Every finding on record at Newcastle Place

Based on observation, staff interview, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 38 residents residing in the facility. Hand hygiene was not appropriately completed during dishwashing.Food temperatures were not consistently completed.The facility did not have logs for the 3-compartment sink and sanitizing buckets. Bowls in the kitchen were not stored upside down or covered. The stove was not thoroughly cleaned.Findings include:On 5/18/26 at 9:35 AM, Surveyor completed an initial kitchen tour. During the tour, Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code.Hand Hygiene:The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (E) After handling soiled equipment or utensils . On 5/18/26 at 10:30 AM, Surveyor observed Dietary Aid (DA)-F wash dishes. DA-F put dishes away on the clean side, walked to the dirty side, grabbed the sprayer, and pushed a rack of trays through the dishwasher. DA-F then walked to the clean side and removed clean plate covers from a rack to put away. DA-F did not complete hand hygiene when going from dirty to clean. DM-D was informed of the observation and acknowledged hand hygiene should have been completed. Temperatures/Logs: The Wisconsin Food Code documents at 1-106.14 Conformance with Approved Variance and HACCP Plan Procedures: (B) Maintain and provide to the regulatory authority or the department upon request, records specified under section 1-106.12 that demonstrate that the following are routinely employed: (1) Procedure for monitoring the critical control points; (2) Monitoring of the critical control points. The facility's Food Service Temperatures policy, revised 4/14/20, indicates: Team members setting up the service line and serving food must follow these procedures .4. Record the temperatures on the temperature log. During the initial kitchen tour on 5/18/26, Surveyor requested to see the facility's food temperature logs. Surveyor reviewed the May 2026 log from 5/1/26 through 5/17/26 and noted the following:~ 5/1/26: There were no breakfast temperatures; 5/2/26: There were no supper temperatures; 5/4/26: There were no lunch or dinner temperatures; 5/5/26: There were no temperatures for any of the meals; 5/6/26: There were no cooking temperatures; 5/7/26: There were no lunch or dinner temperatures. Surveyor noted each day's packet was at least 15 pages long and had pages of items with no temperatures. During an interview with DM-D, DM-D stated the list contained all of the ingredients and temperatures were only completed for food items served.The Wisconsin Food Code documents at Chemical Sanitizer Section 3-3014.14 Wiping Cloths, Use Limitation: Clothes in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 The Wisconsin Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified shall meet the criteria specified in S 7-204.11 sanitizers. Criteria, shall be used in accordance with the EPA-registered label use instructions . During the initial kitchen tour on 5/8/26, Surveyor asked if there were logs for the sanitizing buckets and the 3-compartment sink. DM-D could not find the logs and asked DA-F who indicated there weren't any. DM-D acknowledged there should be logs.Bowls: The Wisconsin Food Code documentas at 3-305.11 Food Storage: Food shall be protected from contamination by storing the food: (2) Where it is not exposed to splash, dust, or other contamination . During the initial kitchen tour on 5/18/26, Surveyor observed 2 bins of soup bowls on a shelf. The bowls were haphazardly placed in the bin. Some of the soup bowls were facing upward and were not covered. DM-D acknowledged the bowls should be covered. Equipment: The Wisconsin Food Code documents at 4 601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. During the initial kitchen tour on 5/18/26, Surveyor observed the inside of the oven. The bottom of the oven contained black crusted build-up. The facility did not have a cleaning log. Chef (CHF)-F indicated the oven probably had not been cleaned over the weekend.

Based on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable and appetizing temperature for 2 residents (R) (R3 and R68) of 3 sampled residents. On 5/18/26, R3 and R68 indicated lunch was served at room temperature and their meals were often not hot. An insulated cart and/or thermal plate warmers were not used to deliver meal trays to R3 and R68's unit. Findings include:Between 5/18/26 and 5/20/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE]. R3's Minimum Data Set (MDS) assessment, dated 4/28/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.Between 5/18/26 and 5/20/26, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE]. R68's MDS assessment, dated 5/12/26, had a BIMS score of 15 out of 15, indicating intact cognition.On 5/18/26 at 11:36 AM, Surveyor observed [NAME] (CK)-C temp food in the steamtable for lunch service. The menu was pot roast, fish, mashed potatoes, green beans, creamed spinach, veggie soup, and cauliflower cheese soup. All food holding temperatures met the standards at that time.On 5/18/26 at 11:51 AM, CK-C started to plate food for R3 and R68's wing. Surveyor noted insulated plate bottoms were not used and resident meal trays for the wing were placed on an open 4-wheel cart. There was not an insulated cart for food delivery and all residents ate in their rooms.On 5/18/26 at 12:01 PM, the cart for R3 and R68's wing left the kitchen.On 5/18/26 at 12:19 PM, Surveyor observed R3 receive the last tray on the cart.On 5/18/26 at 12:20 PM, Surveyor interviewed R68 whose room was at the end of the hallway. R68 was the second to last resident to receive a meal tray. R68 indicated R68's meal was barely warm. R68 indicated meals often are not hot when served, especially breakfast. On 5/18/26 at 12:21 PM, Surveyor interviewed R3 whose room was also at the end of the hallway. R3 was the last resident on the wing to receive a meal tray. R3 indicated R3's food was room temperature. R3 indicated food often isn't hot when it is received. On 5/18/26 at 2:11 PM, Surveyor interviewed DM-D and shared the observation that CK-C did not use insulated bottoms and an insulated cart was not available for staff to help with temperature control. Surveyor also informed DM-D there was approximately 28 minutes betweeen the time the first and last trays were served on the unit and if food was not held hot, there was potential for it to become cold. At that time, CK-E entered the room and stated staff had been asking for an insulated cart to help with food temperature control on the unit and it would be helpful to have one.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R) reviewed for accidents (R3, R5, R8, and R7.) R3's and R5's examples rise to the severity/scope level of G. *R3 was admitted to the facility on [DATE]. On 12/24/25, facility staff assessed R3 to be at high risk for falls. Facility staff did not initiate resident specific fall interventions for R3. According to facility staff, R3 was confused and wandering during the overnight shift. On 12/25/25 at 6:45 AM, R3 was found lying on the floor in R3's room. R3 was sent to emergency room and diagnosed with bilateral (both sides) subarachnoid hemorrhage (bleeding into the space surrounding the brain) and a displaced fracture of left clavicle (broken collarbone that is out of alignment.) R3's fall was not thoroughly investigated by the facility to determine an accurate root cause. *R5 sustained a burn from hot soup served by facility staff. Facility staff did not complete a hot liquid assessment prior to R5 sustaining the burn. Surveyor observed R5 without R5's hot liquid and fall care plan interventions in place. *R8, who was assessed to be at high risk for falls, fell on [DATE]. R8's fall was not thoroughly investigated by the facility to determine a root cause. Surveyor observed R8 without R8's fall prevention care plan interventions in place. *R7 fell on 4/6/26 and the fall was not thoroughly investigated by the facility to determine a root cause. Surveyor observed R7 without R7's fall care plan intervention in place. Findings include: The facility policy titled Fall Mitigation Program with a last revision date of 1/23/26 documents in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . For program identification purposes, the community utilizes high risk and at risk, using scoring method designated on the risk evaluation. Upon admission, the nurse will complete a fall-risk evaluation along with the admission assessment to determine the resident's level of fall risk. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk . High risk residents suggested interventions include but not limited to: . Indicate fall risk on care plan. May implement interventions from At Risk suggested interventions as appropriate . Provide additional interventions as directed by the resident's evaluation, including but limited to: Assistive devices, Increased frequency of rounds, Sitter-if indicated, Medication regimen review, Low bed, Alternate call system access, Scheduled ambulation or toileting assistance . Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. When any resident experiences a fall, the community will: Assess the resident. Complete a post-fall evaluation and continue monitoring for 72 hours. Complete an incident report. Notify physician and family. Review the resident's care plan and update as indicated. Document all assessments and actions. Obtain witness statements (if any) in the case of injury. 1.) R3 was admitted to the facility on [DATE] with diagnoses including Sleep behavior disorder, Stage 3 chronic kidney disease (moderate kidney damage,) and Parkinson's disease. R3's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents: R3 is Independent to make decisions regarding tasks of daily life. R3 uses a walker. R3 requires substantial/maximum assistance for toileting. R3 is frequently incontinent urine. R3 had a fall in the last month. R3 had a fall in the last 2 to 6 months. R3 did not sustain an injury with these previous falls. R3 had a fall since being admitted at the facility. R3 has had a fall with injury since being admitted at the facility. Surveyor noted staff did not attempt a transfer, so transfer assistance required was not assessed or documented on R3's MDS assessment. R3's Hospital Discharge summary dated [DATE] documents in part: Final Discharge diagnoses: Syncope orthostatic hypotension (A sudden drop in blood pressure upon standing, causing dizziness, lightheadedness, or fainting,) thrombocytopenia and acute on chronic heart failure. Hospital Course: [R3] presented with episodes of loss of consciousness associated with rigidity and jerking, always preceded by prodromal dizziness and occurring upon standing. Initial workup included CT head, which showed no acute intracranial pathology . The principal problem during this admission was symptomatic orthostatic hypotension, likely multifactorial in the setting of cardiac amyloidosis (rare and serious condition where abnormal proteins deposit in the heart muscle making the heart stiff and thick) with autonomic dysfunction. [R3's] hospital course was complicated by acute, severe thrombocytopenia following recent heparin exposure during [cardiac] catheterization . Anticoagulation and aspirin were held due to thrombocytopenia . Therapy assessments revealed significant decline in functional status compared to baseline, with ongoing needs for maximal assistance with bed mobility, transfers and ambulation due to orthostatic symptoms, generalized weakness, and Parkinsonism. Surveyor noted R3 was admitted to the facility and has multiple risk factors, history of falls and syncope, orthostatic hypotension, and a significant decline in functional status which contribute to R3's high risk for falls. Surveyor noted R3's therapy assessment completed at the hospital documents R3 requires maximal assistance with transfers and ambulation. Surveyor reviewed R3's Electronic Medical Record (EMR) and noted the facility did not document R3's transfer status on admission. R3's admission blood pressure taken at 3:26 PM, documented 88/49. Surveyor noted a normal blood pressure for adults is defined as less than 120/80. (National Heart, Lung, and Blood Institute: Blood Pressure Reading, July 12, 2018.) Surveyor noted R3's hypotension continued from the hospital, which contribute to R3's high risk for falls. R3's clinical admission assessment dated [DATE] at 3:23 PM, documents in part: . Resident follows commands . Alert and oriented x 3. Oriented to person. Oriented to place. Level of cognitive impairment: Alert (some forgetfulness.) Resident is coherent. Speech is clear . Mental status note: does have episodes of confusion per [family member] when having hypotensive episodes. Mood is pleasant, no unwanted behaviors witnessed. Resident sleeps intermittently. Resident does not wander at night. Safety: The resident had a fall prior to admission/entry or reentry. The resident had a fall in the last 2-6 months prior to admission/entry or reentry . Call light is within reach . Gait is unsteady. Surveyor noted facility staff documented R3 has some forgetfulness, has episodes of confusion with hypotension, has had previous falls, and has an unsteady gait. Surveyor noted all of these put R3 at risk for falls. Surveyor noted facility staff documented R3's call light was within reach in the admission assessment. R3's Fall risk evaluation dated 12/24/25 at 3:19 PM, documents in part: Level of consciousness/mental status-intermittent confusion. Resident is chairbound/incontinent . Predisposing disease: 3 or more present. Resident had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: admitted to [hospital on] 12-18 with falls and hypotensive episodes. Gait/balance: N/A (not applicable) - not able to perform function. Medication: Takes 3-4 these medications (or medication classes) currently and/or within last 7 days. Fall Risk Score: 21. Surveyor noted R3's Fall risk score is 21. Surveyor noted on the Fall risk evaluation form is documented: . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Surveyor reviewed R3's EMR and noted R3 did not have a high risk for falls care plan initiated after scoring high on the fall risk evaluation. On 4/20/26 at 3:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked what the expectation is for care planning when a resident is admitted to the facility. NHA-A indicated the baseline care plan needs to be completed within 72 hours of admission. DON-B stated the facility also completes the admission assessment and that document has care plan triggers that can be initiated and will show up in the care plan. Surveyor reviewed R3's clinical admission assessment for care plan interventions documented. Surveyor noted facility staff did not initiate any care plan interventions from the admission assessment. R3's progress note dated 12/24/2025 at 11:16 PM documents in part: At 2200 (10:00 PM), [R3] noted with Seizure like activity and unresponsiveness . lasted 10-12 seconds, unresponsiveness > (greater than) 8 minutes waiting for 911 to arrive. [R3] breathing normally able to obtain vitals . [temperature] 98.0, [heart rate] 96, [respiratory rate] 21, [blood pressure] 116/55, [oxygen level] 97% [room air]. [R3] slowly began to move and speak however slow to speak and alert and oriented X (times) 2 with confusion. [R3] refusing to let 911 assess. [R3] is own person and continues to refuse. Writer updated on call MD . no new orders. Surveyor noted R3 had an episode of seizure-like activity which R3 had been experiencing at the hospital prior to being admitted to the facility. Surveyor noted facility staff documented R3 had confusion after this episode. On 4/21/26 at 12:48 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-P, who worked the night of 12/24 into 12/25/25. CNA-P stated at the beginning of the shift, EMS (Emergency Medical Services) was at the facility trying to evaluate R3 who was refusing to be evaluated. R3 refused transport to the hospital multiple times. CNA-P stated EMS left the facility and R3 remained. CNA-P stated R3 was confused after the incident. CNA-P stated R3 was wandering the unit hall and had to be redirected into R3's room. CNA-P stated eventually R3 fell asleep. CNA-P stated at the change of shift, CNA-P told the oncoming CNA to keep an eye on R3 because R3 was wandering and confused. Surveyor noted staff recalled after R3 experienced the seizure-like activity, R3 was found wandering and confused. Surveyor noted this would contribute to R3's high fall risk. R3's progress note signed by Licensed Practical Nurse (LPN)-M and dated 12/25/25 at 10:37 AM, documents in part: Writer found [R3] at [approximately 6:45 AM] on floor in room, large amount of blood noted around face and head with large hematoma forming above left eye. [R3] was awake and responding appropriately, stated [R3] was dizzy. Head stabilized, neuro checks and vitals done with initial [blood pressure] at 78/40. [Range of motion evaluated] and [within normal limits (wnl)]. [R3] was able to easily sit onto buttock and then stand with one assist and take two steps onto bed. [R3] placed on back and legs elevated. [Blood pressure] rechecked and now at 114/69. neuro checks again wnl and [R3] continues to respond appropriately however began to have twitching. Writer called ambulance transport to send to ER for [evaluation due to] recent [history] of low platelets (blood thinners currently on hold) and obvious head trauma. Hematoma cleansed while in bed and laceration noted above left eye, which was only oozing, blood-clotting, cold cloth applied for swelling. Also noted 3 skin tears to back of left hand . Ambulance here at approx. [7:30 AM] and transferred to [hospital]. R3's Hospital Emergency Department note dated 12/25/25, documents in part: . Unfortunately, during the night, [R3] had an unwitnessed fall where [R3] suffered injuries to [R3's] left orbit, left shoulder, and left hand. It is unknown whether [R3] had any loss of consciousness. [R3] was found this morning by staff and sent to the emergency department for evaluation . Radiology results: Xray Shoulder