, a quarterly assessment had been completed on 1/22/24. Resident 4's BIMS score from this assessment was a 9, indicating a moderate cognitive impairment. An incident report dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right] hip. Nurse was called to evaluate, res was in grimacing pain and guardian R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic] ordered. Dr notified, Sister [name redacted] called but left message. The incident report also noted that at the time of Resident 4's fall, his pain was rated as a 4 out of 10. A nursing progress note dated 2/9/24 revealed, At 0645 res [resident] was trying to reach for his call light to be helped out of bed and slipped to the floor hurting R [right hip]. Nurse was called to evaluate, res was in grimacing pain and guarding R hip. Res was helped to his chair, he insisted on going to the dining room for breakfast. Res was then helped back into bed. Xray [sic]ordered. Dr notified, Sister [name redacted] called but left message. A nursing progress note dated 2/9/24 revealed, Xray [sic] results reviewed, orders rec'd [recommend] to send res to hospital to more [sic] evaluation on the femual [sic] head Fx [fracture]. Res does not want any family called r/t [related to] his mother being in the hospital right now and doesn't want to [NAME] [sic] out his family further. Res took no personalitems [sic] with him. [Ambulance company redacted] transported to [hospital named redacted]. At 4:45 PM, ER called. [It should be noted that no documentation could be found of a facility investigation into the incident as documented in the progress note on 2/9/24, and reporting to the SSA and Adult Protective Services (APS) was not completed.] Review of a facility policy titled, Abuse Reporting and Responsibilities of Covered Individuals revised 5/4/23, revealed, The facility will report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and submit investigation results, according to regulatory guidelines and in accordance with State law and within the time frames required by federal and state law. The policy also revealed, 5. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Report immediately, but not later than 2 hours, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that caused the allegation involve abuse or result in serious bodily injury. On 3/12/24 at 11:28 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 was the nurse on duty the day Resident 4 fell . RN 2 stated that another staff member that she cannot remember the name of called her into Resident 4's room. RN 2 stated that she examined the resident and lifted him onto his bed. RN 2 stated that she notified Resident 4's physician and facility administration after the fall. RN 2 stated that an x-ray was ordered and that the x-ray staff confirmed that Resident 4 had a hip fracture. RN 2 stated she could not recall what Resident 4's fall interventions were at the time of the fall. RN 2 stated that she could not recall the location of Resident 4's call light when she entered his room. RN 2 stated that CNAs should be checking on residents at least every 2 hours and that anytime a CNA enters a resident's room they should check the positioning of the resident's call light. On 3/12/24 at 2:30 PM, an interview was conducted with the facility administrator (ADM). The ADM stated that the fall was not reported to the state agency because it was investigated fully internally and it was determined that the resident did not experience neglect. On 3/12/24 at 2:32 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the reason the fall was not reported to the stage agency was because multiple staff members had questioned the resident about whether or not he thought he had experienced abuse or neglect and the resident had provided the same answer to each staff member. The RNC stated that Resident 4 did not feel like he had experienced abuse or neglect. 45490 2. Resident 7 was admitted to the facility on [DATE] with diagnosis which included encephalopathy, end stage renal disease, spinal stenosis, weakness, limitation of activities due to disability, need for assistance with personal care, and adult failure to thrive. On 3/12/24 at 9:38 AM, an interview was conducted with resident 7. Resident 7 stated that on 12/29/23 he was going to be transported to dialysis. He stated that the van driver was new and it was the van drivers 3rd or 4th day. Resident 7 stated that the van driver strapped him in the van ok, with two straps at the front of his chair and two in the back. When resident 7 was asked about a lap and shoulder seat belt, he stated he did not have one on and did not remember the van diver attempting to put a shoulder or lap seat belt on him. He stated that he did not refuse to have the seatbelts put on. Resident 7 stated that they were on the freeway, the van driver was using a GPS [Global Positioning System] map to drive to the location, the van driver said that the exit should be coming up soon. Resident 7 stated he was looking out the window and told the van driver that they were about to miss the exit, and the van driver braked hard but not so hard the van squealed and darted over to the emergency lane. He stated the braking did pull him out of his chair feet first and he slammed into the back of the van drivers chair and could tell his legs were broken. Resident 7 stated he was then taken to the hospital and was told his femur bones were shattered. On 11/30/23 a quarterly Minimum Data Set (MDS) assessment documented, resident 7 had a Brief Interview for Mental Status (BIMS) of 15. The MDS also documented, resident 7 required extensive two person assistance with bed mobility, transfers, and toileting. On 9/14/21 a care plan documented resident 7 was at risk for falls related to deconditioning, gait/balance problems. Interventions included, ensure that resident 7 was wearing appropriate footwear when ambulating or mobilizing in w/c[wheelchair]. On 12/29/23 at 6:30 AM, an incident report documented, Van driver came back to facility saying [resident 7] did not make it to dialysis. Van dirvier[sic] stated that he did not fasten the safety belt because [resident 7] declined and stated he didn't need it. He stated while on highway, the driver had missed the turn off so [resident 7] shouted out and startled him so he braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. Van driver called 911 and he was taken to [a local hospital]. Van driver called dialysis and updated dialysis center that he would not be at dialysis today due to hospital admission . Resident unable to give description. The document stated No injuries observed at time of incident. On 12/29/23 at 9:51 AM, a nursing note documented, Van driver came back to facility saying [resident 7] did not make it to Dialysis. He stated while on highway, he had missed the turn off, [resident 7] yelled at him and then he suddenly braked. He stated [resident 7] slipped forward out of geri chair and landed on the van floor. 911 was called and he was taken to [a local hospital]. Van driver called Dialysis and stated he would not be at dialysis today. On 12/29/23 at 4:33 PM, a nursing note documented, Contacted [local hospital] to see if res [resident] had been admitted to hospital. He is in the ICU [Intensive Care Unit], is receiving dialysis there, bilat [bilateral] LE [lower extremities] were affected and they both will be needing surgery. His stay will be awhile. [It should be noted that for the 12/29/23 incident, reporting to the SSA and Adult Protective Services (APS) was not completed.] On 3/12/24 at 11:08 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the incident was not reported to the state agency because there was not an injury of an unknown source and did not feel that there was outright neglect or anything that could insinuate neglect. The RNC stated she had worked with resident 7 and that he was extremely difficult in a lot of incidence. She stated that he had depression and was frustrated and he would lash out at care givers and would refuse to cooperate. She stated that she was not present at the time he was being transported and can not say what happened. On 3/12/24 at 11:56 AM, an interview was conducted with the Previous Director of Nursing (PDON). The PDON stated that, she was notified of the incident by a nurse, and was told resident 7 had come out of his chair in transport and was taken to the hospital. The PDON stated that the transportation coordinator interviewed the Van Driver (VD) and stated that the VD said he was trying to fasten resident 7. The VD stated that resident 7 refused the safety belt, and during transport resident 7 slid off of he chair. The PDON stated that they did not report the event because resident 7 refused the seat belt and nothing was done purposeful to cause harm to the resident. The PDON stated that the risk of not having the waist and shoulder seatbelt on could cause a higher risk of falling out of a chair, a risk of injury such as skin injury or broken bones. On 3/12/24 at 2:26 PM, an follow up interview was conducted with the RNC. The RNC stated that best practice was for a resident to be buckled when being transported. The RNC stated that if a resident refused, they must look at the things that were important, and the residents had the right to choose. The RNC stated that with this situation the driver did attempt to do what he could with a reasonable attempt to buckle, and opted not to per resident 7's request. The RNC stated that for resident 7 dialysis was vital and that he had complications due to refusing dialysis. The RNC stated that ultimately it was best practice to secure residents in transport. [Cross refer F 689]

Based on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident with heart failure had hospital discharge orders for daily weights, the order was not implemented at the facility until 6 days after the resident was admitted . Resident Identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, peripheral vascular disease, presence of prosthetic heart valve, and tricuspid stenosis. A review or resident 1's hospital discharge paperwork documented a discharge order, Monitor weight and record . Please weigh and record your weight: Daily. Call the provider if you have gained or lost pounds: 7-10. Resident 1's care plan did not include any focus areas involving daily weights. A physicians order dated 2/8/24 documented, DAILY WEIGHT R/T [related to] CARDIAC. [It should be noted that resident 1 was admitted to the facility on [DATE] and daily weights were not initiated until 2/8/24.] Resident 1's weights were reviewed from 2/2/24 through 3/2/24. a. On 2/2/24 at 4:59 PM, Resident 1's admission weight was 311.2 lbs. (pounds) b. On 2/8/24 at 11:55 AM, resident 1's weight was 299.2 lbs. [It should be noted there is a 12 pound weight loss during the 5 day period of not being weighed, and no documentation of notification to the provider was found.] c. On 2/8/24 at 1:50 PM, resident 1 was re-weighed 299.2 lbs. Resident 1 had weights missing on 2/3/24, 2/4/24, 2/5/24, 2/6/24, 2/7/24, 2/19/24 and 2/25/24. [Note: Resident 1 had a total of 7 weights missing in a 31 day period.] On 3/12/24 at 2:44 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that daily weights would be important for a resident with heart failure because the weights can make a huge difference. The weight can tell you what the cardiac volume and function and how they are doing. The DON stated that resident 1 was discharged with an order for daily weights from the hospital. The DON stated she was unable to find any documentation of weights for the missing days and stated that the facility missed putting the order in when resident 1 was admitted to the facility.

Based on interview and record review, it was determined that the facility did not consider the views of a resident or family group and act promptly upon the grievances and the recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not follow up on grievances filed by residents. Findings include: On 11/16/23, the facility grievance long was reviewed for the past year. The following grievances were found with no resolutions: On 1/26/23, a grievance was filed about food at the facility. No resolution or follow up on the grievance was documented in the grievance log. On 2/26/23, a grievance was filed about a resident to staff interaction. No resolution or follow up on the grievance was documented in the grievance log. On 4/27/23, two separate grievances were filed about food at the facility. No resolution or follow up on the grievances was documented in the grievance log. On 5/22/23, a grievance was filed by the resident council about food at the facility. No resolution or follow up on the grievance was documented in the grievance log. During the survey, non-compliance was identified with regard to F804, which had been a concern voiced with the residents in resident council 10 months prior. On 11/16/23, at 1:59 PM, an interview was conducted with the Activities Director (AD). The AD stated that grievances filed go in the grievance binder and that the facility Social Worker investigates the grievance or forwards it to the department of concern. The AD stated that prior to the facility being purchased by another company, complaints were not getting resolved. On 11/16/23 at 2:20 PM, an interview was conducted with the facility Social Worker (SW). The SW stated that she started in August of 2023 and was unsure of the grievance resolution process prior to that date. On 11/16/23 at 2:14 PM, an interview was conducted with the facility administrator (ADM). ADM stated that he and the SW are the grievance officers. The ADM stated that he signs off on grievances and then passes them off onto the corresponding department. [Cross refer to F804]

Based on interview and record review, the facility did not transmit to the Centers for Medicare/Medicaid (CMS) System information for each resident contained in the Minimum Data Set (MDS) within 7 days after completion. Resident identifiers: 2, 4, 28, 38, 48, 61, and 78. Findings include: 1. Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease, atrial fibrillation, and congestive heart failure. Resident 38's record was reviewed on 11/14/23. Resident 38's record indicated that an MDS dated [DATE] indicated in the Electronic Health Record (EHR) was export ready. Review of the CMS System indicated that the 8/31/23 MDS for resident 38 had not been transmitted as of 11/14/23. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, bell's palsy and liver transplant status. Resident 2's record was reviewed on 11/14/23. Resident 2's record indicated that an MDS dated [DATE] in the EHR was export ready. Review of the CMS System indicated that the 8/29/23 MDS for resident 2 had not been transmitted as of 11/14/23. 3. Resident 61 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, congestive heart failure, and muscle weakness. Resident 61's record was reviewed on 11/14/23. Resident 61's record indicated that an MDS dated [DATE] in the EHR was export ready. Review of the CMS System indicated that the 8/16/23 MDS for resident 61 had not been transmitted as of 11/14/23. 4. Resident 78 was admitted to the facility on [DATE] with diagnoses that included femur fracture and severe protein-calorie malnutrition. Resident 78's record was reviewed on 11/14/23. Resident 78's record indicated that an MDS dated [DATE] in the EHR was export ready. Review of the CMS System indicated that the 8/18/23 MDS for resident 78 had not been transmitted as of 11/14/23. 5. Resident 28 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy and acute kidney failure. Resident 28's record was reviewed on 11/14/23. Resident 28's record indicated that an MDS dated [DATE] in the EHR export ready. Review of the CMS System indicated that the 8/19/23 MDS for resident 28 had not been transmitted as of 11/14/23. 6. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included spinal stenosis and diabetes mellitus. Resident 48's record was reviewed on 11/14/23. Resident 48's record indicated that an MDS dated [DATE] in the EHR was export ready. Review of the CMS System indicated that the 8/17/23 MDS for resident 48 had not been transmitted as of 11/14/23. 7. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, diabetes mellitus, and dysphagia. Resident 4's record was reviewed on 11/14/23. Resident 4's record indicated that an MDS dated [DATE] in the EHR was export ready. Review of the CMS System indicated that the 8/26/23 MDS for resident 4 had not been transmitted as of 11/14/23. On 11/15/23 at 10:14 AM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC confirmed that the MDS assessments listed above were not transmitted to the CMS System. The MDSC stated that after some investigation she determined that the previous MDSC left at the end of August 2023, prepared the MDS assessments listed above but did not transmit them. The MDSC stated that she was unaware of the untransmitted assessments, and stated that she would be transmitting the missing assessments on 11/15/23.

Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 3 out of 40 sampled residents, a resident with bilateral hand contractures was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. In addition, residents did not received RNA (Restorative Nursing Services). Resident identifiers: 22, 68 and 73. Findings include: 1. Resident 22 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included, hemiplegia and hemiparesis following cerebral infarction affecting left and right sides, muscle weakness, contracture of hand and joint, quadriplegia, and limitation of activities due to disability. A review of resident 22's medical records was conducted on 11/13/23 through 11/16/23. On 11/14/23 at 9:06 AM an observation was made that resident 22 had contractures in both hands. Physician's order states, splints to be placed on bilateral hands for 4 hours as tolerated for contractures management. Directions stated, every day shift for contractures. On 11/16/23 at 10:16 AM an observation was made that resident 22 did not have splints placed on her hands. On 11/16/23 at 10:25 AM an interview with resident 22 was conducted. Resident 22 stated that she usually gets her splints placed on her about 10:00 AM. Resident 22 stated that the nurse that usually puts her hand splints on is not here today. On 11/16/23 at 12:09 PM an observation was made that resident 22 was in bed and no splints placed on her hands. On 11/16/23 at 12:24 PM a review of the Treatment Administration Record (TAR) for November 2023 revealed treatment had been provided for 3 hours on Thursday, 11/16/23 and checked off as completed. On 11/16/23 at 1:17 PM an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that she will put resident 22's hand splints on the resident daily. RN 1 stated that resident 22 goes to activities in the morning so it is usually best for her to put the splints on in the afternoon. On 11/16/23 at 3:01 PM an observation was made that resident 22 was in bed and no splints placed on her hands. On 11/16/23 at 3:19 PM a follow up interview with RN 1 was conducted. RN stated that she marked the TAR as putting the splints on resident 22 that morning. RN 1 stated that when she went in to the resident's room to place the splints on resident 22, resident was sleeping, so she did not put the splints on. A Nursing Care Plan initiated on 5/26/16 for resident 22 revealed a focus of Limited Physical Mobility and the intervention to Provide gentle range of motion (ROM) as tolerated with daily care. An optional state Minimum Data Set (MDS) dated [DATE] indicated the following: A. Section G (functional status) revealed that resident 22 required extensive assistance with bed mobility, personal hygiene, and toilet use. Resident 22 required total dependence with transfers. The RNA Program List dated 10/2/23 revealed resident 22 was on the list for RNA services. 2. Resident 73 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included, traumatic subdural hemorrhage without loss of consciousness, bipolar disorder, history of falling, and limitation of activities due to disability. On 11/14/23 at 9:51 AM an interview with resident 73 was conducted. Resident 73 stated that no one performs Range of Motion (ROM) exercises on her. Resident 73 stated that she feels like she is just lying around and growing weaker since she is not able to move herself very well. A review of resident 73's medical record was conducted on 11/13/23 through 11/16/23. A Nursing Care Plan initiated on 2/1/22 revealed resident 73 has limited physical mobility and staff were to provide gentle ROM as tolerated daily. An optional state Minimum Data Set (MDS) dated [DATE] A. Section G (functional status) revealed that resident 22 required extensive assistance with bed mobility, personal hygiene, and toilet use. Resident 22 required total dependence with transfers. RNA Program List dated 10/2/23 revealed resident 73 was on the list for RNA services. On 11/16/23 at 9:43 AM an interview was conducted with Minimum Data Set Coordinator (MDSC). The MDSC stated she has been at the facility since September, and she oversees the Restorative Nurses Assistant (RNA) program. The MDSC stated she is in the process of training eligible Certified Nurses Assistants (CNA) into RNAs. The MDSC stated only a few of the CNA staff have been fully trained. The MDSC stated, No residents have gotten RNA services. 45490 3. Resident 68 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, spinal stenosis, muscle weakness, limitation of activities due to disability, need for assistance with personal care, protein calorie malnutrition and adult failure to thrive. Resident 68's medical record was reviewed on 11/15/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed: A. Section G (functional status) revealed that resident 68 required extensive assistance with bed mobility, personal hygiene, and toilet use. Resident 68 required total dependence with transfers. A care plan dated 9/6/21 documented a focus area, resident 68 has limited physical mobility. Intervention dated 1/21/22 revealed, provide supportive care, assistance with mobility as needed. Document assistance as needed. A document titled Restorative nursing program inservice was completed by two staff members and signed on 10/18/23. A document titled RNA (restorative nursing assistant) dated 10/2/23 revealed residents on RNA services. Resident 68 was included in the list. On 11/15/23 an interview was conducted with resident 68. Resident 68 stated that he feels he has gotten weaker since he moved to the facility. He stated that he is interested in becoming more independent but needed more therapy in order to do that. Resident 68 stated that his tendons behind his knees are so tight it is difficult to extend his legs. On 11/15/23 at 11:20 AM an interview was conducted with certified nursing assistant (CNA) 2. CNA 2 stated that she had been trained as an RNA but had not been scheduled to perform RNA duties. CNA 1 stated that she had only been scheduled as a CNA since she completed training. On 11/16/23 at 9:43 AM an interview was conducted with the minimum data set coordinator (MDSC). The MDSC stated the RNA program was designed to assist residents with functional maintenance. She stated that the RNA's should be charting in the residents chart if they preformed any RNA service.