Left Impression - . Displaced fracture of left clavicle acromial end . CT (Computed Tomography) head impression - . Multifocal subarachnoid hemorrhage over right greater than left bilateral frontal and temporal lobes . [R3's] CT scan has been discussed with radiology. [R3] has bilateral subdural hematomas . Case has been discussed with [outside hospital]. [MD] from neuro ICU has evaluated [R3's] pictures . [R3] will be transferred . R3's progress note dated 12/25/25 at 12:26 PM, documents in part: writer called . [Emergency Department] for update. Per RN (Registered Nurse), [R3] is currently in ED awaiting transport to [outside hospital] for brain bleed . Surveyor noted R3 was transferred to an outside hospital for continued care of R3's injuries. R3's risk management (investigation) for fall dated 12/25/25 at 6:50 AM, documents in part: Found [R3] on right side in fetal position on floor between foot of bed and bathroom door. Large hematoma forming above left eye and blood covering face and floor. [R3] was awake and responding . Noted that urinal with urine was spilled on floor between bed and doorway and bedside table had been pushed into bathroom doorway. [R3] was in bare feet (slippers noted on floor next to him). Call light was not engaged . Resident description, I don't really remember what I was doing, I am dizzy. Mental status: Oriented to person, situation and time . Other info: Spilled urine noted on floor from urinal however puddle was not near resident and did not appear [R3] had stepped or slipped on puddle . No statements found. Surveyor noted R3 fell less than 24 hours after admission to the facility. Surveyor noted the investigation into R3's fall did not include when R3 was last seen and what R3 was doing the last time R3 was seen by facility staff. Surveyor noted the facility investigation did not include the last time R3 was assisted to the toilet or changed by staff. Surveyor noted facility staff did not collect statements from the previous shift to answer some of these questions. R3's Interdisciplinary Team (IDT) note dated 12/26/25 at 10:29 AM, documents: IDT team met to review 12/25/25 fall. Investigation reveals resident was self-transferring and/or slipped out of bed while utilizing urinal. Care plan was followed at time of fall. In so far as resident was transferred to acute care facility, care plan will be updated if resident returns - for [every 2 hours bowel and bladder] rounding and grippy socks. Surveyor noted the IDT team was uncertain of the root cause for R3's fall and documented R3 was either self-transferring and/or slipped out of bed. Surveyor noted the IDT team documented R3's care plan was followed at time of fall. Surveyor noted R3 did not have a fall care plan at the time of R3's fall. On 4/21/26 at 8:32 AM, Surveyor interviewed LPN-M, who was the nurse who found R3 on the floor. LPN-M stated LPN-M starts work at 6:30 AM and was completing first rounds when LPN-M found R3 on his room floor. LPN-M stated the bed was in a low position and R3 was found on his right side in the fetal position. LPN-M stated LPN-M assessed R3 and started to get vital signs. LPN-M stated R3 was alert but did not recall what had happened. LPN-M called 911. LPN-M treated R3's bleeding wound on his head and continued to monitor R3 while waiting for EMS to arrive. LPN-M stated R3's first blood pressure was low but that subsequent blood pressures were normal. LPN-M stated R3 was able to answer questions. Surveyor asked how long R3 was on the floor before being found by LPN-M. LPN-M stated, I don't know, and I have no way of knowing. LPN-M stated R3 could not tell LPN-M how long he had been on the floor. On 4/21/26 at 1:20 PM, Surveyor returned to LPN-M. Surveyor asked what LPN-M was told during morning report from the previous shift nurse. LPN-M stated the night nurse reported to LPN-M that R3 had been seen trying to self-transfer. LPN-M stated the night nurse told LPN-M R3 was wandering around the hallway outside of his room. LPN-M was also told of the seizure-like activity R3 experienced and then R3's refusal to be sent to the hospital. Surveyor noted LPN-M received morning report indicating R3 was self-transferring and wandering during the night, putting R3 at greater risk for falls. Surveyor noted facility staff could not identify when R3 was last seen or assisted and how long or an approximate time frame of how long R3 was on the floor after R3's fall. On 4/21/26 at 2:05 PM, Surveyor interviewed CNA-O. Surveyor asked what CNA staff need to do if a resident falls. CNA-O stated CNA-O would make sure the resident is safe and get the nurse. CNA-O would then assist the nurse with whatever was needed. CNA-O stated after the resident is cared for, the CNA will fill out an incident report/statement. The information included in the statement is things like if the call light was on or within reach, were there any puddles on the floor, if the resident's bathroom needs were met, and was the resident thirsty or hungry. CNA-O stated there is more but that is the kind of things listed on the statement. Surveyor asked how CNAs know what fall prevention interventions are in place for a resident. CNA-O stated they are listed in the medical record in the care plan. CNA-O stated the nurse will also let the CNAs know of any pertinent information. CNA-O stated the roster sheet has some info on it as well. Surveyor asked what a roster sheet entails. CNA-O stated the roster sheet has a list of the residents on the unit and basic information about the resident. On 4/21/26, Surveyor asked Director of Nursing (DON)-B if Surveyor could view R3's roster sheet. DON-B stated only current residents would have roster sheets available. Surveyor notes R3 is not a current resident. On 4/21/26 at 8:21 AM, Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked what RN-G would do if a resident was found on the floor. RN-G stated RN-G would assess the resident, get vital signs and start neuro checks. Once safe, staff would get the resident off the floor. From there, RN-G would try to figure out why the resident fell. RN-G would start the risk management documentation. RN-G stated if someone else found the resident, RN-G would get a statement from them to put in the risk management document. RN-G then would enter a fall intervention. On 4/21/26 at 2:35 PM, Surveyor interviewed DON-B. Surveyor asked what the expectation is for nursing staff if a resident is found on the floor. DON-B stated the nurse should perform an assessment, complete vital signs and ensure that the resident is not in immediate distress. The nurse would complete passive range of motion to assess for injury. After initial assessment is completed, the nurse will complete the fall check list, which is completed for any fall. The nurse will complete the risk management documentation. Surveyor asked if it is an expectation that statements be collected. DON-B indicated DON-B would expect at bare minimum to enter a staff statement in the statement section of the risk management documentation. DON-B stated DON-B would expect to see statements from staff members involved like the nurse or CNA who found the resident. Surveyor asked if statements or interviews are collected from staff on the previous shift with questions answered like who last saw the resident, what was the resident doing when seen, when was the resident last assisted to the bathroom. DON-B stated they do not typically do that. DON-B indicated DON-B has to prioritize what investigations get a deep dive. Surveyor asked what that meant. DON-B indicated that a fall with injury would require a more thorough investigation. Surveyor asked if DON-B was aware of R3's fall. DON-B indicated DON-B was familiar with the fall. DON-B stated the fall and investigation were complicated by the night shift staff who were agency staff and no longer work at the facility. Surveyor shared the concerns R3 was assessed by facility staff to be at high risk for falls within an hour of admission. Prevention protocol was not immediately initiated and documented on the care plan as the direction on the facility fall risk assessment documents. Facility staff documented R3 was confused and informed Surveyor in interview R3 was wandering during the night shift after seizure like activity. R3 fell and was found on the floor in R3's room. R3 sustained a major injury. R3's fall investigation was not thorough and did not include when R3 was last seen to determine how long R3 was on the floor, when R3 was last toileted, and what R3 was doing when R3 was last seen. Without a thorough investigation an accurate root cause was not identified and interventions to address the root cause could not be determined. On 4/21/26 at 3:30 PM, Surveyor informed NHA-A, DON-B, and Regional Nurse-I of the above concerns. On 4/22/26 at 7:55 AM, NHA-A and DON-B informed Surveyor the facility has a post fall document that is completed after falls that contains more information that helps guide the IDT team in determining a root cause and guides IDT team decisions for a new intervention. In R3's case, however, R3 did not return to the facility after R3's fall and this was not completed. DON-B stated the post fall document is not completed if the resident is discharged from the facility. DON-B indicated it is the facility process currently, but the facility is open to making that improvement of filling it out for every fall going forward. No further information was provided as to why the facility did not ensure R3 received adequate supervision and assistance devices to prevent accidents. *2.) R8 was admitted to the facility on [DATE] with diagnosis that include Dementia, History of falling, Chronic Kidney Disease, Depression, Syncope and collapse, Osteoporosis, and Osteoarthritis. R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents, in part: R8 is severely cognitively impaired. R8 uses a wheelchair. R8 requires substantial/moderate assistance for personal hygiene, toileting, bed mobility and transfers. R8 is always incontinent of bowel and bladder. R8 has had a fall without injury since last assessment. R8's Fall risk assessment dated [DATE] documents a score of 11, indicating R8 is at high risk for falls. R8's fall care plan initiated on 2/20/24 documents the following pertinent interventions: Assist with toileting as needed. Bed in low position when occupied or when not providing direct care. Bilateral floor mats to bedsides. Body pillow in bed to simulate presence of husband in bed. Educated to call for assistance with frequent reminders. Ensure resident is wearing nonskid socks. Pillows to both sides of bed. Floor mats to both sides of bed. Follow facility fall protocol. Increase staff involved activities with resident. R8's progress note signed by Licensed Practical Nurse (LPN)-C and dated 10/21/25 at 4:30 PM, documents, in part: [R8] observed sitting on floor in TV area at [3:45 PM], tried adjusting [themselves] and slid out of chair. [R3] did not hit [R3's] head, sitting with arm cross watching TV. No apparent injuries or bruises noted. [Vital Signs Stable] and [Within Normal Limits], [Bilateral Upper Extremities] and [Bilateral Lower Extremities Range of Motion Withing Normal Limits]. Denies any pain/discomfort at this time. Hoyer lifted back to [wheelchair]. R8's Fall Risk Management document dated 10/21/25 at 3:45 PM, documents, in part: [R8] observe sliding out of chair in TV area. Resident description: I was trying to adjust myself. Mental Status-Oriented to person . Level of Consciousness-confused. Predisposing physiological factors- incontinent. No Statements found. R8's Post fall evaluation dated 10/21/25 at 10:26 PM, documents, in part: Date/Time of fall: 10/21/25 at 3:45 PM. Fall was witnessed . Fall location: TV lounge area. Activity at the time of fall: Adjusting [themself] and slid out of chair. Reason for fall: scooting down in chair . No injury. R8's care plan summary note dated 10/22/25 at 5:57 AM documents, [Power of Attorney] agreed to pay monthly fee for Broda chair. Administrator order[d] chair [and] will be delivered 10/22/25. R8's Progress note dated 10/27/25 at 12:17 AM, documents: [Interdisciplinary Team (IDT)] team met to review 10/21/25 fall. Broda chair implemented as intervention. No further concerns at this time. Care plan updated. Surveyor noted the facility investigation into R8's fall did not document what R8 had on R8's feet, when R8 was last seen before the fall, or when R8 was last assisted with incontinence care. The investigation did not document why R8 was shifting in R8's chair, for example, was R8's brief soiled, was R8 reaching for something, or was R8 in pain and was shifting to reposition. Surveyor noted the facility did not complete a thorough investigation to determine the root cause. On 4/21/26 at 8:57 AM, Surveyor interviewed LPN-C. Surveyor asked if LPN-C could inform Surveyor what happened when R8 fell on [DATE]. LPN-C stated LPN-C was walking by and noted R8 leaning forward. LPN-C came around the corner and R8 had slid to the floor. LPN-C stated R8 was more fidgety and restless but stated R8 had just returned from an activity. LPN-C stated R8 had shoes on at the time of the fall but was unsure of when R8 was last toileted. Surveyor asked what documentation needs to be completed after a resident has a fall. LPN-C stated the risk management document needs to be filled out. LPN-C stated there is a fall checklist to complete as well. Surveyor asked if statements are collected from staff that may have witnessed the fall or been assigned to care for the resident. LPN-C stated the 2 CNAs that are working the unit should give statements. The statements are entered into the risk management document or given to unit supervisor or Director of Nursing (DON)-B. On 4/21/26 at 8:10 AM, 8:45 AM, 9:15 AM and 10:02 AM, Surveyor noted on each observation, R8 was observed in a low bed on R8's back. Surveyor observed R8 had a fall mat on R8's left side of the bed but did not have a fall mat on R8's right side of bed per fall care plan interventions. Surveyor observed R8 did not have a body pillow in bed to simulate presence of husband in bed per fall care plan intervention. Surveyor observed R8 did not have pillows on both sides of the bed per fall care plan intervention. On 4/21/26 at 2:35 PM, Surveyor interviewed DON-B. Surveyor asked what the expectation is for nursing staff if a resident is found on the floor. DON-B stated the nurse should perform an assessment, complete vital signs and ensure the resident is not in immediate distress. The nurse would complete passive range of motion to assess for injury. After initial assessment is completed, the nurse will complete the fall check list, which is completed for any fall. The nurse will complete the risk management documentation. Surveyor asked if it is an expectation statements be collected. DON-B indicated DON-B would expect at bare minimum to enter a staff statement in the statement section of the risk management documentation. DON-B stated DON-B would expect to see statements from staff members involved like the nurse or CNA who found the resident. Surveyor asked if statements or interviews are collected from staff on the previous shift with questions answered like who last saw the resident, what was the resident doing when seen, when was the resident last toileted. DON-B stated they do not typically do that. DON-B indicated DON-B has to prioritize what investigations gets a deep dive. Surveyor asked what that meant. DON-B indicated a fall with injury would require a more thorough investigation. Surveyor asked if fall care plan interventions should be followed by staff. DON-B indicated they should be followed. Surveyor informed DON-B of the concerns R8 was assessed to be at high risk for falls and fell on [DATE]. The facility did not complete a thorough investigation to determine a root cause and to allow for fall prevention interventions that address the root cause of the fall to be implemented. Surveyor asked if DON-B had any thoughts on R8's fall that occurred on 10/21/25. DON-B stated it was witnessed and there was no injury. DON-B stated the intervention of a Broda chair has proven effective since R8 has not fallen since the fall. On 4/21/26 at 3:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A, DON-B and Regional Nurse-I of the above concerns and the concern that fall care plan interventions were observed not to be in place on multiple observations. On 4/22/26 at 7:55 AM, NHA-A and DON-B provided additional information to Surveyor including an Addendum to the post fall evaluation. The document was hand signed by LPN-C on 4/21/26 at 6:30 PM. Surveyor noted the post fall evaluation document was printed out. In the section documenting contributing factors, there is handwritten check marks indicating yes or no answers. The contributing factor section of the document includes pertinent questions like: Recent change in environment, fluid spilled on floor, clutter on floor, poor lighting, was wheelchair involved, Footwear at the time of the fall, etc. Surveyor noted the post fall evaluation was not completed at the time of R8's fall and these answers in the contributing factors section were all left blank on 10/21/25 and are now handwritten in on 4/21/26. Surveyor noted included in the additional information was an addendum to LPN-C's statement documented: [R3] was in [R3's] chair, just coming back from an activity. [LPN-C] was going down the hallway and when [LPN-C] looked back to look at [R8], [R8] was reaching forward and scooting out of the wheelchair and [LPN-C] immediately responded. By the time LPN-C got to [R8], [R8] was sitting on [R8's] bottom watching tv on the floor with [R8's] arms crossed. [LPN-C] evaluated [R8] and [R8's] [family member] was there witnessing. [R8's] shoes were on [R8's] feet. [LPN-C] updated the doctor that day. No skin issues. No concerns. Connected with the DON and intervention was Broda chair for comfort due to fidgeting behavior. Surveyor noted LPN-C documented R8 was reaching forward. Surveyor noted LPN-C documented R8 had shoes on and had returned from an activity. Surveyor noted LPN-C also documented the intervention put in place was due to fidgeting behavior. Surveyor noted initially facility staff documented the fall occurred from adjusting in R8's chair. Surveyor noted in the addendum provided, facility staff documented R8 was fidgety and reaching forward however the investigation does not address the cause of the fidgety or leaning forward behavior. On 4/22/26 at 11:20 AM, after reviewing all provided documentation, Surveyor returned to NHA-A, DON-B and Regional Nurse-I and informed facility leaders of the continued concern R8's fall was not thoroughly investigated in October of 2025 to determine a root cause. DON-B indicated R8's fall investigation needed some work and DON-B acknowledged that. NHA-A stated facility staff look at the entire person, thoughtfully enter new interventions and noted that R8's intervention has been effective. No further