Based on observation, interview, and record review it was determined, for 3 of 38 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision, implement interventions nor complete interventions in an effort to prevent falls from occurring. One resident fractured each wrist, one week apart and one resident, had a fall after no interventions and fractured a wrist. Resident identifiers: 3, 30 and 41. Findings include: 1. Resident 3 was admitted to the facility on [DATE], she was discharged to the hospital and returned on 8/28/19, with [DIAGNOSES REDACTED]., repeated falls, muscle weakness, hypoxemia, [MEDICAL CONDITIONS], obstructive sleep apnea, [MEDICAL CONDITIONS], and asthma. On 9/9/19 at 12:15 PM, an interview was conducted with resident 3. Resident 3 stated that she had had multiple falls at the facility, and had hit her head at least once. Resident 3's medical record was reviewed on 9/10/19 and revealed the following falls: a. On 12/28/18 resident 3 had a fall with no noted injury. A nurse's note documented Nurse was assisting resident's roommate and saw this resident standing up after using the restroom and slipped and fell into a sitting position on the floor. Resident stated that her feet started to slide and she fell to a sitting position. An intervention documented on the facility incident report and the nurse's note stated Encouraged resident to wear nonskid socks when walking or transferring. (Note: this fall and intervention were not documented on resident 3's care plan.) b. On 12/30/18 resident 3 had a fall and hit her head. A nurse's note documented Res (resident) roommate used call light, CNA (certified nurse assistant) answer and found res in rest room res was sitting on floor. Res did not have traction socks on. Ask res what happens? res stated that she was on toilet, reach for walker then started to slipping. Res stated she hit her R (right) side of head on wall, and R arm on the floor. An intervention documented on the facility incident report and the nurse's note stated educate res to used traction socks and put on for res. (Note: this was the same intervention documented for the fall that happened 2 days prior. Additionally, this fall and intervention were not documented on resident 3's care plan.) c. On 1/12/19 resident 3 had a fall and hit her head which caused a scalp hematoma. A nurse's note documented Recreation notified this nurse that she was in resident's room helping her and saw her fall to the floor and her back was leaning against the bed frame. Resident stated she was standing up and was reaching for her walker but it was too far and lost her balance and fell . She said she hit her back and her head on the bed frame. An intervention documented on the facility incident report and the nurse's note stated Encourage resident to ask for assistance. (Note: this fall and intervention were not documented on resident 3's care plan.) d. On 1/14/19 resident 3 had a fall with no noted injury. A nurse's note documented Res stated that she was in her recliner, try to get up to her walker and slipped to floor. Res was next to her recliner.Res (sic) stated she did not hit her head, and denied pain. An intervention documented in the nurse's note stated Educate res to use call light, and help res to used rest room. Another intervention documented as an Interdisciplinary Team (IDT) note stated Staff to remind and assist resident in keeping her walkerclose (sic) by. (Note: this fall and intervention were not documented on resident 3's care plan.) e. On 5/27/19 resident 3 had a fall and hit her head which caused a laceration. A nurse's note documented (Resident 3) fell in her room at approx. (approximately) 1100 (11:00 AM). She was standing and trying to sign a piece of paper for Jack the housekeeper. she (sic) said all of a sudden I just felt myself going down. She hit her head on the left side and has a small laceration to her left ear. An intervention documented on 5/28/18 as an IDT note stated Resident is currently on OT (occupational therapy). OT to instruct to keep one hand on a solid surface. (Note: the fall and interventions were not documented on resident 3's care plan. Additionally, an interview with staff indicated that there was not a housekeeper named Jack, nor was anyone trying to obtain a signature from resident 3.) f. On 6/29/19 resident 3 had a fall with no noted injury. A nurse's note on 6/30/19 documented (Resident 3) was using her 4 wheeled walker as a wheelchair and another resident brought her dog in. (Resident 3) leaned over to pet the dog forgetting to lock the brakes on her walker. The walker then rolled out from under her causing her to slide to her bottom. No injury noted and was witnessed by 3 other people, she did not hit her head. An intervention documented on resident 3's care plan stated Re-educate (resident 3) to use her walker as a walker and apply the brakes when moving. (Note: this was the first fall intervention documented on resident 3's care plan since (YEAR), which was prior to these most recent falls.) g. On 7/9/19 resident 3 had a fall with no injury noted. A nurse's note on 7/10/19 documented ~1930 (7:30 PM) Resident was found on the floor sitting on her buttock by CN[NAME] Res stated she was going to the restroom and her legs gave out. Then she butt walked forward to let staff know. She did not hit her head, No skin injuries upon assessment. An intervention documented on resident 3's care plan stated Repair (resident 3's) electric wheelchair so she will no longer use walker as a wheelchair and remind to use call light for assistance. On 9/11/19 at 9:32 AM, an observation was made of resident 3 sitting in her recliner. Resident 3's call light was clipped to her bed and was not within reach. h. On 7/19/19 resident 3 had a fall in which she hit her head and had a change in her vital signs and level of consciousness. A nurse's note on 7/20/19 documented Res was found in he (sic) bathroom sitting on floor. Res stated she feel (sic) while standing up reaching for her wheel walker. Res wheel walker was not lock. Res has two lumps on right skull, res stated pain in R shoulder, R side of head, and R breast. Res initial vitals were WNL (within normal limits), after second vital res BP (blood pressure), O2 (oxygen) sat (saturation) begin to decline. Res become more confused. (Nurse Practitioner) gives the OK to send res toER (sic) (emergency room ). Res came back from (name of hospital) at 0400 (4:00 AM), with no new orders. An intervention documented resident 3's care plan stated Putting her walker closer to her while in the bathroom and ensuring the brake is engaged. An intervention documented on the facility incident report and the nurse's note stated She continues to use her walker as a wheelchair and has had falls rt (related to) not using her walker appropriately. Resident educated regarding walker use and to call staff for assistance. (Note: this was the 2nd time these interventions were used.) i. On 7/30/19 resident 3 had a fall and hit her head. A nurse's note documented CNA heard a call for help and found (resident 3) on the floor in her room. She stated she was getting up to go to the bathroom and slipped on some water she spilled. Denies any pain. No physical injuries noted. States she slightly hit her head. An intervention documented on resident 3's care plan stated Provide (resident 3) new grippy socks for traction. (Note: this was the 3rd time this intervention was used, but the 1st time it was documented on the care plan.) On 9/10/19 at 3:12 PM, an observation was made of resident 3 with no grippy socks on. On 9/11/19 at 8:04 AM, resident 3 was observed sitting on the side of her bed with no grippy socks on. There were no grippy socks on her bed or anywhere near her to indicate that she had them on recently. On 9/11/19 at 11:26 AM, an observation was made of resident 3 in her recliner with no grippy socks on. Resident 3's spouse was in the room at that time and stated that staff never put grippy socks on resident 3 unless she requested it. j. On 8/5/19 resident 3 had a fall and hit her head which caused a laceration, she also had a left wrist fracture. A nurse's note documented This nurse and two other staff members heard resident yelling for help and went in room to find resident on ground face down at 1900 (7:00 PM) this evening. Staff members helped resident back up into her recliner. She stated she was on her way to the bathroom and tripped on her side table. She has a bump on her forehead with a small laceration, cleaned and dressed with a bandaid. She had increased pain in her left arm rated 10/10 with decreased ROM. Pain medication and ice given. MD notified and ordered x-ray for left shoulder and wrist. X-ray performed and showed fracture to left wrist. MD notified and ordered to send out for further treatment in ER. An intervention documented on resident 3's care plan stated Install grippy tape to the bathroom floor for traction in the event there is water inadvertently splashed on the floor.Install grippy tape to the foot of (resident 3's) recliner. An intervention documented on the facility incident report and the nurse's note stated Staff to apply brightly colored tape on her bedside table to assist with visual cues. On 9/10/19 at 3:12 PM, an observation was made of resident 3's bathroom with no grip tape on the floor. Resident 3's roommate stated that to her knowledge, there had never been any grip tape on the floor in the bathroom. On 9/11/19 at 9:32 AM, an observation was made of resident 3's bedside table without any brightly colored tape for visual cues. k. On 8/10/19 resident 3 had a fall with no noted injuries. A facility incident report documented CNA found res is room sitting on floor by her recliner. Res stated she slid out of recliner onto floor, and did not hit her head. An intervention documented on the facility incident report and the nurse's noted stated Grippy tape to be placed at the foot of her recliner. (Note: this was the 2nd time this intervention was used. Additionally, no updates were made to resident 3's care plan.) l. On 8/16/19 resident 3 had a fall with no noted injuries. A nurse's note documented Res more alert today, however she tried once to get up on her own at 1100 (11:00 AM), nurse found res on floor, examined res, found no injury. An intervention documented on resident 3's care plan stated PT (physical therapy) eval (evaluation) for strength and training to use bedside commode and ambulate. An intervention documented on the facility incident report and the nurse's note stated Resident educated regarding call light use. Bedside commode placed by bedside to assist resident. On 9/11/19 at 9:32 AM, an observation was made of resident 3's room with no bedside commode. m. On 8/18/19 resident 3 had a fall with a right wrist fracture. A nurse's noted documented Around 0330 (3:30 AM) CNA found res on the floor in prone position, bed was on the lowest position. Res stated she tried to get up and some how rolled out of bed. (Note: there was no intervention documented for this fall on resident 3's care plan, in the nurse's note, or in a facility incident report.) n. On 8/22/19 resident 3 had a fall with no noted injuries. A facility incident report documented RES found on floor have way to bathroom, res on R side, bed was in the lowest position r/t res trying 2 other times that morning to get out of bed. An intervention documented on the facility incident report stated that resident 3 was sent to the hospital for a psychiatric evaluation. (Note: this fall and intervention were not documented on resident 3's care plan.) A review of resident 3's care plan revealed the following interventions were initiated prior to the fall on 12/28/18: a. Resident referred to pt (physical therapy) for proper walker usage and eval (evaluation) for front wheeled walker. Initiated on 9/17/17 b. Anticipate and meet (resident 3's) needs. Initiated on 6/13/16 c. Be sure (resident 3's) call light is within reach and encourage (resident 3) to use it for assistance as needed. (Resident 3) needs prompt response to all requests for assistance. Initiated on 6/13/16 d. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). Initiated on 6/13/16 e. (Resident 3) given education to let staff help her with toileting to prevent further falls. Initiated on 5/8/17 f. Education given to (resident 3) to ensure that she asks for assistance with bed mobility Initiated on 3/20/173 g. Staff education to check with (resident 3) frequently for toileting needs and if she needs any assistance with toileting to prevent falls. Initiated on 5/8/17 (Note: the intervention to remind resident 3 to ask for assistance and use her call light for mobility and transfers was used seven times.) On 9/9/19 at 12:15 PM, an interview was conducted with resident 3's spouse. Resident 3's spouse stated that resident 3 usually fell when trying to get up to go the bathroom because staff did not answer call lights very quickly. (Note: seven of the fourteen falls were going to or from the bathroom.) A review of call light times around resident 3's falls found: a. On 12/28/19, just prior to resident 3's fall, her call light was on for 11 minutes and 4 seconds. b. On 12/30/19, just prior to resident 3's fall, her call light was on for 8 minutes and 56 seconds. c. On 1/12/19, just prior to resident 3's fall, her call light was on for 3 minutes and 33 seconds. d. On 1/14/19, just prior to resident 3's fall, her call light was on for 4 minutes and 45 seconds. e. On 7/9/19, just prior to resident 3's fall, her call light was on for 10 minutes and 30 seconds. f. On 8/5/19, call light times surrounding this fall were not provided by the facility. g. On 8/10/19, just prior to resident 3's fall, her call light was on for 6 minutes and 42 seconds. h. On 8/16/19, call light times surrounding this fall were not provided by the facility. i. On 8/18/19, call light times surrounding this fall were not provided by the facility. j. On 8/22/19, call light times surrounding this fall were not provided by the facility. A review of the Medicare Minimum Data Set (MDS) Assessments for the previous year documented that resident 3 had a Brief Interview for Mental Status (BIMS) score of 13-15 which would indicate resident 3 was cognitively intact. Additionally, resident 3's functional status was documented as requiring one person, extensive assistance for toilet use and transfers. On 9/11/19 at 8:04 AM, an observation was made of resident 3 sitting on the side of her bed. Resident 3 stated she had a headache and was trying to call the nurse but could not figure out how to push her call light. Resident 3 was observed holding her oxygen tube in her hand and trying to push it as if it were a call light. When told that it was her oxygen tubing in her hand, resident 3 insisted it was the call light. On 9/11/19 at 10:08 AM, an interview was conducted with resident 3's Physical Therapist (PT). The PT stated that resident 3 was only oriented to person and her room. The PT stated that resident 3 was not able to retain education that was completed with her, even with practice and repetition. The PT stated that PT and OT would work with residents that were high risk for falls to identify causes. The PT stated that one of resident 3's issues was the clutter in her room. The PT stated that he assisted in initiating interventions, stated that he would talk to the floor staff about implementing those interventions. The PT stated that there was no paperwork or documentation that they use to communicate with the floor staff, stated that all communication was word of mouth. On 9/11/19 at 7:31 AM, an interview was conducted with CNA 6. CNA 6 stated that resident assistance needs were listed on their CNA report sheets. (Note: resident 3 was documented needing 2 person assistance.) CNA 6 stated that the CNA's had to ask the nurses if a resident had any fall interventions ordered. CNA 6 stated that the CNA's did not have access to any of that information. CNA 6 stated that she was very familiar with resident 3, stated that she did not know of any fall prevention interventions that were supposed to be used for resident 3. CNA 6 stated that resident 3 never refused interventions. On 9/11/19 at 7:36 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that new interventions were entered into the care plan by nurse management, stated that the interventions were also entered into the electronic charting system as an order to communicate the interventions to the staff. RN 1 stated that some examples of interventions ordered for falls were to put the resident beds in the lowest position, place fall mats on the floor by the bed, and use pressure alarms; RN 1 verified that resident 3 had no orders for fall prevention interventions. RN 1 stated that resident 3 required frequent reminders to use her call light, stated that resident 3 often forgot. RN 1 reviewed resident 3's care plan and stated that resident 3's fall interventions were to keep her room free of clutter and provide prompt nursing care. RN 1 was unable to verbalize what prompt nursing care was. RN 1 stated that resident 3 was very compliant with cares and interventions, stated that resident 3 never refused. On 9/11/19 at 11:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that all falls were followed up on by the clinical team on the next business day. The DON stated that the team tried to identify root cause and trends, stated that no trends had been identified for resident 3. The DON stated that interventions were usually entered into the resident care plans during the fall follow up meeting by the nurse management, stated the interventions were also entered as an order to communicate to the nurses. The DON stated that the CNA Coordinator would also document the interventions on the CNA report sheets immediately following the meeting. The DON stated that interventions were also documented on the resident's Kardex. The DON stated that during the fall follow up meeting past interventions were re-evaluated for effectiveness. The DON verified that the intervention of prompt nursing care for resident 3, as verbalized by the floor nurse was kind of vague and was unable to provide further clarification. The DON was unable to explain the discrepancies between the incident reports and care plan interventions. The DON stated that all of those interventions should have been implemented; the DON was unable to explain why resident 3 did not have grippy socks, the call light was not within reach, there was no grip tape on the bathroom floor, no bedside commode, nor bright tape on the bedside table. A review of resident 3's Kardex documented the following interventions: a. Anticipate and meet (resident 3's) needs. b. Be sure (resident 3's) call light is within reach and encourage (resident 3) to use it for assistance as needed. (Resident 3) needs prompt response to all requests for assistance. c. Ensure that [NAME]yn's floor is free from tripping hazards and personal items. On 9/11/19 at 12:00 PM, an interview was conducted with CNA 7. CNA 7 stated that the CNA report sheets did not have any interventions documented on them. CNA 7 stated that he was very familiar with resident 3, stated that resident 3 was only oriented to person and place. CNA 7 stated that resident 3 could not remember to use her call light and ask for assistance despite reminders from staff. CNA 7 stated that CNA's could not access the nurse's notes or incident reports for any interventions documented in those places. CNA 7 stated that he did not know where to find the Kardex to review it for interventions. (Note: A copy of a CNA report sheet was obtained and verified there were no interventions listed for any residents.) On 9/11/19 at 2:57 PM, a follow up interview was conducted with RN 1. RN 1 stated that resident 3 was continent of bowel and bladder but that resident 3 had urinary urgency and could not always get to the bathroom in time. RN 1 stated that education was not effective with resident 3 because despite constant safety reminders, resident 3 never remembered them. RN 1 stated that the facility had not tired a toileting program for resident 3, stated that a toileting program would probably be a good option for resident 3 because of her urinary urgency. RN 1 stated that she did not review past nurse's notes or incident reports for interventions documented in those places. On 9/16/19, further information was provided by the facility via e-mail. A Risk vs. Benefits form dated and signed by resident 3 on 8/9/19 documented: 1. Area of concern: Using Walker in place of wheelchair to sit on. 2. Benefits: Autonomy in decision making. (Resident 3) had the ability to sit if she becomes fatigued when walking and has episodes of SOB (shortness of breath) or anxiety. 3. Risks related to noncompliance: (Resident 3) falls when trying to sit down on walker seat. (Resident 3) forgets to lock the brakes when using walker as appropriate, this could lead to further broken bones and critical/severe injuries up to and including death. (Note: resident 3's walker was not a factor in her falls that occurred after 8/9/19 when this form took effect.) A note from MD 1 provided by the facility stated (Resident 3) also suffered from complex psychiatric diagnoses, which include [MEDICAL CONDITION] Disorder and Dissociative Identity Disorder which was evidenced by frequent changes in her mood, cognition and tangential responses, often multiple times throughout the day. This complexity of (Resident 3's) mental health status ultimately resulted in a psychiatric crisis which made fall prevention impossible as she was impulsive, reactionary, and extremely labile in her moods and actions. MD 1 also indicated that no matter what the facility implemented to prevent a fall with (resident 3), her constant mood changes and flight of ideas would have still resulted in falls. The complexity of her Dissociative Identity Disorder would have also complicated the ability of the facility to identify an intervention because the person for which the intervention was directed to would not be effective for one of (Resident 3's) alternate personalities. Review of the facility behavior monitoring and nurse's notes did not document that the facility floor staff was aware of, or monitoring for mood changes, cognition, or tangential responses. Resident 3's Pre-Admission Screening Resident Review (PASRR) Level II was provided by the facility as further information. Documented under Current Psychiatric Functioning the Licensed Clinical Social Worker (LCSW), that evaluated resident 3, documented: Pt's (patient's) husband reported pt (patient) having 5 or 6 personalities. Pt's husband stated that pt has not had many exacerbations in regards to dissociative identity disorder since admission into the SNF (skilled nursing facility). Pt was evaluated by (mental health facility) in (MONTH) 2019 for counseling and medication management; pt is getting counseling ever (sic) couple weeks and medication management every few months. On 9/19/19 at 1:50 PM, a phone interview was conducted with MD 1. MD 1 stated that resident 3 arrived at the inpatient geriatric psychiatric unit on 8/22/19 very agitated and had impulsivity. MD 1 stated he was the attending physician that treated her. MD 1 stated that based on her previous information from resident 3's mental health facility he believed this psychiatric issue was an acute exacerbation and could only be a contributing factor in the most recent fall. MD 1 stated that the cases where resident 3 fell while going to and from the bathroom were not psychiatric issues. MD 1 stated that he treated resident 3's impulsivity and agitation, not tripping over things. MD 1 stated that regardless of the reason for the falls, the facility should have attempted to keep resident 3 safe with continued interventions. MD 1 stated that resident 3 required a one-on-one staff assignment to keep resident 3 safe while in the hospital. 