Based on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (R5 & R4) of 9 residents. *R5 spilled hot soup on R5's right abdomen, right lower breast and left pinky assessment on 1/23/26. There is no evidence the nurse spoke with the physician on 1/23/26, a treatment was not ordered until 1/24/26 and the area was not assessed until 1/26/26 by the physician. *The facility did not obtain R4's admission weight on 12/8/25 and daily weights on 12/9/25 & 12/10/25 according to R4's physician orders. Findings include: 1.) R5's diagnoses includes hypertension (high blood pressure), muscle weakness, Alzheimer's disease (progressive brain disorder that causes gradual cognitive decline), dementia (loss of cognitive function that interferes with a person's daily life and activities), and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). R5's quarterly MDS (minimum data set) with an assessment reference date of 12/30/25 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R5 is assessed as requiring partial/moderate assistance for eating. R5's nurses note dated 1/23/26 at 17:45 (5:45 p.m.), written by Licensed Practical Nurse (LPN)-C documents [R5's first name] was not observed wasting hot to R (right) abdomen, R lower breast, and L (left) pinky finger. [R5's first name] called out for help after wasting soup, temp (temperature) of skin 98.8, fire engine red, no broken skin or blister noted at time of assessment. Forehead temp 97.5, P (pulse) 82, R (respirations) 18, BP (blood pressure) 159/79 and O2 (oxygen) 99RA (room air). Pain rated 6/10 schedule Tylenol given, cool compress applied. Report relief after 15 minutes. On call updated, POA (power of attorney) and [Physician-U] office notified. In w/c (wheelchair) with nurse at nursing station for reassurance everything will be okay. Dietician updated with request to change order to all hot liquids to be covered at mealtimes. Plan of care assess every shift x (times) three days. R5's nurses note dated 1/24/26 at 13:28 (1:28 p.m.), written by LPN-C documents Skin to R (right) abdomen area noted with scattered clear filled blisters. Largest blister noted 0.5cm (centimeter) x (times) 1cm and the rest smaller. Redness to abdomen 3.5cm x 7cm and breast redness 3cm x 4.5 decreased in size. [R5's first name] denies pain/discomfort. [Physician-U's name] after hours notified. [Physician-V's name] gave verbal order Vaseline daily followed by boarder foam dressing until resolved. Assess for any changes and S/S (signs/symptoms) of infection update with concerns. POA [Name] updated with care plan. Dietary staff updated with order to cover all hot liquids with meals. R5's late entry nurses note dated 1/25/26 at 8:06 a.m., written by LPN-C documents All clear filled blisters open, cleanse with wound cleanser, pat dry, Vaseline applied covered with boarder foam dressing. Report discomfort with dressing change. In bed with call light within reach. R5's nurses note dated 1/26/26 at 07:30 (7:30 a.m.), written by LPN-C documents Dressing to R abdomen not intact. [R5's first name] noted holding area due to discomfort. Wound area beefy red with no S/S infection noted. Cleanse with wound cleanser, pat dry, Vaseline applied followed by boarder foam dressing. Reports itching during dressing change, encourage not to rub or scratch. R5's nurses note dated 1/26/26 at 11:05 a.m., written by LPN-C documents [Physician-U's name] did face to face visit today. NOR (new order received) Cleanse wound to R breast and abdomen with wound cleanser, pat dry, apply Vaseline, followed by dry dressing BID (twice daily) and PRN (as needed). Monitor closely for S/S of infection. Update MD (medical doctor) with any concerns or signs of infection. [R5's first name] in bed with call light in reach. R5's skin assessment dated [DATE] at 15:10 (3:10 p.m.) written by Unit Manager/Registered Nurse (UM/RN)-F documents Skin Issue: #001: Skin issue has been evaluated. Location: Abdomen – generalized. Issue type: Burn. Progress: New: new wound. Full thickness burn. Wound acquired in-house. Wound is new. Signs and symptoms of infection: None. Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Aching. Pain description: Sharp. Wound pain interventions: Change in position. Wound pain interventions: Relaxation techniques. Wound pain interventions: Distraction techniques. Relief from interventions: Yes. Staged by: N/A (not applicable). Length (cm): 0.75 Width (CM): 0.34 Depth (cm): 0 Area (cm2) 0.12 Undermining: No. Tunneling: No. Epithelial: 50%. Eschar: 50% Exudate amount: None. Exudate type: None. Odor after cleansing: None. Other wound bed: pink or red. Other wound bed: scab. Peri wound: Attached. Surrounding tissue: Erythema. Induration: None present. Edema: No swelling or edema. Peri wound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal < (less than) 25%. Modalities: None. Surveyor noted R5's burn was not assessed until three days after R5 spilled hot soup on themself. R5's burns were assessed by Physician-U. There was not an RN assessment until six days later on 1/29/26. On 4/21/26, at 12:02 p.m., Surveyor asked LPN-C on 1/23/26 after R5 spilled hot soup on herself did she speak with the doctor or left a message. LPN-C informed Surveyor she would have to look at her progress note. Surveyor informed LPN-C her nurse's note documents [name of Physician-U's] office notified. LPN-C stated we call and fax. Surveyor asked LPN-C if the doctor got back to her that night. LPN-C replied not that night but the following morning he did. On 4/21/26, at 3:04 p.m., Surveyor asked Director of Nursing (DON)-B when does a Registered Nurse (RN) complete an assessment on a new skin impairment. DON-B informed Surveyor it has been the practice the nurse on the floor does the assessment regardless of if they are a RN or LPN. On the next weekly wound round the RN will do an assessment. Surveyor informed DON-B a LPN can gather information, but a RN must complete an assessment. Surveyor informed DON-B R5 spilled hot soup on herself on 1/23/26, there was not an assessment until three days later by Physician-U and a RN assessment was completed six days after R5 spilled her hot soup on herself. 2) R4 was admitted to the facility on [DATE]. R4's admission physician orders document: -Admit weight one time only for 1 day-order date of 12/8/25 and end date of 12/9/25. -Daily weight X (times) 2 days, every day shift for 2 days-order date of 12/8/25 and end date of 12/11/25. Surveyor reviewed R4's Medication Administration Record (MAR) for December 2025. Surveyor notes: -Admit weight one time daily for 1 day is blank for 12/8/25. -Daily weight X2 days is blank for 12/9/25 and 12/10/25. Surveyor notes the facility did not obtain weights as ordered by R4's physician. On 4/21/26, at 3:03 PM, Surveyor informed Director of Nursing (DON)-B R4's weights were not obtained on admission as R4's physician ordered. DON-B confirmed R4's weights should have been obtained, and physician orders should be followed. On 4/21/26, at 3:46 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Regional Nurse (RN)-I, and DON-B that R4's physician orders for weighs to be obtained were not followed.

Based on observation, interview, and record review the facility did not ensure 2 (R7 & R1) of 2 residents reviewed for parenteral fluids are administered in accordance with physician orders and comprehensive person-centered care plan.*R7 was admitted to the facility on [DATE] with a PICC (Peripherally Inserted Central Catheter) which is a soft, thin, flexible tube in a vein used to administer IV (Intravenous) medications and fluids. The facility did not obtain physician orders or create a care plan for R7's PICC line until 4/14/26.*Physician orders for R1's PICC line were not followed on 1/29/26, 2/5/26, 2/7/26, 2/11/26, and 2/16/26.Findings include:The facility's policy titled, Central Venous Catheter Care and Dressing Changes revised March 2022 under Purpose documents The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Under General Guidelines documents 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 5. Assess central venous access devices with each infusion and at least daily: a. Visually inspect the entire infusion system (solution, administration set and dressing); b. Check expiration dates of the infusion, dressing, and administration set; c. Assess the patency of the vascular access device; d. Palpate and inspect the skin, dressing and securement device for signs of complications, including: (1) dislodgement; (2) redness; (3) tenderness; (4) swelling; (5) infiltration; (6) induration; (7) elevated body temperature; or (8) drainage. e. Ask the resident if he or she is experiencing pain, tingling or numbness; f. Remove any non-transparent dressing and visually inspect the insertion site if any signs or symptoms of complication are present. 6. Measure the length of the external central vascular access with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. 8. For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis.1.) R7 was admitted to the facility on [DATE] with diagnoses which includes malignant neoplasm (cancerous tumor) of endometrium (inner lining of uterus), and malignant ascites (accumulation of cancer cell containing fluid in the abdomen).R7's hospital labs and imaging include documentation of IR (interventional radiology) venous access PICC placement dated 4/2/26 under narrative documents VAT placed 4 French Double Lumen Solo PICC at bed side; L (left) arm basilic. Arm circ (circumference) 28 cm (centimeters). PICC length 42 cm at hub externally.R7's clinical admission assessment with an effective date of 4/6/26 at 19:02 (7:02 p.m.), under the Special Care section includes 17. PICC Line - Care Profile, 32. Length of PICC, 33. PICC solution, 34. PICC location, 35. PICC patency, 36. PICC patency - Other, & 37. PICC site. Surveyor noted none of these items have been completed. R7's skin check note dated 4/6/26 at 19:02 (7:02 p.m.), written by Registered Nurse (RN)-K documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Resident does not have an external device. Foot evaluation completed. Skin Issues: Skin Issue: #001: Skin issue has not been evaluated. Location: Buttocks - generalized. Issue type: Other skin issue. Other skin issue description: pink, blanchable skin Wound was present on admission. Skin Issues Noted: pink, blanchable buttocks. BUE (bilateral upper extremities) bruising; resident states That's from the IV (intravenous) and pokes Skin issue education: Change clothing/briefs. Skin issue education: Turn every 2 hours. Skin issue education: Change/shift positions frequently. Surveyor noted this skin check does not include R7's PICC line.R7's nurses note dated 4/6/26 at 23:42 (11:42 p.m.), written by RN-K documents Resident is a [age and sex] admitted to [facility's initials], Rehab East, Room [number] on 4/6/26 at 1619 (4:19 p.m.) from [Name] hospital. Arrived to [facility's initials] via ambulance; arrived to unit on stretcher accompanied by EMS (emergency medical services). Admitting diagnosis: weakness. Resident alert and oriented x (times) 4, able to make needs known to staff. Pleasant and cooperative; relaxed and calm. Fall education provided; resident states understanding of fall education. Call light education provided; resident states understanding of call light education. Resident states she will use call light to call for help when needed. Resident oriented to: [facility's initials], unit, room, TV remote, bed remote, food service, call light. admission paperwork reviewed with resident; resident states understanding of admission paperwork; admission paperwork signed by resident. Code preference discussed with resident; resident states understanding of code preference discussion Resident signs code preference. Code preference: Full code/CPR (cardiopulmonary resuscitation). Zyprexa consent reviewed with resident; resident states understanding of Zyprexa consent; consent signed by resident. [Medical Doctor (MD)-L's name] notified of resident's admission to unit; discharge summary and medication list reviewed by [MD-L's name]. No new orders. See PCC (point click care) charting for admission clinical assessment, skin assessment, Braden scale score, and elopement evaluation score. Surveyor noted this nurse's note does not include R7's PICC line.Medical Doctor (MD)-L's post-acute care admission history and physical dated 4/7/26 under assessment and plan for Endometrial serous carcinoma includes PICC line placed 4/2.R7's skin check dated 4/9/26 at 13:40 (1:40 p.m.), does not include documentation of R7's PICC line.R7's admission MDS (minimum data set) with an assessment reference date of 4/9/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.Surveyor reviewed R7's physician orders when R7 was admitted on [DATE] and noted there are no orders for monitoring and care of R7's PICC line and a care plan was not developed until 4/14/26, eight days after admission.Surveyor reviewed R7's physician orders for R7's PICC line orders and noted orders dated 4/14/26 document Sodium Chloride 0.9% Use 10 milliliters intravenously two times a day for flush PICC line. Change PICC line dressing and injection caps weekly every evening shift every Tue (Tuesday) and Monitor LUE (left upper extremity) PICC line for signs and symptoms of infection two times a day. Surveyor noted there is not an order to measure the length of R7's PICC line and arm circumference to assess for edema and possible DVT (deep vein thrombosis).On 4/20/26, at 9:58 a.m., Surveyor observed R7 sitting in a personal type of recliner in R7's room. R7 explained to Surveyor this is the beginning of her third week at the facility and was diagnosed with cervical cancer at the hospital. Surveyor asked R7 if she has a PICC line. R7 replied yes, thinks for infusions. R7 explained she had one infusion and wanted to speak to the social worker as she goes to [name of hospital] stand alone clinic for infusions. Surveyor asked R7 what staff do for her PICC line. R7 informed Surveyor they flush it every day. On 4/20/26, at 2:19 p.m., Surveyor informed Licensed Practical Nurse (LPN)-E R7 was admitted to the facility on [DATE] and asked if she knew why there weren't any orders for R7's PICC line until 4/14/26. LPN-E replied I'm not sure.On 4/21/26, at 10:03 a.m., Surveyor observed sitting in a personal type recliner with her legs up and knees bent. Surveyor asked R7 if her PICC line was flushed today. R7 replied yes and last night. Surveyor asked R7 if she was admitted to the facility with the PICC line. R7 replied yes explaining she received the PICC line at [name of hospital]. R7 showed Surveyor her PICC line site which has a dressing dated 4/14.On 4/21/26, at 10:10 a.m., Surveyor asked Licensed Practical Nurse (LPN)-M if she flushed R7's PICC line this morning. LPN-M replied yes explaining she flushes the line when she does R7's medications. Surveyor asked LPN-M if she knew why the weren't any order relating to R7's PICC line until 4/14/26 when R7 was admitted on [DATE]. LPN-M informed Surveyor she didn't know.On 4/21/26, at 10:15 a.m., Surveyor asked Unit Manager/Registered Nurse (UM/RN)-D when a resident is admitted who is responsible for the resident's orders. UM/RN-D informed Surveyor the nurse whoever is on the shift would complete the orders. Surveyor asked who ensures the orders are complete. UM/RN-D informed Surveyor the unit managers typically. Surveyor informed UM/RN-D R7 was admitted on [DATE] and there were no orders for R7's PICC line until 4/14/26. Surveyor asked UM/RN-D if she knew why there weren't any orders until eight days after admission. UM/RN-D replied I would have to look to get you exact information, that is used for chemotherapy. Surveyor asked UM/RN-D to investigate this and get back to Surveyor.On 4/21/26, at 11:45 a.m., Director of Nursing (DON)-B asked to speak to Surveyor regarding R7's PICC line. DON-B informed Surveyor upon admission there were no orders from the hospital for dressing change, R7 wasn't on IV medication and it's their hope the hospital provides orders. Surveyor asked if the hospital doesn't include orders for PICC line is it his expectation the nurse would get orders from the doctor. DON-B replies yes. DON-B informed Surveyor he did contact the hospital for them to investigate why there were no orders for R7's PICC line. DON-B informed Surveyor part two of the story is the expectation is when R7 came in under the skin check should have been documented the PICC line which it did not. DON-B informed Surveyor the two nurses that performed the skin check received coaching and they did a skin sweep. Surveyor informed DON-B R7's clinical admission assessment dated [DATE] PICC line section was not completed. DON-B informed Surveyor this is typically completed by the PM (evening) nurse. Surveyor asked if anyone reviews this assessment. DON-B informed Surveyor it's the responsibility of the nurse manager. DON-B informed Surveyor R7's PICC line should have been picked up with the skin assessment.2.) R1 was readmitted to the facility on [DATE] and discharged on 2/25/26.Diagnoses include infection and inflammatory reaction due to internal left hip prosthesis, presence of left artificial hip joint, presence of left artificial knee joint, hypertension (high blood pressure), depression (serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities, interfering with daily life), and anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life).R1's physician progress note dated 1/23/26 under subjective documents [R1's name] is a [age and sex] with multiple comorbidities and recent 1. Left total hip arthroplasty antibiotic and antifungal spacer. 