2. Resident 41 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/11/19 resident 41's medical record was reviewed. Nursing progress notes revealed the following entries: a. 7/4/2019 10:46 (AM) Nursing Note Late Entry: Note Text: Pt (patient) was in the bathroom when staff heard her yelling for help. Pt was sitting on the floor, stated she was pulling her pants up, when she lost her balance and fell to her knees and then sat on the floor. No injuries noted, neuro (neurological) checks started. MD (medical doctor) and family notified. b. 7/5/2019 19:37 (7:37 PM) Nursing Note Note Text: FALL: Resident denies any pain/discomfort r/t (related to) fall in restroom yesterday. This RN (Registered Nurse) encountered her toileting herself unsafely in restroom this afternoon and mentioned her fall yesterday, to which she replied I didn't fall, did I? No visible injuries/bruising/redness r/t fall yesterday. Neuro checks are continuing per facility protocol and vital signs remain WNL (within normal limits) for resident. She did request assistance (extensive given) from this RN to get her legs up onto her bed to lie down early in shift, which shows a substantial decline in her strength over last couple of months. c. 7/31/2019 04:39 (AM) Nursing Note Note Text: Resident was using her wheeled walker to bathroom with gripper socks on and felt dizzy and sat down per resident. Nurse assessed resident and no injuries noted at this time. Floor with (sic) clean and dry and there was a sign for wet floor by the door. Resident stated she was dizzy and sat down and hit the sign. When asked if she hit her head she stated NO. Nurses helped resident up off the floor and sat her on her walker. She stated she needed to use the bathroom. She was helped on the toilet, nurse was able to assess her for injuries at this time, no redness no injuries noted. (Nurse Practitioner) notified of fall and nurse left message for her nephew to call facility when he gets the message. Vital signs completed; T (temperature):97.6, BP(blood pressure):142/89, P (pulse):76, R (respirations) :14, O2 (oxygen) Sat (saturations): 97% on room air. Staff will continue to monitor for 3 day on fall charting. d. 7/31/2019 09:54 (AM) Nursing Note Note Text: IDT (interdisciplinary) team met regarding residents recent fall. Social work, PT (physical therapy), nursing and administration present. Resident was found down by her room. Resident stated she felt dizzy and sat down on the floor. Resident was assessed by nurse and no injuries were noted. Resident is currently on OT (occupational therapy) Orthostatic BP to be completed the next three days. Will monitor. (NOTE: According to the Treatment Administration Record (TAR) for (MONTH) 2019, the orthostatic [MEDICAL CONDITION] blood pressures were signed off as being completed, however, the documented blood pressures for resident 41 were 8/2/2019 15:33 135 / 68, 8/3/2019 12:18 125 / 78, 8/3/2019 16:52 126 / 69, 8/3/2019 12:18 125 / 78. According to the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, the protocol for assessing for orthostatic [MEDICAL CONDITION] includes, have patient lie in bed with the head flat for a minimum of 3 minutes, and preferably 5 minutes. Measure the blood pressure and the pulse while the patient is supine. Instruct patient to sit up for 1 minute. Ask patient about dizziness, weakness, or visual changes associated with position change. Note diaphoresis or pallor. Check sitting blood pressure and pulse. If the patient has symptoms associated with position change or sitting blood pressure = 90/60, put patient back to bed. Instruct patient to stand. Ask patient about dizziness, weakness, or visual changes associated with position change. Note diaphoresis or pallor. If patient is unable to stand, sit patient upright with legs dangling over the edge of the bed. The patient should be permitted to resume a supine position immediately if [MEDICAL CONDITION] or near [MEDICAL CONDITION] develops. Measure the blood pressure and pulse immediately after patient has stood up, and then repeat the measurements 3 minutes after patient stands. Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement. The facility vital sign record should have had 3 separate blood pressure measurements with just minutes apart for three days. The facility documented blood pressures did not have a documented blood pressure on 8/1/19, one documented blood pressure on 8/2/19 and two documented blood pressures on 8/3/19 which were approximately 4 and 1/2 hours apart.) e. 8/18/2019 18:17 (6:17 PM) Nursing Note Note Text: Staff answered call light and found resident laying on her back on the floor next to her bed. Resident stated she was standing to go to the bathroom and she fell backwards. Resident denies hitting her head. Two staff members assisted resident up and she ambulated to the bathroom. Resident is able to move all extremities. No apparent injuries noted upon assessment. Neuro checks have been initiated and are at baseline for resident. Resident was wearing non-slip socks. Family called and message left. MD and supervisor notified. f. 8/19/2019 09:58 (AM) Nursing Note Note Text: IDT team met regarding residents recent fall. Social work, PT, nursing and administration present. Resident was found down in her room by her bed. Resident stated she was trying to walk to the restroom when she fell backwards. No injuries noted and resident denies hitting her head. Resident was helped to the restroom. Resident had non-slip footwear on. PT to eval (evaluate). Will monitor. g. 8/19/2019 13:17 (1:37 PM) Nursing Note Note Text: Resident is alert and oriented to self with confusion. Resident is complaining of left hand and left wrist pain s/p (status [REDACTED]. Resident received prn (as needed) pain med (medication) this am with positive effect. Resident took a nap after taking her pain meds. Left hand and left wrist are tender when touched. MD has been notified and order received for X-ray of the left hand and left wrist. (X-ray company) has been notified to perform x-ray. Resident is currently sitting in the dining room eating lunch. She's pleasant. h. 8/19/2019 22:33 (10:33 PM) Nursing Note (TRUNCATED)

Based on observation, interview and record review it was determined for 3 of 54 sample residents that the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, based on the comprehensive assessment. Specifically, a resident complained of pain in her ankle after a staff assisted fall and staff did not assess the resident's ankle through the night. In addition, the resident was not provided pain medication when she complained of pain. Another resident was not provided her pain medication according to physicians orders and another resident was not assessed after complaining of mouth pain. Resident identifiers: 39, 62 and 100. Findings include: 1. Resident 100 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/11/18 at 3:12 PM, an interview was conducted with Resident 100. Resident 100 stated that she sustained a fall which hurt her left leg and ankle. Resident 100 stated that she cried out in pain all night long. Resident 100 stated that her left leg and ankle hurt all night long. Resident 100 stated that a nurse provided her pain medication after she sustained the fall. On 9/12/18 at 10:55 AM, a follow up interview was conducted with resident 100. Resident 100 stated that she tried to sleep during the night but was unable to sleep. Resident 100 stated that she was not sure if the nurse offered to send her to the hospital but she would have agreed to go to the hospital because her pain was bad and was over an 8 all night. Resident 100 stated that she did not remember what happened in the hospital but she woke-up with a boot on her left ankle. Resident 100's medical record was reviewed on 9/10/18. An Emergency Documentation form dated 4/6/18 revealed, [AGE] year-old white female complains of left ankle pain. Probably she fell in the last 24 hours. She speaks in a whisper and is felt to be a poor historian. The form further revealed, .Patient was seen and examined for her fall. Her only injury is the left ankle. An x-ray showed a bimalleolar fracture and disruption of the talar mortise. The patient is totally nonweight bearing normally. I spoke with (name of physician) of orthopedics. Consultation was performed with (name of physician) mid-level who applied a posterior splint. It was (name of physicians) opinion the patient did not warrant admission since this is not surgical, and she will follow up in his clinic next week. According when a posterior splint was applied and the patient was discharged back to her care center. A physicians order dated 4/5/18 at 5:37 PM revealed L (left) ankle X-ray r/t (related to) pain from a transfer with assisted fall having 2 CNAs (Certified Nursing Assistant) at residents side. A physicians order dated 4/13/18 revealed, Resident is capable of understanding and exercising rights. The x-ray results revealed an exam date of 4/5/18 at 10:57 PM and was signed on 4/5/18 at 11:31 PM. The Impression revealed, Acute nondisplaced oblique distal fibular fracture as above. Resident 100's progress notes revealed the following entries: a. On 2/27/18 at 8:36 PM, .A&Ox3 (alert and oriented to person, place and date), able to make needs known. b. On 4/5/18 at 4:30 PM, At 1630 (4:30 PM), Res (resident) was given shower after returning from Neuro (neurology) appt. (appointment) 2 CNA's were transferring res from w/c (wheelchair) to bed when the res quit giving support with her legs. Res was assisted to the floor. Nurse called to examine res, L knee was found to be bruising, res was lifted to bed with hoyer lift. Res c/o (complained of) pain in L ankle at 1700 (5:00 PM), L ankle Xray ordered, pain meds (medications) given. c. On 4/6/18 at 9:01 AM, Orders rec'd (received) for ortho (orthopedic) or ER (emergency