2. Left total knee arthroplasty rigid antibiotic spacer. 3. Left femur periprosthetic fracture. 4. History of fungal and poly microbial infection left total hip arthroplasty, left femoral plate fixation. Major procedures: (see full procedure/operative note(s) for details). Procedures: Left arthroplasty femur total Wound Class: Contaminated - Incision Closure: Deep and Superficial Layers. Left removal hardware knee with cement spacer - Wound Class: Contaminated - Incision Closure: Deep and Superficial layers. Left - Arthroplasty hip revision (posterior approach) to total femur- patient was sent out to the hospital because of brownish tannish drainage from let hip incision. Patient was evaluated underwent washout of incision followed by closure. She has been put on vancomycin as she tested positive for staph epi dermatitis infection to the wound along with Pseudomonas. Currently on cefepime and vancomycin. Transferred back to facility for ongoing care. Work with PT (physical therapy) OT (occupational therapy) no other nursing concerns denies any chest pain diaphoresis palpitation all hospital records were reviewed.Surveyor reviewed R1's physician orders and noted the following orders:*Change injection caps weekly w/(with) PICC (peripherally inserted central catheter) line dressing change in the evening every Thu (Thursday) with a start date of 1/22/26.*Change PICC line dressing weekly in the evening every Thu (Thursday) with a start date of 1/22/26.*Monitor PICC line site every shift for signs & symptoms of infection every shift + = s/sx (signs/symptoms) of infection noted - = No s/sx of infection noted with start date of 1/22/26.*Flush PICC line lumens every shift w/10ml (with 10 milliliters) normal saline every shift with a start date of 1/22/26.*Measure PICC external catheter length (cm) (centimeter) with weekly dressing change in the evening every Thu, Notify MD (medical doctor) of change in length with a start date of 1/22/26.*Measure PICC line arm (left) circumference 3in (inches) above the insertion site Q (every) shift. Every shift notify MD of change in length with a start date of 1/29/26.Surveyor reviewed R1's January 2026 TAR (treatment administration record) and noted on 1/29/26 change injection caps weekly with PICC line dressing change in the evening every Thursday, Change PICC line dressing weekly in the evening every Thursday, Measure PICC external catheter length (cm) with weekly dressing change in the evening every Thursday, Measure PICC line arm (left) circumference 3 in above the insertion site every shift and Monitor PICC line site every shift for signs and symptoms of infection are all blank for the evening shift. Treatments completed have a check mark with the nurse's initial on the TAR.Surveyor reviewed R1's progress note for 1/29/26 and did not locate any documentation as to why R1's PICC physician orders were not followed.Surveyor reviewed R1's February 2026 TAR. On 2/1/26 Monitor PICC line site every shift for signs and symptoms of infection is blank for the night shift. On 2/5/26 change injection caps weekly with PICC line dressing change in the evening every Thursday, Change PICC line dressing weekly in the evening every Thursday, Measure PICC external catheter length (cm) with weekly dressing change in the evening every Thursday, Measure PICC line arm (left) circumference 3 in above the insertion site every shift for the evening and night shift, Flush PICC line lumens every shift with 10 ml normal saline is blank for the evening & night shift and Monitor PICC line site every shift for signs and symptoms of infection for the evening shift are blank.On 2/7/26 Flush PICC line lumens every shift with 10 ml normal saline, Measure PICC line arm (left) circumference 3 inches above the insertion site every shift and Monitor PICC line site every shift for signs and symptoms are blank for the night shift.On 2/11/26 Monitor PICC line site every shift for signs and symptoms of infection is blank for the day shift. On 2/16/26 Measure PICC line arm (left) circumference 3 inches above the insertion site every shift and Monitor PICC line site every shift for signs and symptoms of infection are blank for the day shiftSurveyor reviewed R1's progress notes for 2/5/26, 2/7/26, 2/11/26, & 2/16/26 and did not locate any documentation as to why R1's PICC physician orders were not followed.On 4/22/26, at 11:53 a.m., Surveyor asked Unit Manager/Registered Nurse (UM/RN)-F what is the expectation when a nurse completes a treatment for a resident. UM/RN-F informed Surveyor it would be in the TAR or a note if it was a one-time treatment. The expectation is that the nurse signs it out. Surveyor informed UM/RN-F of the multiple dates R1's PICC orders in January & February that were not initialed as being completed.

Based on interview and record review the facility did not provide pharmaceutical services ensuring medications were available to be administered as ordered by their physician for 1 (R4) of 3 residents.*R4 has an order to receive Potassium Chloride Crys ER (Extended Release) Oral Tablet Extended Release 10 MEQ for Hypokalemia effective 12/9/25. R4 did not receive this medication on 12/27, 12/28, and 12/29/25.Findings Include:The facility policy titled, Providing Pharmacy Products and Services, dated 6/1/24, documents: . Applicability: This policy 1.0 sets forth procedures relating to the provision of Pharmacy Products and Services in accordance with the Pharmacy Services Agreement.Procedure1. Pharmacy will provide facility with the facility-specific pharmacy information placard which details how facility staff can contact pharmacy twenty-four hours a day, seven days a week.2. If orders for medications are received from physician/prescriber when pharmacy is closed, facility staff should take the following steps:2.1 Remind physician/prescriber that pharmacy is closed and that a delay in medication therapy can be prevented by using a medication that is included in facility's emergency supply.2.2 If a medication cannot be substituted, ask physician/prescriber if the medication therapy can be initiated the next morning. 2.2.1 If it is possible to initiate the medication therapy the next morning, facility staff should document the conversation with the prescriber and include the start time in the order.2.3 If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided by the pharmacy.R4 was admitted to the facility on [DATE] with diagnoses including Hyperlipidemia (high levels of fat particles in blood), Hyperosmolality (elevated concentration of solutes such as sodium, glucose, or urea in blood plasma), Hypernatremia (deficit of total body water relative to sodium causing dehydration and neurological dysfunction).R4's admission Minimum Data Set (MDS) completed 12/21/25 documents R4's Brief Interview for Mental Status (BIMS) score to be 8 indicating R4 demonstrated moderately impaired skills for daily decision making. On 12/27/25, at 10:51 AM, Licensed Practical Nurse (LPN)-C documents: . Writer called pharmacy and spoke with [name] in regard to Potassium Chloride crystal ER 10mg when will it be delivered. [Name] indicated that it was delivered on 12/23 at 1437 (2:37 PM) signed by LPN-G. Writer checked west cart and med room medication not found. Updated on call for facility physician (MD)-H updated and gave verbal okay to give when medication arrive.Surveyor reviewed R4's physician orders. Effective 12/9/25, R4 was to receive Potassium Chloride Crys ER Oral Tablet Extended Release 10 MEQ for Hypokalemia. Surveyor reviewed R4's Medication Administration Record (MAR) and noted R4 did not receive Potassium Chloride on 12/27, 12/28, and 12/29/25.On 4/21/26, at 3:03 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the process for medication delivery from the pharmacy. DON-B explained if a medication is not available then the first step is for the nurse to check in contingency. The second step is to call the pharmacy and contact the provider to get an intervention. DON-B stated all nurses were educated on the process in October of 2025. DON-B shared the expectation that no resident goes without their prescribed medication. Surveyor shared the concern R4 did not receive Potassium Chloride 12/27-12/29/25. DON-B was unaware R4 went without Potassium Chloride and stated that is concerning especially because most likely R4 was also on a diuretic. DON-B stated R4's Health Care Power of Attorney (HCPOA) should have been notified that R4 did not receive Potassium Chloride for three days. On 4/21/26, at 3:46 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Regional Nurse (RN)-I, and DON-B that R4 did not receive R4's Potassium Chloride for three days. On 4/22/26, at 8:11 AM, DON-B informed Surveyor the expectation of the process when a medication is not available is crystal clear to the nurses. DON-B shared performance improvement plan (PIP) was initiated back in October 2025, and DON-B started re-educating nurses last night on the process to follow when a medication is not available. Surveyor notes the re-education includes establishing a root cause of the issue, notify the resident and HCPOA, and document in the progress notes. The process must be followed each and every time the medication is unavailable.On 4/22/26, at 11:50 AM, Surveyor reviewed the concern of R4 not receiving Potassium Chloride for three days.

Based on interview, record review, and facility policy review, the facility did not assess a resident's ability to self-administer medication before leaving medication at the bedside for 1 resident (R) (R1) of 5 sampled residents reviewed for self-administration of medication.Findings include:Review of the facility's policy titled Administering Medications policy, last revised 4/2019, revealed residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy and hypertension. Review of R1's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/13/25, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R1 was severely cognitively impaired. Review of an Incident Note, dated 12/29/25, revealed whole medications were left at the bedside over the weekend. R1's daughter notified the nurse that two pills had been found in R1's room.Review of R1's care plan revealed R1 did not have a care plan for self-administration of medication. Review of R1's assessments revealed R1 had not been assessed for self-administration of medication.Review of R1's physician orders revealed R1 did not have an order to leave medications at the bedside for R1 to self-administer.During an interview on 1/22/26 at 11:47 AM, Family Member (FM) 2 reported when she visited R1 on 12/29/25 there were two pills sitting on the bedside table which the nurse said may have been blood pressure medication.During an interview on 1/21/26 at 5:28 PM, the Administrator was asked if R1 was assessed for self-administration of medication and responded, .She wouldn't be able to. She was living in our memory care unit before she was admitted to our skilled nursing unit when she came in from the hospital.

Based on interview, record review, and facility policy review, the facility did not ensure 1 resident (R) (R1) of 5 residents reviewed for medication administration was free from a significant medication error. On 12/29/25, R1 received duplicate doses of prescribed blood pressure medication. This error resulted in R1 experiencing hypotension (low blood pressure) and requiring evaluation in the Emergency Department (ED). Findings include:Review of the facility's policy titled Administering Medications, last revised 4/2019, revealed medications are administered in accordance with prescriber orders, including any required timeframes .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy and hypertension (high blood pressure). Review of R1's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/13/25, revealed R1 was assessed with a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R1 was severely cognitively impaired. Review of R1's Medication Administration Record (MAR), dated December 2025, revealed R1 had an order, dated 12/10/25, for carvedilol (blood pressure medication) oral tablet 25 milligrams (mg) .Give 1 tablet by mouth two times a day for hypertension (HTN). Take with meals. The medication was scheduled for AM and PM. There was no order to self-administer the medication. Licensed Practical Nurse (LPN) 2 documented that LPN 2 administered R1's two evening medications on 12/28/25, including carvedilol.Review of R1's care plan revealed R1 did not have a care plan for self-administration of medication. Review of an Incident Note, written on 12/29/25 by LPN 1, indicated whole medications were left at R1's bedside over the weekend. At approximately 10:30 AM while administering AM medications, R1's daughter notified LPN 1 that two pills were found in R1's room. R1's daughter stated she assumed the pills were R1's AM medications and had already given them to R1 prior to LPN 1's arrival. LPN 1 clarified that no medications had been administered yet that morning. R1's daughter described the pills as white and long form. LPN 1 showed R1's daughter several of the pills prescribed to R1. R1's daughter identified the pills as likely to be R1's blood pressure medication. R1's vital signs were stable; R1's blood pressure at 10:00 AM was 132/67. Approximately thirty minutes later, R1's daughter reported that R1 seemed very tired and fell asleep in the middle of a card game. LPN 1 assessed R1 and noted R1 wasn't responsive to verbal or tactile stimuli. R1's vitals were retaken and revealed a significant drop in blood pressure (78/54). R1 was symptomatic and experienced altered consciousness. R1 was transferred to the ED for monitoring. Review of R1's ED provider notes, date of service 12/29/25, revealed R1 had a blood pressure of approximately 88 systolic with slight bradycardia (low heart rate) of 58 after taking 2 doses of carvedilol earlier that day.R1 was slightly hypotensive at 104 systolic with bradycardia of 58. Poison control was contacted and an electrocardiogram (EKG) (a quick, painless, noninvasive test lasting about 5-10 minutes that measures the heart's electrical activity to detect arrhythmias, heart damage, and structural issues) was completed. No other treamtent was administered in the ED. The provider notes indicated R1 could be sent home.Review of the facility's Investigative Summary, dated 12/29/25, revealed the Director of Nursing (DON) investigated the medication error and determined the pills in R1's room were left by staff from a previous shift. R1's daughter identified the pills as likely to be R1's carvedilol and atorvastatin (cholesterol medication); both medications were ordered to be administered in the evening. The facility's investigation revealed the medications were left at the bedside by LPN 2. During an interview on 1/21/26 at 12:51 PM, LPN 2, who documented administering R1's evening medications on 12/28/25, stated, The Director of Nursing asked me if I left medications at (R1's) bedside and I told him that I didn't. During an interview on 1/21/26 at 3:22 PM, LPN 1 stated, I worked that morning shift on 12/29/25 and normally when I get in, I start to take the residents' vital signs and then I start passing my medications. When I took (R1's) vital signs, her family was not in her room yet, and I didn't notice any medications on (R1's) bedside table. Before going into (R1's) room, I crushed her blood pressure medication (carvedilol) and mixed it with apple sauce. While I was scooping the blood pressure medication in apple sauce out of the medicine cup and giving (R1) the medication, the daughter notified me that her mom took two pills that were in a medicine cup a few minutes ago. When I asked the daughter to describe the pills to me, they were colored white and shaped like an oblong. When I checked (R1's) MAR for 12/28/25 for evening shift, they were likely to be blood pressure medication .fifteen minutes later, I was called to (R1's) room. I checked (R1) and she was unresponsive to verbal and tactile stimulation. The family said that she fell asleep during a board game or a card game. When I checked (R1's) blood pressure, it was in the 70s systolic. She was sent out via 911 by the doctor. During an interview on 1/22/26 at 11:47 AM, Family Member (FM) 2 stated, When my husband, my son, and I arrived at (R1's) room around 10:15 AM, there were a couple of pills sitting on the bedside table. My mom ended up taking the medication in the cup. About ten minutes later, one of the nurses came in with apple sauce in a medicine cup. While she was scooping the apple sauce out of the medicine cup and giving it to my mom, I was telling her that my mom just took the two pills in a medicine cup that was sitting on the bedside table. The nurse told me to always check first before giving anything to my mom. The nurse continued to give the apple sauce while I was asking her if there was any 'danger of things' interacting or a chance of there being a problem that my mom took those pills and the nurse immediately answered, 'I will go and check the records.' When the nurse came back, she showed me pills and asked if the pills I found on the bedside table looked like 'this.' I said they were white and oblong in shape. She said that the pills may have been blood pressure medication and that she had to report this to the nurse manager. Soon after, the nurse gave the apple sauce to my mom. Probably about 30 to 45 minutes later, my mom started looking drowsy and then just kind of fell asleep while we were playing gin with her.During an interview on 1/21/26 at 5:28 PM, the Administrator stated R1 could not self-administer medication left at the bedside due to her cognition.

Based on observation, staff interview, and record review, the facility did not ensure adequate supervision for 1 resident (R) (R7) of 3 residents reviewed for elopement.R7 was assessed as at risk for elopement and had a WanderGuard on R7's left ankle. R7 lived on the second floor of the facility and had multiple documented attempts of entering the emergency exit stairwell near R7's room. The facility's WanderGuard system did not work with emergency exit stairwell doors. R7 expressed a desire to jump down the stairwell and staff used medical equipment to block the stairwell and divert R7 from the door. On 5/31/25, R7 exited the building via the stairwell and was found outside near an employee parking lot. The facility did not complete an investigation into R7's elopement. The facility also did not update R7's plan of care with person-centered approaches after R7's attempted elopements and actual elopement.The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement created a finding of immediate jeopardy that began on 5/6/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 7/29/25 at 10:27 AM. The immediate jeopardy was removed on 7/29/25, however the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include:The facility's Elopement, Unsupervised Absence, Hazardous Wandering and Missing Residents policy, revised 11/7/24, indicates the facility will implement procedures that strive to identify, prevent, and respond to resident elopement attempts. The facility will follow Centers for Medicare & Medicaid Services (CMS) regulations and guidelines and will conduct assessments of residents on admission as well as periodic re-evaluation of behaviors that may lead to wandering and elopement. An elopement occurs when a resident receiving health care exits the Health Center or licensed healthcare provider, exits the community's property, and is no longer under the supervision or line-of-sight of a team member, volunteer, or family member .Community access allowance or transfer to a more secure level of living may occur for the protection of the resident based upon further assessment or past and future incidents of elopement After an elopement occurs: The means of egress (if known) that the resident used to leave the community or care area should be analyzed to prevent further occurrences. Door alarms, alarm panels, wander prevention systems, and locking mechanisms should be checked for proper functioning by Environmental Services and/or security team members. Accurate, thorough, and timely documentation of all aspects of the elopement will be documented in the resident's record. Documentation should include time frame and notification of physician, responsible party, law enforcement, and all involved parties. An incident report will be completed and the resident's responsible party and physician will be notified. The Director of Nursing and Health Center Administrator will conduct a root cause analysis and review documentation with the Interdisciplinary Team to critically analyze the event and ensure appropriate interventions and care plan updates are in place to prevent future occurrences. Resident's elopement risk will also be reviewed. The facility's Mood and Behavior Management policy, revised 4/17/25, indicates: .6.The Health Center utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Team members will: .c. Monitor the resident closely for expressions or indications of distress .h. Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record .j. Discuss potential modifications to the care plan. 7. The resident and as appropriate the resident's family are included in the comprehensive assessment process .The care plan shall: .h. Be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. From 7/28/25 to 7/29/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, pressure ulcer to sacrum, type 2 diabetes, muscle weakness, and unsteadiness on feet. R7's Minimum Data Set (MDS) assessment, dated 5/30/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R7 had severe cognitive impairment. R7 had an activated Power of Attorney for Healthcare (POAHC). R7 was admitted to the facility after a hospital stay from 3/22/25 to 4/2/25 for a chronic pressure ulcer that R7's previous memory care facility was unable to manage. R7 was admitted from the hospital to the facility's rehab unit which was located on the second floor. R7 discharged to R7's previous memory care facility on 6/2/25. An activities of daily living (ADL) self-care performance deficit care plan, initiated on 4/2/25 and revised on 4/11/25, indicated R7 transferred with the assistance of one staff with a gait belt and walker (revised 4/7/25). A care plan, initiated on 4/11/25, indicated R7 was at risk for falls related to deconditioning, dementia, and use of psychotropic medication.An elopement assessment, dated 4/2/25, indicated R7 was at risk for elopement.A progress note, dated 4/3/25, indicated R7 had a WanderGuard on the left lower extremity.An elopement care plan, initiated on 4/3/25, indicated R7 was at risk for elopement/wandering related to disorientation to place, history of attempts to leave the facility, and wandering aimlessly. The care plan contained interventions (initiated on 4/3/25) to encourage R7 to be in common areas and redirect from doors and to a safe area when necessary. A WanderGuard to the lower left extremity was added on 4/11/25. (The care plan had not been updated since 4/11/25.)A care plan, initiated on 4/3/25 and last revised on 5/20/25, indicated R7 had a behavior problem related to delusions and refused medication, wandered the halls, and wandered into others' rooms. The care plan contained interventions (initiated on 4/3/25) to anticipate and meet R7's needs, approach in a calm and nonthreatening manner, use a calm, slow approach during care, and provide psych services. (There were no interventions added to the care plan after 4/3/25.) (An impaired cognitive function care plan, initiated on 4/10/25, indicted R7 had impaired thought processes related to dementia with agitation and neurocognitive disorder.)A trauma/victimization care plan, initiated on 4/3/25, indicated R7 lived in [NAME] during the war, lost multiple friends and family, was mugged and robbed at home, and was assaulted by a resident in another setting. The care plan contained interventions (initiated on 4/3/25) to assess pain every shift and as needed, direct/assist to groups/activities daily, and identify and model healthy activities to combat boredom and lack of self-stimulation. (A care plan, initiated on 4/30/25, indicated R7 was grieving the loss of a neighboring resident.)A progress note, dated 5/6/25 at 2:43 PM, indicated R7 exited an alarmed door on the fire escape at approximately 1:30 PM. R7 was discovered on the landing attempting to go downstairs. R7 stated R7 needed Family Member (FM)-L. R7 was speaking in German and stated jump. R7 exited the fire door again and set off the alarm at approximately 2:30 PM. Staff located R7 on the landing. R7 said R7 was going to jump and needed to go home and attempted to bite staff during redirection. R7 refused a walker and pushed staff away. A progress note, dated 5/6/25 at 3:53 PM, indicated staff spoke with FM-L about a transfer due to R7's increased wandering. FM-L understood the safety risk and gave consent for referrals which were sent to 2 facilities. A progress note, dated 5/6/25 at 8:28 PM, indicated R7 tried to open the stairway door multiple times and stated R7 wanted to go home. R7 tried to leave through the stairway door and became agitated during redirection. 1:1 supervision was provided due to wandering and behaviors.A progress note, dated 5/7/25 at 9:19 PM, indicated R7 wandered the unit from 2:40 PM to 5:30 PM and tried to open residents' doors. R7 was agitated and combative when redirected. R7 tried to leave unit via an emergency exit door at the end of the hallway. R7 was impulsive, disoriented, and sundowning and was provided 1:1 supervision at times for safety. A progress note, dated 5/9/25 at 2:10 PM, indicated an alarm sounded and R7 exited the unit via the stairwell at approximately 7:00 AM. R7 declined to leave the stairwell for 20 minutes. R7 stated R7 was going to jump, wanted to go home, and attempted to bite staff multiple times. R7 initially declined to take medication and stated staff were lying and trying to poison R7. After speaking with a Nurse Practitioner (NP), R7 agreed to take medication. Staff attempted to obtain a urine sample for a urinalysis and labs were ordered. A Social Services note, dated 5/15/25 at 11:56 AM, indicated a behavior management meeting was held with the Interdisciplinary Team (IDT). R7 was prescribed trazadone, Seroquel, and Namenda. A titration of Namenda was recommended. A progress note, dated 5/18/25 at 1:48 AM, indicated R7 stated a man with a knife was trying to kill R7. R7 attempted to leave the floor via elevator and the stairwell. The physician was notified and R7 was sent to the Emergency Department (ED). A provider note, dated 5/18/25 at 1:23 AM, indicated R7 was agitated and psychotic and was found in the stairwell trying to escape the unit. R7 refused to talk to the provider. R7 was hostile toward staff and stated someone was trying to kill R7. R7 refused to take anything by mouth and stated the nurse was trying to kill R7. R7's diagnoses included metabolic encephalopathy (primary). R7 was referred to the ED for labs and acute management. A follow-up progress note, dated 5/18/25 at 5:35 AM, indicated R7 did not have symptoms of infection and would return to the facility.A progress note, dated 5/19/25 at 7:44 PM, indicated R7 wandered into residents' rooms, wandered the unit, refused medication, and thought a man in the basement was after R7. Staff provided Facetime with FM-L. The NP asked R7 to take Seroquel which R7 did.A progress note, dated 5/19/25 at 10:24 PM, indicated R7 was agitated, wandered the unit, tried to open the stairwell door, and stated R7 needed to go to the basement to kill the man who hurt R7. Reassurance, redirection, and reorientation were ineffective. R7 had a butter knife and fork and tried to stab staff with the utensils. R7 declined to give up the utensils and stated R7 needed to kill the man with the knife. Staff redirected R7 away from the stairs. 1:1 supervision was provided. The NP was notified and R7 agreed to take Seroquel. A progress note, dated 5/27/25 at 9:00 AM, indicated R7 was agitated and aggressive with staff, threw a walker at R7's window, and attempted to dismantle an air mattress to use the motor to break the window. R7 also attempted to barricade R7's self in the room and moved furniture around to block the doorway. The NP told staff to request a psych consult and continue to encourage R7 to adhere to R7's medications regimen. A psych consult was requested on 5/28/25.A progress note, dated 5/31/25 at 4:19 PM, indicated R7 used the L wing fire escape door to elope from the facility and was found outside near the employee entrance at approximately 2:00 PM. R7 expressed suicidal ideation and was resistant to return to the facility. Therapeutic communication was eventually effective and R7 was assisted back inside with with 3 staff. R7 returned to unit and tried to strangle R7's self with a gait belt. Staff intervened and no injuries were sustained. The police department and crisis team were on site from approximately 2:45 PM to 3:30 PM. 1:1 supervision was provided. A progress note, dated 6/2/25, indicated R7 was found in a secured courtyard (during the elopement on 5/31) and was discharging back to R7's secured memory care facility on 6/2/25.On 7/28/25, Surveyor observed R7's room on the second floor which was the last room in the hallway before an alcove. The alcove contained 4 rooms and an emergency stairwell exit door. On 7/28/25, Surveyor requested incident reports for R7. Surveyor was provided with an incident report for a fall on 5/16/25 but was not provided with any incident reports related to elopement.On 7/28/25 at 10:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who verified R7 repeatedly attempted to get in the stairwell. LPN-G stated staff put equipment in front of the stairwell door to keep R7 from going down the stairwell. On 7/28/25 at 11:45 AM, Surveyor interviewed LPN-E via phone who verified R7 wandered frequently and often got into the emergency stairwell near R7's room. LPN-E indicated LPN-E wrote a progress note when R7 eloped from the building toward the end of R7's stay and was found outside near the employee entrance. Surveyor read the progress note (dated 5/31/25 at 4:19 PM) to LPN-E and informed LPN-E of the progress note on 6/2/25 that indicated R7 was in a courtyard. LPN-E indicated R7 was outside the building but not in a courtyard. LPN-E indicated 3 staff brought R7 back inside and thought one was a kitchen staff. LPN-E did not hear an alarm when R7 left the unit and did not recall completing an incident report. LPN-E thought LPN-E completed an elopement evaluation after the incident, however, R7's medical record did not contain an elopement assessment. LPN-E indicated the protocol was to notify the Director of Nursing (DON), the on-call nurse, and in some situations, the Nursing Home Administrator (NHA) which LPN-E did. LPN-E indicated there was a lack of support in keeping R7 safe and stated staff had asked for a 1:1 caregiver for R7 many times. Messages in the scheduling system asking if staff wanted to help went unanswered so staff tried to provide 1:1 supervision with the staff they had. LPN-E indicated it was difficult to manage and keep R7 when R7 exhibited behaviors. LPN-E indicated the alarm on the emergency stairwell sounded when the door opened but stopped when the door closed. LPN-E stated LPN-E contacted crisis after R7 attempted to strangle R7's self with a gait belt and expressed suicidal ideation. LPN-E stated crisis responded and recommended 1:1 supervision. LPN-E indicated R7 was on 1:1 supervision after the incident but was not aware of any care plan updates or new interventions.On 7/28/25 at 1:33 PM, Surveyor interviewed CNA-F who was working on 5/31/25 when R7 eloped from the facility. CNA-F indicated CNA-F returned from break, noticed R7 was not in R7's room, and started looking for R7. CNA-F checked the stairwell and R7 was not there. CNA-F looked out a window and observed R7 outside on a sidewalk in an area where employees park. CNA-F indicated it was difficult to get R7 back inside and could not recall who was there to assist. CNA-F was not sure how long R7 was gone and thought the incident occurred after lunch. CNA-F was not interviewed by the facility as part of an elopement investigation. CNA-F indicated R7 went into the stairwell almost every time CNA-F worked and verified R7 was on 1:1 supervision after the incident. CNA-F indicated staff put equipment in front of the door to prevent R7 from going down the stairwell, however, R7 moved the equipment.Following the interview, Surveyor walked down 2 flights of stairs in the stairwell and out the L exit door and paced to where R7 was found. When the door opened, Surveyor observed a sidewalk that was approximately 20 paces to the main sidewalk. Surveyor turned right and walked approximately 20 paces to where CNA-F indicated R7 was standing. Surveyor noted there was a parking lot but no courtyard in the area. Surveyor noted if R7 continued to walk on the sidewalk for approximately 50 more paces, R7 would have arrived at the employee entrance. On 7/28/25 at 11:56 AM, Surveyor tested the L wing stairwell door with LPN-G who indicated the WanderGuard system does not alert when the stairwell door opens. LPN-G also indicated staff do not carry pagers if a door alarm is set off. The door contained a magnet alarm on the left side and a box on the upper right side. When LPN-G opened the door, the magnet alarm emitted a high-pitched sound. The alarm stopped when the door closed. There were no other audible alarms. LPN-G was not aware that R7 had eloped but confirmed R7 frequently got into the stairwell.On 7/28/25 at 11:58 AM, Surveyor descended 2 flights of stairs in the stairwell to the first floor and noted there were 2 doors on the lower level, including a door that went into a first floor resident area and an egress door that contained a sign that stated Push until alarm sounds. Door can be opened in 15 seconds. Surveyor asked Maintenance Staff (MS-M) to test the exit door. MS-M pushed the door which opened right away. The door did not alarm and there was not a delayed 15 second locking mechanism. MS-M indicated the alarm would sound on the main fire panel. MS-M and Surveyor walked to the front entrance of the facility and observed the alarm panel which indicated the system was normal and no alarm was sounding. MS-M then contacted Maintenance Director (MD)-J. On 7/28/25 at 12:06 PM, Surveyor showed MD-J the L wing exit door that opened without alarming and without a delayed lock. MD-J opened the door and confirmed the door opened immediately and did not alarm. MD-J was not sure the sign on the door that stated Push until alarm sounds. Door can be opened in 15 seconds was