room ) visit r/t pain in ankle from fall with positive Xray fx (fracture). Res was sent to (local) ER at 0900 (9:00 AM) via (facility) transport. Daughter to meet her there. d. On 4/6/18 at 2:26 PM, Res returned from the (local) ER (emergency room ) with soft cast on LLE (left lower extremity), daughter at res side. Hoyer lift used to get res into bed. Res to have only bed baths during healing process. Called to make f/u (follow up) appt with (name of doctor).Res is now to only be transferred by Hoyer lift. e. On 9/13/18 at 11:07 AM, Resident is alert and oriented x 4, able to make need known. Resident 100's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 4/5/18 at 10:48 PM, [MEDICATION NAME] Tablet Given 650mg (milligrams) by mouth every 6 hours as needed for pain was administered. Facility Nurse documented resident's pain level was a 7 and the medication was ineffective. (Note: The pain level was on a pain scale of 0 to 10 with 0 representing no pain and 10 being excruciating pain.) b. On 4/6/18 at 3:32 AM, [MEDICATION NAME] HCL (hydrogen chloride) tablet 5 MG by mouth every 4 hours as needed for pain 1 to 2 tabs (tablets) q (every) 4 hours prn (as needed) pain. On 9/12/18 at 7:45 AM, an interview was conducted with CNA 12. CNA 12 stated that she gave resident 100 a shower on 4/5/18. CNA 12 stated that she wheeled resident 100 back to her room and pushed the call light to signal another aide to come help with transferring resident 100 into her bed. CNA 12 stated that her and another CNA were transferring resident 100 when resident 100's leg gave out and she fell to the floor twisting her ankle. CNA 12 stated that the nurse assessed resident 100 and then assisted her off the floor and into bed. CNA 12 stated that resident 100 complained of right knee pain. CNA 12 stated that she positioned resident 100 in her bed and left the room. CNA 12 stated that resident 100's call light was alarming about 5 to 10 minutes later. CNA 12 stated that she went into resident 100's room and resident 100 was complaining of pain to her left ankle. CNA 12 stated that she reported resident 100's pain to Registered Nurse (RN) 3. CNA 12 stated her shift ended and she left for the day and did not know if the nurse re-assessed resident 100's ankle. On 9/12/18 at 8:10 AM, an interview was conducted with RN 3. RN 3 stated that two CNAs were transferring resident 100 into bed from her wheelchair when resident 100's legs buckled and the CNAs lowered her to the floor. RN 3 stated that an X-Ray was obtained which revealed resident 100's ankle was fractured. RN 3 stated that she believed she administered pain medication because resident 100 complained her ankle hurt a little. RN 3 stated that she did not remember what pain medication she administered. RN 3 stated that any medications administered were documented in the MAR. RN 3 stated that since there was no documentation of pain medications administered, she must have not administered the pain medication. RN 3 stated that she assessed resident 100's ankle prior to moving her off the floor after the fall. RN 3 stated that resident 100 did not have tears so she must have not administered the medication. RN 3 stated that she sent resident 100 to the emergency room after she made rounds to her room between 8:00 AM and 9:00 AM on 4/6/18. RN 3 stated that she administered medications to other residents and did not get to resident 100's room until about 8:00 AM. RN 3 stated that resident 100 was sent to a local emergency room at about 9:00 AM. RN 3 stated that the X-ray order was obtained because she wanted to make sure everything was okay. RN 3 stated that she did not feel there was an indication that resident 100 had a fracture because there was no facial grimacing or any concern. On 9/12/18 at 12:49 PM, an interview was conducted via telephone with Agency RN 1. Agency RN 1 stated that the DON had called her to discuss resident 100 prior to our phone call. Agency RN 1 stated that she started her shift on 4/5/18 at about 10:00 PM. Agency RN 1 stated that she received a verbal report that resident 100 had sustained a fall earlier that day. Agency RN 1 stated that she remembered that resident 100 was crying when she came on shift. Agency RN 1 stated that resident 100 complained of pain in her leg or ankle. Agency RN 1 stated she administered Tylenol to resident 100 because she was complaining of pain. Agency RN 1 stated that the pain medication was ineffective because resident 100 did not calm down. Agency RN 1 stated that resident 100 slept for a little while and then woke up crying. Agency RN 1 stated that an x-ray was completed and the x-ray technician told her to watch for the x-ray results because her ankle was not looking good. Agency RN 1 stated that she obtained an order for [REDACTED]. Agency RN 1 stated that it took some time to get pain medications. Agency RN 1 stated that she faxed the x-ray results to the Physicians Assistant (PA) around 12:30 AM. Agency RN 1 stated that she had faxed the pain medication order to the pharmacy and had to leave a telephone message with the pharmacy. Agency RN 1 stated that the pharmacy faxed a code to her which allowed her to access the emergency kit (e-kit). Agency RN 1 stated that she then had to call and leave a message again with the pharmacy to get another code over the phone to open the e-kit. Agency RN 1 stated that she was unable to locate the e-kit in the facility. Agency RN 1 stated that she had to find another nurse in the facility to help her locate the e-kit. Agency RN 1 stated that resident 100 was yelling out when she woke up which indicated to her that resident 100 was in pain. Agency RN 1 stated that she felt resident 100's pain was excessive and did not seem okay. Agency RN 1 stated that resident 100 did not usually have pain because she only had orders for Tylenol to treat her pain. Agency RN 1 stated that the PA told her that if resident 100's pain was uncontrolled then to send her to the ER. Agency RN 1 stated that she did not send resident 100 to the ER that night because she calmed down after receiving the [MEDICATION NAME]. Agency RN 1 stated that she did not document her assessment of resident 100's ankle. On 9/12/18 at 7:00 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that resident 100 fell on [DATE] at 3:41 PM, had an x-ray obtained at 9:57 PM and the x-ray results were provided to facility on 4/6/18 at 12:30 PM. On 9/13/18 at 11:27 AM, an interview was conducted with DON. The DON stated she was not sure why resident 100 was not sent out prior to 9:00 AM on 4/6/18 after learning there was a fracture at 12:30 AM. On 9/13/18 at 1:24 PM, a follow up interview was conducted with the DON. The DON stated that the pharmacy received the faxed physicians order for [MEDICATION NAME] On 4/6/18 at 12:14 AM. The DON stated that the pharmacy provided the written code for the e-kit at 2:45 AM. The DON stated that there was a delay in obtaining the medication from the e-kit. The DON stated that resident was confused and had a decrease in cognition during that time and went back to the ER a week later. The DON stated she did not have additional information that resident 100 was assessed through the night after sustaining a fall and complaining of pain. On 9/13/18 at 2:53 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that resident 100 was having times of mental confusion but the nurses were documenting that she was alert and oriented times three around 4/5/18. The MD stated he was aware the resident 100 was in extreme pain the night of 4/5/18 and the agency nurse had documented that the Tylenol was not effective. The MD stated he felt her pain could have been managed at the facility verses the emergency room . The MD stated that there was an issue with nurses being able to access the [MEDICATION NAME] from the e-kit for several hours. The MD stated that it was problematic that the facility did not get pain medication timely. The MD stated that resident 100 was provided a soft boot in the ER which helped with her pain. 2. Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/10/18 at 8:08 AM, an interview was conducted with resident 62 related to her scheduled pain medication. Resident 62 stated that she was given half of her scheduled [MEDICATION NAME] that morning. Resident 62's medical record was reviewed on 9/12/18. On 8/17/18, a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documentation of resident 62's pain rating. A review of the controlled substance tracking log revealed that there was only one [MEDICATION NAME] film available for administration on the morning of 9/10/18. On 9/13/18 at 9:16 AM, an interview was conducted with the DON. The DON stated that there was no way for RN 1 to document that she administered [MEDICATION NAME] 1 film as opposed to the ordered 2 films. The DON was unable to provide additional information as to why the [MEDICATION NAME], two films were not available for administration and why resident 62's pain level was not assessed or documented. 3. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/11/18 at 10:30 AM, resident 39 was observed calling out for staff. Resident 39 stated that she had pain. On 9/12/18 at 9:32 AM, resident 39 stated that she had mouth and throat pain. Resident 39 stated that she was unable to eat breakfast. On 9/12/18 at 9:33 AM, CNA 4 stated to resident 39 that she would get resident 39 some tea and tell the nurse about the pain complaint. On 9/12/18 at 9:41 AM, resident 39 was observed to receive tea from another CNA. There was no observation of a nurse evaluating resident 39 at this time. On 9/12/18 at 9:51 AM, resident 39 was observed calling out. CNA 4 was observed looking into resident 39's room, but did not enter. On 9/13/18 at 8:02 AM, resident 39 was observed calling out for assistance. Resident 39 stated that her mouth hurt. On 9/13/18, a record review was completed. Resident 39 was prescribed Fluconazole on 2/6/18, with instructions that stated: Give 100 milligrams (mg) by mouth one time a day starting on the 7th and ending on the 16th of every month for yeast take for 10 days every month. On 9/11/18 at 10:38 AM an interview was conducted with CNA 4. CNA 4 stated that resident 39 doesn't complain about any pain. On 9/11/18 at 10:43 AM, an interview was conducted with CNA 8. CNA 8 stated that resident 39 forgets that she had medication. CNA 8 stated that even if resident 39 just had pain medication, resident 39 will ask for more. On 9/13/18 at 8:04 AM, an interview was conducted with CNA 4. CNA 4 reported that she didn't remember resident 39 complaining of pain. CNA 4 stated that she did not report pain for resident 39 to the nurse. On 9/13/18 at 8:06 AM, RN 2 was interviewed. RN 2 stated that she was unaware of resident 39 complaining about mouth pain. RN 2 stated that resident 39 has a history of thrush. RN 2 stated that resident 39 had a history of [REDACTED]. RN 2 stated that resident 39 had requested salt water on Wednesday but did not tell the nurse why. RN 2 stated that she would follow up with resident 39 and the doctor. On 9/13/18 at 10:02 AM, DON was interviewed. The DON stated that she was aware of a history of thrush for resident 39. The DON stated that the unit nurse was responsible to evaluate the resident's reported pain.