appropriate for the door. MD-J pointed to an alarm box on the door, stated the alarm went to a panel behind a desk, and pushed the button on the box (which did not sound). Surveyor and MD-J then went to the panel and noted the alarm was not sounding and the panel did not indicate an alarm had been activated. Surveyor asked 2 nursing staff in the lobby if they carried pagers or phones that alerted them of an alarm. The staff indicated they do not hear anything except the magnet alarm which stops when the stairwell door is closed. On 7/28/25 at 12:18 PM, Surveyor and MD-J tested the K wing stairwell door. When MD-J opened the door, the alarm sounded, the door did not open, and a red light blinked on the handle. The door opened after 15 seconds of MD-J pushing on the door. MD-J confirmed the L door did not do that and did not contain a blinking light on the push bar. MD-J turned off the alarm with a key. MD-J also indicated a pager should sound, however, MD-J was not wearing a pager. MD-J and Surveyor went to the panel behind the secretary's desk on the second floor and noted a red blinking light for the K door but not the L door. MD-J indicated the L door should be lit up as well, however, there was no alarm sounding. MD-J attempted to disarm the alarm by entering several codes in a key pad but was unsuccessful. There were no staff at the desk. Surveyor observed the alarm panel on the wall behind the secretary's desk and noted the secretary's back would face the alarm panel. MD-J confirmed if staff did not watch the panel, they would not know an alarm was triggered since there was no audible sound. MD-J also confirmed the only audible alarm sound tested was the magnet alarm on the stairwell exit door which only sounds when the door is open. MD-J indicated there is a second alarm on the door that needs to be reset with a button, however, the alarm would not sound for nursing staff to hear. On 7/28/25 at 1:38 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-K who indicated ADON-K was told R7 got down the stairwell and was found in a courtyard. ADON-K indicated R7 had a history of trying to leave the unit and frequently needed redirection and 1:1 supervision. ADON-K was not sure if an elopement investigation was completed and did not recall interviewing staff or checking doors. ADON-K was not aware that staff used equipment to block the stairwell door and confirmed equipment should not be used to block an exit door. ADON-K confirmed R7's care plan and interventions should have been updated to ensure safety and monitoring. ADON-K was aware the WanderGuard system did not work with stairwell doors, but was not aware the L wing exit door did not work properly. ADON-K was also not aware that staff indicated R7 was observed outside the building on a sidewalk near the employee entrance/parking lot. ADON-K indicated there was not a formal process for behavioral management and stated it was more of a collective of ideas for brainstorming with social workers and providers. ADON-K indicated the facility has a psychiatrist and verified care plans should be updated in clinical meetings. On 7/28/25 at 1:52 PM, Surveyor interviewed DON-B who indicated staff informed DON-B that R7 was found in an enclosed courtyard but was not sure how R7 got there. DON-B was not sure who found R7, who reported the information, or if an investigation was completed. DON-B indicated R7 got down the L stairwell and stated all stairwells have an exit door. Surveyor indicated the L stairwell leads to an employee parking area and not a courtyard. DON-B was not aware the WanderGuard system does not work with stairwell exit doors. When Surveyor informed DON-B that the L stairwell lower level exit door did not work correctly when Surveyor tested the door, DON-B did not recall testing stairwell doors as part of an elopement investigation. DON-B confirmed staff should not block exit doors with equipment and confirmed precautions should have been implemented, assessments should have been completed, and care plans should have been updated when R7 expressed suicidal ideation and repeatedly attempted to exit the facility. On 7/28/25 at 2:06 PM, Surveyor interviewed NHA-A who confirmed a thorough investigation should have been completed for R7's elopement and R7's plan of care should have been updated with appropriate interventions to keep R7 safe. NHA-A was not aware staff used equipment to block an exit door to try to deter R7 from going down the stairwell. Surveyor informed NHA-A that the magnet alarm was the only audible alarm staff heard upstairs and it only sounded when the door was open. Surveyor informed NHA-A that the panel that lights up if a door is opened is located behind the secretary's desk which is between the east and west units and staff are only at the desk during the day from Monday through Friday. Surveyor also informed NHA-A that the panel did not audibly alarm which meant staff had to physically see the light to know if a door was open. NHA-A confirmed all doors should be working and nursing staff should be alerted timely when a door alarms.On 7/29/25 at approximately 8:30 AM, Surveyor interviewed Plant Manager (PM)-I via phone who indicated PM-I checked the L wing exit door after Surveyor's observation. PM-I confirmed the L exit door was not working and stated the facility contacted a vendor who was coming to repair the door. PM-I indicated there was a power surge over the weekend that may have caused the panel on the L door to burn out. PM-I confirmed each stairwell door has a magnet alarm that audibly sounds when the door is opened and stops when the door is closed, and a second alarm box called the Pal-care system which, if triggered, has to be reset by pushing a button on the box. PM-I indicated the Pal-care system also alarms at the panel and via pagers. PM-I indicated first and second shift maintenance staff carry pagers as well as a rapid responder for the whole community. PM-I indicated a rapid responder located in a building near the independent living section of the campus carries a pager on the third shift. Surveyor explained the concern of floor staff not getting alerted when a door is triggered, except for the magnet alarm that only sounds when the door is open and the alarm panel that is not audible and not in a location where nursing staff can keep an eye on it when staff aren't at the desk. PM-I indicated on the evening of 7/28/25, the facility downloaded the door alarm program onto nursing laptops so staff are alerted if a door is triggered. The facility provided Surveyor with a door alarm report for the L door from 6/28/25 through 7/28/25. Surveyor requested to review the door alarm report that covered 5/31/25, however, PM-I indicated the door report only went back 30 days. PM-I also provided a bi-annual inspection report of all doors completed on 5/12/25 that indicated all doors passed inspection. The facility's last elopement drill was completed on 11/1/24 with 12 staff. The facility also provided door inspections that were completed on 5/21/25, 6/11/25, and 7/9/25 with no concerns noted.On 7/30/25 at 3:09 PM, Surveyor interviewed Social Worker (SW-H) via phone. SW-H recalled R7 and indicated the facility had a behavior management meeting once per month in which all residents taking psychotropic medication and/or had behaviors were reviewed. SW-H did recall discussing R7 at the meetings and would have placed a note in the chart. When Surveyor read the progress note (dated 5/6/25) that indicated R7 wanted to jump in the stairwell and discussed R7's repeated attempts to enter the stairwell and exit the building, SW-H was not aware that R7 expressed a desire to jump down the stairwell on 5/6/25. SW-H indicated SW-H would have contacted the physician, updated the care plan, and met with the team to put interventions in place for R7's safety. SW-H did not recall discussing formal 1:1 supervision for R7 or moving R7 away from the stairwell door or to the first floor. SW-H indicated all of the options would have been on the table to discuss with the team had SW-H been aware of R7's suicidal ideation. SW-H did recall R7's elopement on 5/31/25, but thought R7 was found in a courtyard. SW-H was not sure who informed SW-H and indicated SW-H did not take part in an investigation.The failure to supervise a resident with a history of accessing a stairwell, expressing a desire to jump, and attempting to elope from the facility and the failure to ensure exit doors alarmed appropriately created a reasonable likelihood for serious harm that led to a finding of immediate jeopardy. The immediate jeopardy was removed on 7/29/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harms/isolated) as the facility continues to implement the following action plan:Equipped direct care team members with emergency notification devices (i.e., tablets, cell phones) connected to each stairwell and egress door.Educated staff on the following: The revised notification process when a stairwell door is accessed and prompt response to the alarm: Not to block emergency exits with equipment; Emergency preparedness procedures related to the loss of utilities.Corporate staff educated the NHA and DON on conducting a thorough investigation following an elopement.Reviewed residents at risk for elopement or change in condition at daily clinical meetings for 3 months to ensure safety.Implemented bi-weekly exit and egress door audits.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R)5 (R1 and R15) of 2 sampled residents.R1 reported that R1 was missing $40 and a silver dollar coin. The facility did not report the allegation of misappropriation to local law enforcement.R15 reported that $280 was taken from R15's room. The facility did not report the allegation of misappropriation to the State Agency (SA) or local law enforcement.Findings include: The facility’s Abuse, Neglect and Exploitation Policy, dated 9/20/24, indicates: It is the policy of this community to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The Community will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations. The Community will designate an Abuse and Neglect Prevention Coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law .The Community will have written procedures that include: 1. Reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (law enforcement when applicable) within specified timeframes. 1.On 7/28/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including rhabdomyolysis, diabetes, muscle weakness, peripheral vascular disease (PVD), congestive heart failure, and spinal stenosis. R1’s Minimum Data Set (MDS) assessment, dated 6/14/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition. On 7/28/25, Surveyor reviewed a facility-reported incident that indicated on 6/14/25, R1 and a family member reported to Registered Nurse (RN)-C that R1 was missing $40 and a silver dollar coin. RN-C documented the report and informed Nursing Home Administrator (NHA)-A and the on-call nurse. The investigation did not indicate local law enforcement was not notified. On 7/28/25 at 10:19 AM and 10:36 AM, Surveyor interviewed NHA-A who indicated as R1 was being discharged , R1 reported to RN-C that R1 was missing $40 and a silver dollar coin. NHA-A indicated RN-C offered to call law enforcement but R1 and R1's family did not want that. NHA-A indicated the facility did not have documentation regarding the offer to call law enforcement, however, NHA-A called RN-C to provide a statement. 2. On 7/28/25, Surveyor reviewed R15’s medical record. R15 had diagnoses including diabetes, left femur fracture, PVD, and heart failure. R15’s MDS assessment, dated 5/24/25, had a BIMS score of 15 out of 15 which indicated R15 had intact cognition. On 7/28/25, Surveyor reviewed an incident that indicated R15 reported money missing. The investigation did not indicate local law enforcement was notified of the missing money. On 7/28/25 at 11:20 AM, Surveyor interviewed RN-C via telephone. RN-C verified RN-C was working on 5/24/25 when R15 was discharged from the facility. RN-C indicated R15’s daughter stated NHA-A was going to give R15 a $200 gift certificate related to R15’s missing money. RN-C called NHA-A and received a text message that NHA-A that it would be taken care of. RN-C had no prior knowledge of the missing money or a gift card and received no further information after 5/24/25. On 7/28/25 at 11:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D via telephone. CNA-D indicated R15 reported to CNA-D that $280 was taken from R15’s room and R15 indicated the facility would only reimburse R15 $200. CNA-D reported the missing money approximately one week before R15 discharged but could not remember the exact date or to whom it was reported. CNA-D indicated NHA-A and the Social Worker (SW) were aware of the allegation of misappropriation. On 7/28/25 at 12:10 PM, Surveyor interviewed NHA-A who indicated NHA-A had little knowledge of the allegation and the SW (who was unavailable) was working on a grievance that was not yet on file. NHA-A verified NHA-A received a text from RN-C on 5/24/25 and delivered a $200 gift card to R15 that day. NHA-A verified the facility did not report the allegation of misappropriation to the SA or notify local law enforcement.

Based on staff interview and record review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 residents (R) (R1 and R15) of 2 sampled residents. R1 reported that R1 was missing $40 and a silver dollar coin. The facility did not thoroughly investigate the allegation of misappropriation.R15 reported that $280 was missing from R15's room. The facility did not thoroughly investigate the allegation of misappropriation.Findings include: The facility’s Abuse, Neglect and Exploitation Policy dated 9/20/24 indicates: It is the policy of this Community to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The Community will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations. The Community will designate an Abuse and Neglect Prevention Coordinator in the Community who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; Providing complete and thorough documentation of the investigation. 1.On 7/28/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including rhabdomyolysis, diabetes, muscle weakness, peripheral vascular disease (PVD), and spinal stenosis. R1’s Minimum Data Set (MDS) assessment, dated 6/14/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition. On 7/28/25, Surveyor reviewed a facility-reported incident that indicated on 6/14/25, R1 and a family member reported to Registered Nurse (RN)-C that R1 was missing $40 and a silver dollar coin. RN-C documented the report and informed Nursing Home Administrator (NHA)-A and the on-call nurse. The facility interviewed several residents. None reported missing money. The investigation indicated each resident's room is equipped with a lockable drawer and key which is provided to the resident. An audit was conducted to ensure all rooms were properly equipped. The investigation indicated the facility could not be substantiate misappropriation due to a lack of evidence and the inability to identify a suspect. The investigation did not indicate staff interviews were completed. On 7/28/25 at 10:19 AM, Surveyor interviewed NHA-A who indicated as R1 was being discharged , R1 reported to RN-C that R1 was missing $40 and a silver dollar coin. NHA-A verified NHA-A interviewed residents but did not interview staff regarding R1's missing items. 2. On 7/28/25, Surveyor reviewed R15’s medical record. R15 had diagnoses including diabetes, left femur fracture, PVD, and heart failure. R15’s MDS assessment, dated 5/24/25, had a BIMS score of 15 out of 15 which indicated R15 had intact cognition. On 7/28/25, Surveyor reviewed an incident that indicated R15 reported money missing. The incident did not indicate that an investigation was completed. On 7/28/25 at 11:20 AM, Surveyor interviewed RN-C via telephone who verified RN-C was working on 5/24/25 when R15 was discharged from the facility. RN-C indicated R15’s daughter stated NHA-A was going to give R15 a $200 gift card for R15’s missing money. RN-C had no prior knowledge of R15’s missing money or a gift card. On 7/28/25 at 11:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D via telephone who indicated R15 reported to CNA-D that $280 was taken from R15’s room. R15 indicated the facility would only reimburse R15 $200. CNA-D indicated CNA-D reported the missing money approximately one week before R15 discharged but could not remember the exact date or to whom it was reported. CNA-D indicated NHA-A and the Social Worker (SW) were aware of the allegation of misappropriation. On 7/28/25 at 12:10 PM, Surveyor interviewed NHA-A who indicated NHA-A had little knowledge of the allegation and the facility's SW (who was unavailable) was working on a grievance which was not yet on file. NHA-A confirmed the facility did not complete a thorough investigation for the allegation of misappropriation and verified the facility did not interview other residents or staff who may have been able to provide information related to the allegation.

Based on staff and resident interview, record review, and review of the facility's policy, the facility did not ensure the medical record was complete and accurate for 1 resident (R) (R9) of 9 sampled residents. R9 had medications brought from home that R9 administered independently. The medications were not identified in R9's medical record. This had the potential for staff not to be aware of what medications were being independently administered by R9 which could potentially create a medication error. Findings include: R9's undated Face Sheet located under the Profile tab in R9's electronic medical record (EMR) indicated R9 was admitted to the facility on [DATE]. R9's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. During an interview on 6/10/25 at 10:00 AM, R9 stated, The first night that I was here, the facility was not ready for me and didn't have my medications here that I needed to take. I got so upset that I called my husband at work and told him I needed him to bring me my medicines so that I would have something to take. I have to take my pain medicine and the nurse told me there wasn't any of it here for me to take. The nurse said she called the pharmacy and they wouldn't give her permission for me to have any until it was delivered and it was going to be around 3:00 AM. R9 confirmed R9 took pain medication and insulin that R9's husband brought to the facility on the first night. R9's nursing progress notes did not contain documentation that Licensed Practical Nurse (LPN)1 spoke to R9 about what medications were available at the facility for R9 other than a documented conversation that indicated R9's pain medication would be available once received from the pharmacy delivery at approximately 3:00 AM. The documentation also indicated the physician was not notified that R9 took R9's medications from home because R9's medications were not available until 3:00 AM during the next pharmacy delivery. During an interview on 6/10/25 at 1:05 PM, Director of Nursing (DON)B revealed DONB spoke with the nurse who was assigned to R9 on the evening R9 was admitted . DONB indicated the nurse told R9 the facility had R9's insulin and offered the insulin. R9 refused and stated R9 would take R9's insulin when R9's spouse returned to the facility with it. The nurse indicated the facility did not have R9's narcotic medication and had to wait until the pharmacy delivered the medication at approximately 3:00 AM. When DONB was asked if this was documented in R9's medical record, DONB stated, I would have to look at the documentation for that specifically. There was no further documentation provided from DONB regarding medications brought into the facility by R9's family member. During an interview on 6/10/25 at 1:28 PM, LPN2 revealed R9 was a difficult admission. LPN2 said LPN2 asked R9 that evening what medications R9 took. LPN2 indicated R9 took R9's own insulin even though LPN2 told R9 the facility had insulin in the emergency refrigerator that LPN2 could administer. The facility's Charting and Documentation policy, dated July 2017, indicates: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's electronic medical record. The electronic medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. The practice had the potential to affect all residents residing in the facility. Staff did not wear hair or beard restraints in the kitchen and kitchenettes. Staff did not have ensure the dishwasher rinse cycle reached the required temperature. In addition, staff did not document dishwasher surface temperatures to ensure proper sanitization. Staff did not test the quaternary sanitizing solution per manufacturer's instructions. Findings include: During an initial kitchen tour that began at 9:11 AM on 2/24/25, Director of Culinary Service (DCS)-D indicated the facility follows the Food and Drug Administration (FDA) Food Code. Hair/Beard Restraints: The 2022 FDA Food Code documents at 2-402.11: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles. The facility's Uniform Dress Code policy, revised 1/2024, indicates: Personal cleanliness and a neat appearance are essential for the food service worker .Wear the approved hair restraint when on duty regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents .Restrain all facial hair with a beard net/restraint . The facility's Dress Guidelines for Food Service Management and Clinical Nutrition Staff policy, revised 1/2022, indicates: Dress for food service management and clinical nutrition staff must be professional in appearance and function to portray a positive image of the department .Hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guests, such as vendors . During a continuous kitchen observation that began at 10:45 AM on 2/25/25, Surveyor entered the kitchen and observed Activity Aide (AA)-G in the dry storage area obtaining snack food without a hair restraint. AA-G indicated AA-G did not enter the kitchen area and did not need to wear a hair restraint in the dry storage area. Surveyor also observed Dietary Aide (DA)-I enter the kitchen without a hair restraint. DA-I walked through the kitchen to a back office, bagged cookies from a prep shelf, and then cleaned and completed kitchen tasks. Surveyor interviewed DA-I who indicated DA-I was not doing food prep and does not ever wear a hair net because DA-I's hair is in a ponytail. Surveyor also observed [NAME] (CK)-F prepare food for lunch. Surveyor noted CK-F had a full beard and mustache and was not wearing a beard restraint. Surveyor interviewed CK-F who indicated CK-F did not need to wear a beard restraint per the facility's policy because CK-F's beard was not longer than two inches. On 2/25/25 at 11:57 AM, Surveyor observed AA-H in the first floor kitchenette (where the steam table was located and food was served) without a hair restraint. Surveyor interviewed AA-H who indicated AA-H should not be in the kitchenette without a hair restraint. On 2/25/25 at 1:23 PM, Surveyor interviewed DCS-D who indicated staff who enter or work in the kitchen regardless of their position are required to wear a hair restraint, including those who enter unit kitchenettes where food service occurs. DCS-D indicated staff with beards should wear beard restraints. DCS-D was not sure if the facility's policy specified a beard length. Mechanical Ware Washer and Three-Compartment Sink Sanitization: The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Ware Washing: Water temperature is critical to sanitization in ware washing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual ware washing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the ware washing machine meet or exceed the required 71 degrees Celsius (C) (160 degrees Fahrenheit (F)). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical ware washers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The 2022 FDA Food Code documents at 4-501.110 Mechanical Ware Washing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type ware washers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74 degrees C (165 degrees F); (2) For a stationary rack, dual temperature machine, 66 degrees C (150 degrees F); (3) For a single tank, conveyor, dual temperature machine, 71 degrees C (160 degrees F); or (4) For a multi-tank, conveyor, multi-temperature machine, 66 degrees C (150 degrees F). The 2022 FDA Food Code documents at 4-501.112 Mechanical Ware Washing Equipment, Hot Water Sanitization Temperatures. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines Annex 3-173: The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. During an initial kitchen tour that began at 9:11 AM on 2/24/25, Surveyor and DCS-D noted the facility's ware washing machine was a hot water sanitizing machine. DCS-D confirmed the ware washing machine should reach 150 degrees F for the wash cycle and 180 degrees F for the sanitizing cycle. Surveyor observed the first load of dishes and noted the temperature reached 150 degrees F for the wash cycle and 163 degrees F for the sanitizing cycle. DCS-D reloaded the dishes and ran the wash cycle again. Surveyor noted the temperature reached 160 degrees F for the wash cycle and 163 degrees F for the sanitizing cycle. DCS-D indicated the ware washing machine was recently serviced and previously worked fine. During the observation, Surveyor did not observe an alternative sanitizing method for dishes used for cooking and resident meal consumption. Surveyor reviewed the facility's ware washing documentation which indicated a temperature of 180 degrees F for all sanitizing cycles in February of 2025. Surveyor interviewed DCS-D who indicated staff are required to use internal temperature strips. Surveyor noted there were no internal temperature strips noted on the ware washing documentation. During a continuous kitchen observation that began at 10:45 AM on 2/25/25, DCS-D approached Surveyor and indicated the ware washing machine booster was not working and the ware washing machine was not reaching a temperature of 180 degrees F for the sanitizing cycle. DCS-D indicated the ware washing machine was being used to wash and rinse dishes and the three-compartment sink quaternary sanitizer was being used to sanitize pots, pans, prep dishes, utensils, and dishware used by residents for meal service. On 2/25/25 at 1:23 PM, Surveyor interviewed DCS-D who confirmed the ware washing machine did not reach the required temperature and was unsure when the machine stopped working. DCS-D indicated the machine reached the appropriate temperature at times and verified staff were not documenting that internal surface temperature strips were used to ensure proper sanitization. Sanitizing Solution Testing: The Diversey quaternary test strip package insert indicates the test solution should be between 65 and 85 degrees F at the time of testing. During an initial kitchen tour that began at 9:11 AM on 2/24/25, Surveyor observed dishes in the three-compartment sink. DCS-D indicated pots, pans, prep bowls, and other items are washed in the three-compartment sink. DCS-D indicated staff use quat sanitizer in the third compartment of the sink to sanitize the dishes and in buckets to sanitize and clean food prep areas. During a continuous kitchen observation that began at 10:45 AM on 2/25/25, Surveyor observed CK-E fill the third compartment of the three-compartment sink that contained Diversey quat sanitizing solution. CK-E indicated CK-E does not test the water temperature and indicated a test strip was used to test the parts per million (PPM) of the sanitizing solution. CK-E retrieved a mechanical ware washing surface temperature strip and asked Surveyor if it was the correct strip to use. CK-E indicated CK-E was not sure and read the strip. CK-E then took a chlorine test strip and indicated CK-E would use the strip to ensure the quat sanitizer was at the correct PPM. Surveyor noted Diversey quat sanitizer test strips were in a bag of various test strips that CK-E used to obtain the ware washing surface temperature and chlorine sanitizing solution test strips. Surveyor observed CK-E use the chlorine sanitizing test strip and confirm the PPM for a chlorine-based sanitizer at 200 PPM. Surveyor interviewed CK-E who indicated it was the correct test strip and the correct PPM. CK-E confirmed the water temperature of the sink that contained sanitizing solution was not tested . Surveyor then requested CK-E obtain the water temperature. Surveyor observed CK-E test the temperature of the water and sanitizing solution which was 139 degrees F. Surveyor noted the quat sanitizer test strips contained the following manufacturer's instructions: Diversey Qt-10 Quaternary Sanitizer Test Kit: For testing quaternary sanitizing solutions .Changes color depending on solution strength .Dipping it into a bucket of solution 10 seconds .Temperature test between 65 F and 85 F. Surveyor requested a copy of the facility's 3 compartment sink log which indicated sanitization at 200 PPM. The log did not contain documentation or a column to document the temperature of the sanitizing compartment of the three-compartment sink.

Based on staff interview and record review, the facility did not implement their abuse policy and procedure for 4 of 4 employees reviewed for caregiver background checks. The facility did not complete reference checks for Certified Nursing Assistants (CNA)-J, CNA-K, CNA-L, and CNA-M. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/20/24, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Checks include attempting to obtain information from the previous or current employer of potential team members. 2. Screenings may be conducted by the Community itself, a third-party agency, or academic institution. 3. The Community will maintain documentation of proof that the screening occurred On 2/25/25, Surveyor requested background check information, including references and CNA registry information for CNA-J, CNA-K, CNA-L, and CNA-M. Surveyor reviewed the background check information and noted the following: ~ CNA-J was hired by the facility on 1/28/25. ~ CNA-K was hired by the facility on 1/7/25. ~ CNA-L was hired by the facility on 1/14/25. ~ CNA-M was hired by the facility on 7/23/24. Surveyor noted reference checks were not provided for CNA-J, CNA-K, CNA-L, or CNA-M. On 2/25/25 at 11:00 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility does not do reference checks and the facility's system does not have the capability to do reference checks. NHA-A indicated conversations were started on 1/9/25 about making changes to the procedure. On 2/26/25 at 12:43 PM, Surveyor interviewed Human Resources Assistant (HRA)-N who indicated the facility does not do reference checks. HRA-N was not aware of a policy regarding the completion of reference checks and referred Surveyor to Director of Human Resources (DHR)-O. On 2/26/25 at 12:46 PM, Surveyor interviewed DHR-O who confirmed the facility does not do reference checks for employees because they are not a part of the onboarding package put together by the corporate office. DHR-O was not familiar with the facility's policy regarding reference checks for potential employees. DHR-O was familiar with the facility's abuse policy which specifies reference checks will be completed for potential employees. DHR-O indicated DHR-O became aware of the abuse policy reference check requirement approximately 6 weeks prior. DHR-O indicated no changes were made to the policies since 1/9/25 and verified reference checks were not being completed and had not been completed previously. On 2/26/25 at 1:00 PM, Surveyor interviewed NHA-A indicated NHA-A sent an email to corporate personnel on 1/9/25 and indicated the facility's abuse policy references the requirement for reference checks. NHA-A indicated NHA-A had not heard back from corporate personnel since the 1/9/25 email was sent and had not reached out again regarding the issue. NHA-A confirmed the facility's abuse policy is not being followed.