Based on interview and record review it was determined, for 1 of 29 sample residents, that the facility did not ensure that each resident's environment remained as free from accident hazards as was possible or provide adequate supervision and assistance devices to prevent accidents. Specifically, a resident was not evaluated per facility policy for safe smoking, was not provided protective devices for smoking, nor was she adequately supervised while smoking resulting in burns on her chest and breasts. The deficient practice identified for the resident was found to have occurred at a Harm Level. Resident identifier: 4. Findings include: HARM Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 9:30 AM, an observation was made of resident 4 smoking alone and unsupervised outside the west doors of the facility. Resident 4 was observed without a smoking apron. Resident 4 could not state what the smoking policy was for the facility. Resident 4 stated that some residents need to be supervised but she did not. On 9/26/17 at 8:30 AM, an observation was made of resident 4 smoking without a smoking apron outside the west doors of the facility. Certified Nurses Assistant (CNA) 3 was observed outside with resident 4. While resident 4 continued to smoke CNA 3 returned into the facility. On 9/26/17 resident 4's medical records were reviewed. A medical order dated 3/14/17 revealed, resident to wear smoking apron every time she goes out to smoke. Staff to monitor and document for compliance each shift. Resident 4's Monitoring record indicated staff verified use and placement of a smoking apron on 9/25/17 and 9/26/17. On 9/26/17 at 10:30 AM, an interview was conducted with resident 4. Resident 4 stated she used a smoking apron when she smoked. Resident 4 stated she had not used a smoking apron on 9/25/17 and 9/26/17 because it was in the wash. Resident 4 stated that she had burned herself while smoking in the past at the facility. Resident 4 stated she did not have a smoking apron at the time of her past smoking injury. On 9/26/17 at 2:20 PM, an interview was conducted with CNA 3. CNA 3 stated that some residents required supervision while smoking, some were independent, and some wore 'bibs'. CNA 3 stated, I don't know for sure if (resident 4) is required to wear a bib while smoking. She has one and sometimes won't wear it. A review of resident 4's progress notes revealed the following: On 3/18/17 at 8:56 PM, Another resident came to this nurse and stated that (resident) caught her clothes on fire. this nurse went to smoking area outside and found resident sitting in wheelchiar (sic) with her robe top down and her bra smoking. quickly assisted her to remove bra and then called for aide for assistance. Obtained another robe and covered her up. Another floor nurse was alerted and came out to assist. Bra was placed on the blacktop and extinguished with water. No flames erupted. Resident was then taken inside and assessed for injuries. (Nurse Practitioner) notified and ordered dressing of neosporin and dry dressing applied. (Director of Nursing) notified and (resident) must be monitored while smoking from now on. A review of resident 4's Plan of Care revealed the following: (Resident) is a smoker. She requires a smoking apron when she goes out to smoke. Resident often refuses to wear the apron. Instruct (resident) about the facility policy on smoking: locations, times, safety concerns. date initiated 3/24/17. (Note: The smoking plan of care and the order for a smoking apron was not initiated until 3/24/17, 6 days after resident 4 experienced an injury while smoking.) A review of the the facility Smoking Safety Guideline revealed the following: Upon admission, facility residents that smoke will be evaluated for their ability to smoke safely. This evaluation will be completed for residents on a quarterly basis and as needed to ensure their continued safety . The Nursing department/Activities designee will manage and distribute smoking materials and supervise residents whose evaluation has demonstrated the need or who have demonstrated unsafe smoking practices upon staff observation. Facility staff will ensure appropriate supervision is provided . The (Director of Nursing)/Designee and the (Interdisciplinary Team) will review the resident's Smoking Safety Evaluation and care plan and implement interventions as required. A review of resident 4's record revealed a Smoking Screen dated 8/18/2017 which revealed, (Interdisciplinary Team) Decision . (resident) is a smoker. She requires a smoking apron when she goes out to smoke . Instruct (resident) about the facility policy on smoking: locations, times, safety concerns . Protective gear was given and demonstrated to the resident. (Note: There was no other recorded Smoking Screen for resident 4.) A further review of resident 4's progress notes revealed the following: On 9/7/17 at 12:00 PM, Nurse went into resident's room and saw multiple half smoked cigarettes and cigarette butts on the floor in her room and her oxygen concentrator was on. Cigarettes cleaned up and notified unit manager and social worker. Resident will at times go out to smoke and forget her smoking apron and will at times fall asleep while smoking and is at risk of burning herself. Will continue to monitor. On 9/26/17 at 6:00 PM, (Interdisciplinary Team members: (Director of Nursing), (Administrator), (resident) and (resident's daughter). Resident had a new smoking assessment completed. Resident deemed safe to smoke with supervision while wearing smoking apron. (Resident's daughter) and resident notified of assessment results. Both were notified of the change to plan of care requiring resident to be a supervised smoker. Resident and (resident's daughter) agreed to the new plan of care. Resident agreed to give all smoking paraphernalia to nurse. Resident aware that when she wants to smoke, staff will take her outside to smoke. Currently, resident does not have any cigarettes. Resident said a friend brings cigarettes in for her. Resident agreed to have friend give cigarettes to nurse when the friend brings them in. Due to the fact that resident does not have cigarettes, offered to ask (Medical Director) for a nicotine patch. Resident denied. She did not want a nicotine patch. Ombudsman notified of new plan of care. (Note: Interdisciplinary Team meeting occurred during state survey after an investigation regarding smoking safety for resident 4 commenced.) On 9/27/17 at 3:11 AM, an interview was conducted with CNA 4. CNA 4 stated, I think (resident)'s cigarettes were taken from her today because she wasn't using her apron. She should be supervised while smoking, she's more confused lately. Right now she is set up only for smoking (no supervision). On 9/27/17 at 8:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that evaluations for safe smoking are required as per facility policy, quarterly. The DON confirmed that a plan of care for safe smoking had not been initiated for the resident until 3/24/17 (6 days after resident 4's smoking injury). The DON confirmed that a safe smoking evaluation was not performed until 8/18/17 (5 months after resident 4's smoking injury). The DON stated that an evaluation and assessment should have been made of resident 4 regarding safe smoking immediately after the incident. The DON stated that if resident 4 did not have an apron available that she would get another apron as soon as possible and provide supervised smoking until an apron was available. The DON stated on 9/26/17 an Interdisciplinary Team meeting occurred for resident 4 and she was deemed safe to smoke with an apron and supervision and that resident 4 could smoke anytime she liked under those conditions. The DON could not provide any Smoking Screens for resident 4 other than the screen performed on 8/18/17. The DON was unable to explain why resident 4 had not been evaluated for safe smoking prior to 8/18/17. The DON was not able to explain why resident 4 did not have a plan for safe smoking prior to her smoking injury on 3/24/17.

Based on observation, interview, and record review it was determined, for 2 of 29 sample residents, that the facility did not provide each resident with the care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. Specifically, facility staff failed to get additional orders for medication to treat a resident's uncontrolled pain and facility staff did not coordinate care with the [MEDICAL TREATMENT] center in regards to a resident's order for a fluid restriction. Resident identifiers: 47 and 179. HARM Findings Include: 1. On 9/25/17 at 1:15 PM, resident 179 was interviewed. Resident 179 stated that he was admitted to the facility on Friday, 9/22/17. Resident 179 stated that upon admission he had told facility staff that the pain medication ordered by the hospital was not going to be adequate to control his pain. Resident 179's spouse was in the room at the time of the interview and stated that she had expressed the same concern to the staff, on admission, and also reported that resident 179 could not take the [MEDICATION NAME] that had been ordered. Resident 179's spouse stated that they (her and resident 179) were told by staff that resident 179 would need to wait 72 hours before resident 179 could be seen by the physician. Resident 179 began to cry and stated that he had had a terrible weekend as he had been in pain and he had been requesting the pain medication every four hours to try and get some relief. Resident 179 stated that he had seen the MD (Medical Doctor) today, 9/25/17, and the doctor had ordered an increase in his pain medication. Resident 179's spouse stated that the pain medication had been changed to [MEDICATION NAME] 10 mg (milligram) tablets with the option to take two 10 mg tablets every four hours and that the Tylenol had been taken out of the prescription because the doctor was worried that resident 179 was taking too much Tylenol. Resident 179's spouse stated that she had received calls from resident 179 over the weekend and that resident 179 had been crying due to pain. Observations of resident 179 during the interview revealed that resident 179 was crying, was restless, was grimacing, and making frequent position changes. On 9/25/17 at 1:40 PM, resident 179 was observed to tell a facility Certified Nursing Assistant (CNA) that he needed pain medication. On 9/25/17 at 1:45 PM, the facility CNA was observed to report to Registered Nurse (RN) 4 that resident 179 had requested pain medication. On 9/25/17 at 2:00 PM, resident 179 was interviewed. Resident 179 stated that he had received two 7.5 mg [MEDICATION NAME] at 1:50 PM. Resident 179 stated that he did not know why he had not received the increased dose of pain medication. On 9/25/17, resident 179's medical record was reviewed. Review of the admission orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During resident 179's interview with the surveyor, resident 179 was observed to request pain medication at 1:40 PM. No observations were made of facility staff administering pain medication at 1:20 PM. On 9/25/17 at 2:20 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that the facility did have an Emergency medication Kit (E kit) that contained pain medications. The DON stated that if the staff received an order for [REDACTED]. The DON further stated that the staff should be signing out the medications when they were administered and not thirty minutes before administration. On 9/25/17 at 2:35 PM, the facility Medical Director was interviewed. The Medical Director stated that he was not on call over the weekend. The Medical Director refused to answer what his expectation was regarding staff notifying him if the resident's pain was not controlled. On 9/25/17 at 2:46 PM, the Medical Doctor (MD) 2, that was on call over the weekend for 9/23 - 9/24/17, was interviewed via telephone. MD 2 stated that he had received a text on 9/22/17 regarding resident 179. MD 2 stated that the facility had texted that resident 179 had reported that the pain medication ordered from the hospital was not going to be efficient and that resident 179 could not take [MEDICATION NAME]. MD 2 stated that he had told facility staff that he would be in on Saturday to see resident 179 or resident 179 could be seen on Monday. MD 2 stated that since resident 179 had just been admitted he had instructed the staff to watch resident 179 and give the current ordered dose a chance to see if it was an adequate dose. MD 2 stated that if the dose ordered was not controlling resident 179's pain by the next day, he would have expected the facility staff to call him back. MD 2 stated that he felt bad that resident 179 had been in pain all weekend. MD 2 stated that he believed the Medical Director had increased resident 179's pain medication that day, 9/25/17. MD 2 stated that he had received no other calls from facility staff regarding resident 179 except the text message on 9/22/17. Review of the physician's orders [REDACTED]. On 9/25/17 at 3:00 PM, RN 4 was interviewed. RN 4 stated that he had administered two 7.5 mg [MEDICATION NAME] to resident 179 at 1:50 PM. RN 4 stated that he did not think about pulling the increased dose from the E kit. RN 4 confirmed that he had administered the lesser dose to resident 179. On 9/26/17 at 7:40 AM, resident 179 was interviewed. Resident 179 stated that he had received the increased dose of pain medication last night, 9/25/17, and that he had finally slept. Resident 179 stated that the increased dose was better controlling his pain. Review of resident 179's medical record revealed the following progress notes: a. 9/22/17 - Res (resident) arrived at 1730 (5:30 PM) via Avalon transport on a gurney. Res is alert and oriented X 3, able to make needs known. Res here post Lumbar fusion, wound healing and strengthening. Res stated pain med (medication) ordered will not be enough, and refuses to take [MEDICATION NAME] r/t (related to) giving him an increase in spasms, res uses [MEDICATION NAME] instead, need house Dr. to examine res and order med. b. 9/24/17 - . Meds given as ordered, whole with water. PRN (as needed) meds given the max amount Q (every) 4 hrs (hours) and res states he needs more, Dr contacted to review meds. No documentation could be found to show that the facility staff contacted the physician on 9/22/17 or 9/24/17. Review of the MAR indicated [REDACTED]. Additionally, facility staff were documenting E for effective regarding the effectiveness of the dose administered. Review of the Progress Notes revealed that facility staff documented that on 9/23/17 at 1:43 am, resident 179 received a dose of the 7.5 mg [MEDICATION NAME]. Staff documented the dose was effective at 1:53 AM. On 9/23/17 at 12:00 PM, facility staff documented that resident 179 had received two 7.5 mg [MEDICATION NAME]. Staff documented at 12:01 PM, that the dose was effective. On 9/23/17 at 16:39 (4:43 PM), facility staff documented that resident 179 had received two 7.5 mg [MEDICATION NAME]. Staff documented at 16:54 (4:54 PM), that the dose was effective. According to documentation, facility staff were waiting between 1 - 15 minutes to document the effectiveness of the pain medication received without a post pain score. On 9/26/17 at 2:00 PM, the facility Director of Nursing was re-interviewed. The DON stated that facility staff should be documenting a pre and post pain score. The DON stated that facility staff should not be documenting effective after administering pain medication but should be obtaining a number between 1-10 to determine a pain level. The DON stated that facility staff should be obtaining the post pain score 30 minutes to an hour after the administration of the pain medication. On 9/26/17 at 2:20 PM, RN 4 was interviewed. RN 4 stated that he would obtain a pre pain score and would wait 30 minutes to an hour after administration and obtain a post pain score. RN 4 stated that he knew on Friday night that resident 179 had stated that the ordered pain medication was not going to be adequate for pain control RN 4 stated that he was told in report on Monday morning, 9/25/17, that resident 179 needed an increase in his pain medication because the current dose was not controlling his pain. RN 4 stated that he was not sure why facility staff had not called the MD over the weekend to get an increase to resident 179's pain medication. RN 4 stated that, It seemed to have slipped through the cracks over the weekend. RN 4 stated that the increased dose of pain medication seemed to be controlling resident 179's pain more effectively. 2. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/26/17, resident 47's medical record was reviewed. A review of the physician's orders [REDACTED].) A review of the facility's [MEDICAL TREATMENT] communication sheets revealed the following recommendations from resident 47's [MEDICAL TREATMENT] center: a. On 6/19/17, (Please) monitor and limit pt (patient) fluid intake. Pt gain 8.7 kg (kilograms) from last wt (weight) post [MEDICAL TREATMENT] tx (treatment). b. On 6/26/17, Keep watching pt fluid intake. c. On 6/28/17, Continue monitoring fluid intake. On 9/27/17 at 7:42 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that the facility received orders from resident 47's [MEDICAL TREATMENT] center via phone call or via a [MEDICAL TREATMENT] communication sheet. RN 2 stated that the nurses were responsible for documenting and limiting fluid intake during medication administration. RN 2 stated that Certified Nursing Assistants (CNAs) were responsible for documenting fluid intake outside of medication administration. RN 2 stated that she was aware of a fluid restriction for resident 47, but that she was not aware of a specified fluid limit for resident 47. RN 2 further stated that she was concerned that the fluid limit had not been clarified with resident 47's [MEDICAL TREATMENT] center. On 9/27/17 at 8:15 AM, CNA 2 was interviewed. CNA 2 stated that there was not a fluid restriction for resident 47. CNA 2 stated that the CNAs were responsible for documenting the fluid intake of the residents, however, the kitchen was solely responsible for limiting fluid intake at meals. CNA 2 stated that the CNAs had not been provided with direction from any of the RNs or from the Director of Nursing (DON) to limit resident 47's fluid intake. On 9/27/17 at 8:33 AM, CNA 3 was interviewed. CNA 3 stated that she wasn't aware of a fluid restriction for resident 47. CNA 3 stated that the nurse and the dietitian would be responsible for monitoring fluid intake for the resident. When asked by the surveyor if the CNAs charted on intake of bedside water and fluid at meals, CNA 3 confirmed that the CNAs were responsible for documenting these intakes. On 9/27/17 at approximately 8:40 AM, the DON was interviewed. The DON stated that she would expect staff to call the resident's [MEDICAL TREATMENT] center to clarify the order for the fluid restriction. The DON stated that she was concerned that the order had not been clarified.