Based on staff interview and record review, the facility did not ensure vaccinations were offered or administered for 4 residents (R) (R12, R30, R148, and R346) of 5 sampled residents. The facility did not offer R12, R30, R148, or R346 the PCV20 vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. 1. From 2/24/25 to 2/26/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including fracture of right femur, diabetes, and hemiplegia. R12 was [AGE] years old and did not have an activated Power of Attorney (POA). R12's medical record indicated R12 received the PPSV23 vaccine on 5/17/99 and the PCV13 vaccine on 8/4/16. R12's medical record did not indicate R12 was offered or administered the PCV20 vaccine. 2. From 2/24/25 to 2/26/25, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including diabetes, dysphagia, respiratory failure, and pneumonia. R30 was [AGE] years old and had an activated POA. R30's medical record indicated R30 received the PPSV23 vaccine on 10/10/07 and the PCV13 vaccine on 9/7/16. R30's medical record did not indicate R30 was offered or administered the PCV20 vaccine. 3. From 2/24/25 to 2/26/25, Surveyor reviewed R148's medical record. R148 was admitted to the facility on [DATE] and had diagnoses including discitis, diabetes, and pleural effusion. R148 was [AGE] years old and did not have an activated POA. R148's medical record indicated R148 received the PPSV23 vaccine on 1/17/12 and the PCV13 vaccine on 1/11/16. R148's medical record did not indicate R148 was offered or administered the PCV20 vaccine. 4. From 2/24/25 to 2/26/25, Surveyor reviewed R346's medical record. R346 was admitted to the facility on [DATE] and had diagnoses including asthma, ulcerative colitis, and myelopathy. R346 was [AGE] years old and did not have an activated POA. R346's medical record indicated R346 received the PPSV23 vaccine on 4/11/13 and the PCV13 vaccine on 1/11/18. R346's medical record did not indicate R346 was offered or administered the PCV20 vaccine. On 2/26/25 at 1:32 PM, Surveyor interviewed Infection Preventionist (IP)-C who indicated it was IP-C's understanding that R12, R30, R148, and R346 did not need further vaccinations. IP-C indicated IP-C was not aware IP-C needed to offer the PCV20 vaccine and did not have a system in place to offer residents PCV20 vaccination. When Surveyor showed IP-C the CDC guidelines for PCV20 vaccination, IP-C verified the recommendations and indicated IP-C would offer the PCV20 vaccine in the future.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R248) of 1 sampled resident received care and treatment based on the resident's needs and medical orders. R248 was not provided wound care for a right below-the-knee amputation (BKA) as ordered. In addition, staff did not monitor R248's vital signs in accordance with the facility's policy, Findings include: The Facility's Wound Care policy, dated October 2010, indicates: The purpose of this procedure is to provide a guideline for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician order for this procedure .13. Dress wound .Mark tape with initials, time, and date and apply to dressing .Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given .6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. The Facility's Vital Signs policy, dated 2024, indicates: The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs .3. Vital signs shall be obtained at least in the following circumstances: .c. At least daily for a resident receiving skilled services. From 2/24/25 to 2/26/25, Surveyor reviewed R248's medical record. R248 was admitted to the facility on [DATE] and had diagnoses including sepsis, gangrene, right BKA, diabetes, hypertension, and thyroidectomy. R248's Minimum Data Set (MDS) assessment, dated 2/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R248 was not cognitively impaired. R248 was responsible for R248's healthcare decisions. On 2/24/25 at 11:36 AM, Surveyor interviewed R248 who expressed a fear of infection since R248's right BKA surgical incision dressing had not been changed since admission. Surveyor observed R248's dressing which was dated 2/17/25. R248 also expressed concern that R248's blood pressure was not being monitored. R248 indicated R248 had a history of retaining fluids and R248's endocrinologist was diligent with monitoring R248's blood sugar and blood pressure. R248 indicated staff informed R248 that the facility was not a hospital and would address R248's concerns on 2/24/25 (Monday). R248's medical record contained an order, dated 2/21/25, for R248's right BKA surgical wound that stated to cleanse with wound cleanser and pat dry. Apply Xeroform followed by an ABD pad. Wrap with Kerlix and secure with tape. Wrap with Ace or Coban wrap every evening shift every other day and as needed. Replace if soiled or dislodged. R248's medical record did not contain a physician order that indicated how often to monitor R248's vital signs. Surveyor reviewed the facility's vital signs policy which stated vital signs should be completed at least daily for a resident who receives skilled services. R248's medical record did not indicate R248's vital signs were obtained on 2/24/25. On 2/26/25 at 9:15 AM, Surveyor interviewed R248 who indicated R248's right BKA dressing was changed on 2/24/25 and the nurse informed R248 that the dressing should have been changed sooner. On 2/26/25, Surveyor reviewed R248's Treatment Administration Record (TAR) and noted R248's right BKA dressing change was initialed as completed on 2/21/25 and 2/23/25 but not on 2/24/25. On 2/26/25 at 10:15 AM, Surveyor interviewed Director of Nursing (DON)-B who reviewed nursing notes that indicated a nurse changed R248's dressing on 2/24/25, however, the dressing change was not documented in R248's TAR. DON-B stated DON-B would check the TAR documentation from 2/21/25 to 2/23/25 since R248's dressing change was noted as completed. (Note: Surveyor observed R248's dressing on 2/24/25 which was dated 2/17/25 and R248 stated the dressing had not been changed since admission.) DON-B indicated DON-B expects staff to complete dressing changes as ordered and document completion in the TAR. DON-B also indicated vital signs are based on Medical Doctor (MD) orders. DON-B indicated if a resident does not have an order, the facility's standing order is implemented upon admission which indicates vital signs should be obtained every shift for 3 days and then daily or as ordered. DON-B verified R248's vital signs were not monitored on 2/24/25. DON-B indicated DON-B expects staff to obtain vital signs daily or as ordered. On 2/25/25 at 11:06 AM, Surveyor interviewed Registered Nurse (RN)-T who indicated if the Medical Director does not follow a resident, the expectation is that vital signs are completed every shift. Surveyor noted the Medical Director followed R248. On 2/26/25 at 1:31 PM, Surveyor interviewed DON-B who indicated DON-B spoke with the nurse who documented R248's dressing change in the TAR on 2/21/25 and verified the dressing change was not completed as documented. DON-B was unable to reach the nurse who indicated the dressing change was completed on 2/23/25.

Based on observation, staff interview, and record review, the facility did not ensure a fall intervention was implemented for 1 resident (R) (R17) of 2 sampled residents. R17 had a history of falls and a care plan intervention that stated R17's walker should be within reach. The intervention was not consistently followed. Findings include: The facility's Falls-Clinical Protocol policy, dated 2001, indicates: For an individual who has fallen, the staff and practitioner will try to identify possible causes within 24 hours of the fall .The staff and physician will continue to collect and evaluate information until either the cause of the fall is identified, or it is determined that the cause cannot be found or is not correctable .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on the assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . From 2/24/25 to 2/26/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including osteoarthritis, generalized muscle weakness, unsteadiness on feet, right leg atherosclerosis and thrombosis, severe protein-calorie malnutrition, restlessness and agitation, and subarachnoid hemorrhage (bleeding in the brain). R17's most recent Minimum Data Set (MDS) assessment, dated 2/4/25, indicated R17 had moderate cognitive impairment. R17 did not have an activated Power of Attorney (POA) for healthcare. R17's medical record indicated R17 was prescribed anticoagulant (blood thinning) medication and was at risk for falls. On 2/14/25, R17 had an unwitnessed fall and was found on the left side next to R17's bed. R17 stated R17 hit the back of R17's head on the nightstand. R17 sustained two abrasions on the back of the head and a bleeding abrasion on the right elbow. On 2/22/25, R17 had another unwitnessed fall and was found sitting on R17's buttocks in a closet in R17's room. R17 indicated R17 attempted to walk from the bed to R17's wheelchair when R17 fell . R17 stated R17 hit R17's head during the fall. A care plan, initiated 1/28/25, indicated R17 was at risk for falls related to deconditioning, right femoral artery occlusion, impaired mobility, and pain (revised 2/2/25). The care plan contained the following interventions (dated 1/28/25): Anticipate and meet R17's needs; Assist with toileting; Bed in low position; Educate to call for assistance; Follow facility fall protocol; Physical therapy evaluate and treat as ordered or as needed; Review information on past falls and attempt to determine cause of falls; Educate resident/family/caregivers/interdisciplinary team as to causes. An intervention was added on 2/14/25 to ensure walker is within reach. An intervention was added on 2/22/25 for bilateral body pillows when in bed. A care plan, initiated 1/28/25, indicated R17 had an activity of daily living (ADL) self-care performance deficit. The care plan contained the following interventions (dated 1/28/25): R17 requires the assistance of one staff for turning and repositioning in bed; R17 requires the assistance of one staff for toileting; R17 requires the assistance of one staff to move between surfaces. On 2/24/25 at 11:05 AM, Surveyor observed R17 in a chair on the left side of R17's bed. Surveyor noted R17's walker was folded up and propped against the bedside table on the right side of the bed. On 2/26/25 at 10:00 AM, Surveyor observed R17 in a chair on the left side of R17's bed. Surveyor noted R17's walker was in the shower in R17's bathroom and not within sight or reach of R17. On 2/26/25 at 10:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-U who confirmed R17's walker was in the bathroom and out of R17's reach. CNA-U indicated R17 was at risk for falls and had fallen at the facility. CNA-U expressed concern that R17 would fall again if R17 attempted to use the walker unsupervised. On 2/26/25 at 10:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-V who confirmed R17's walker was not within reach. LPN-V confirmed R17's care plan indicated R17's walker should be within reach. LPN-V indicated R17's gait was unsteady and expressed concern that R17 would fall if R17 attempted to use the walker without staff assistance. LPN-V indicated LPN-V did not feel it was safe to leave R17's walker within reach. On 2/26/25 at 10:29 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R17's walker should be within reach as care planned. DON-B indicated R17 fell on [DATE] because R17 was reaching for the walker. DON-B was not aware of staffs' safety concerns about having R17's walker within reach. On 2/26/25 at 10:54 AM, Surveyor interviewed Rehabilitation Department Director (RDD)-W who indicated R17 required moderate assistance with transfers and ambulation. RDD-W indicated it was not safe for R17 to walk unsupervised and it was unsafe for R17 to use the walker independently. RDD-W indicated R17 required 50-75% of physical assistance with transfers. On 2/26/25 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed NHA-A expects staff to keep R17's walker within reach if it is a part of R17's care plan.

Based on observation, staff interview, and record review, facility did not ensure proper care and treatment for 2 residents (R) (R250 and R148) of 4 sampled residents who received medication through a peripherally inserted central catheter (PICC) line. R250 and R148's PICC line dressings and injection caps were not changed as ordered. Findings include: The facility's Central Venous Catheter Care and Dressing Changes policy, dated March 2022, indicates: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). 1. On 2/25/25, Surveyor reviewed R250's medical record. R250 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, endocarditis, hypoxia, and diabetes. R250's Minimum Data Set (MDS) assessment, dated 2/24/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R250 had moderate cognitive impairment. R250 was responsible for R250's healthcare decisions. On 2/25/25 at 9:55 AM, Surveyor interviewed R250 regarding the PICC line in R250's left upper arm and noted R250's PICC line dressing and injection caps were dated 2/17/25. R250 indicated the dressing and injection caps had not been changed since admission. R250 had orders, dated 2/17/25, to monitor the PICC line site every shift for signs and symptoms of infection and change the PICC line dressing and injection caps weekly one time a day every Monday. R250's treatment administration record (TAR) indicated R250's PICC line dressing and injection caps were changed on 2/24/25. On 2/25/25 at 10:02 AM, Surveyor interviewed Registered Nurse (RN)-T who indicated a checkmark in the TAR means the order was completed. RN-T and Surveyor then observed R250's PICC line dressing and injection caps. RN-T verified R250's PICC line dressing was dated 2/17/25. On 2/25/25 at 10:11 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated if an order is signed off on the TAR, DON-B expects staff to complete the order. DON-B verified R250's PICC line dressing and injection caps were not changed as ordered. DON-B indicated DON-B expects staff to change PICC line dressings and injection caps per the resident's orders. 47248 2. From 2/24/25 to 2/25/25, Surveyor reviewed R148's medical record. R148 had diagnoses including discitis (infection of the spinal column), spinal stenosis, lumbar region with neurogenic claudication (a syndrome caused by a pinched spinal nerve that causes pain in the legs and lower back), diabetes mellitus type 2, and enterocolitis (inflammation of the inner lining of the small intestine and the colon) due to Clostridium difficile (C. diff). R148's MDS assessment, dated 2/19/25, had a BIMS score of 15 out of 15 which indicated R148 had intact cognition. On 2/24/25 at 11:15 AM, Surveyor interviewed R148 who indicated staff change R148's PICC line dressing and equipment on Mondays which should be completed that day. Surveyor noted R148's PICC line dressing and equipment were dated 2/17/25. R148's medical record contained the following orders: ~ Change injection caps weekly with PICC line dressing change one time a day every Monday. ~ Change PICC line dressing weekly. Label with date one time a day every Monday. On 2/25/25 at 9:00 AM, Surveyor reviewed R148's TAR which indicated R148's PICC line dressing and injection caps were changed on the 2/24/25 AM shift. On 2/25/25 at 10:51 AM, Surveyor observed R148 in bed and noted R148's PICC line dressing and injection caps were dated 2/25/25. R148 indicated nursing staff just changed R148's dressings and injection caps. R148 indicated nursing staff must have been busy yesterday and the dressing was not changed on 2/24/25 as ordered.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R12) of 3 sampled residents. R12 had a wound and was on enhanced barrier precautions (EBP). On 2/24/25 and 2/26/25, staff provided care for R12 without wearing the proper personal protective equipment (PPE). Findings include: The facility's Enhanced Barrier Precautions policy, revised 4/5/24, indicates: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organism (MDROs) to staffs' hands and clothing .1. Enhanced Barrier Precautions will be implemented for the following (including new admissions) .Wounds: This generally includes residents with chronic wounds, and not those with only shorter lasting wounds, such as skin breaks or skin tears covered with a Band-Aid or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers .4. All team members will wear appropriate PPE (gown and gloves) for high-contact resident cares but not limited to: peri-care, device care (central line, urinary catheter, feeding tube, tracheostomy/ventilator, ostomy). transfers, toileting (excludes transfer outside of the resident's room (i.e., dining room, living room), bathing, wound care, hands on exercises (including therapy and restorative), when handling soiled linens (including housekeeping), specimen collection (i.e., blood draws, cultures, urine collection) . From 2/24/25 to 2/26/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including urinary tract infection (UTI), cerebral infarction, and type two diabetes mellitus. R12's Minimum Data Set (MDS) assessment, dated 1/30/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R12 had intact cognition. R12 acquired skin wounds while at the facility. On 2/24/25 at 10:49 AM, Surveyor observed the entrance to R12's room which contained an EBP sign near the door and a PPE cart and a garbage can near the entrance. R12's door was closed and staff were inside assisting R12 into bed. Surveyor could hear the staff speaking with R12 about peri-care and dressing. On 2/24/25 at 10:56 AM, Surveyor observed Certified Nursing Assistant (CNA)-M and CNA-P exit R12's room with a Hoyer lift. Surveyor noted CNA-M and CNA-P were not wearing gowns or gloves and interviewed CNA-M and CNA-P as they exited the room. CNA-M and CNA-P indicated they transferred R12 into bed. CNA-M confirmed CNA-M did not wear a gown during cares. When Surveyor asked CNA-M if R12 was on EBP, CNA-M indicated CNA-M was not sure because R12 was in the hallway when CNA-M brought R12 to R12's room for cares and to be transferred into bed. Surveyor and CNA-M then observed the EBP sign near R12's door. CNA-M indicated CNA-M did not think R12 was on EBP because R12's catheter was removed over two weeks ago. On 2/24/25 at 11:09 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Q who indicated R12 had open wounds on the buttocks and mid-spine. LPN-Q indicated R12's back wound was discovered that day and confirmed R12 was on EBP. LPN-Q indicated staff who provide cares and transfer R12 should follow the EBP orders and wear appropriate PPE, including a gown and gloves. R12's medical record contained the following orders: ~ Cleanse moisture-associated skin damage (MASD) to left buttock with soap and water, rinse and pat dry. Apply Xeroform to open areas. Cover with border foam every day shift. (Start date: 2/21/25) ~ Back mid-spine. Cleanse with soap and water, rinse and pat dry. Apply Xeroform to open area then cover with border foam in the morning. Back middle of spine. (Start date: 2/25/25) ~ Pro-Stat AWC Oral Liquid (Amino Acids-Protein Hydrolysate). Give 30 milliliters (ml) by mouth in the afternoon for wound healing (Start date: 2/25/25) ~ Enhanced Barrier Precautions. Gown and gloves should be worn while providing high-contact resident care (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting). (Start date: not indicated) R12's plan of care indicated the following: ~ R12 had a pressure injury on the spine related to impaired mobility, bony protrusion of spine, reference to remain in bed majority of day and on back, history of cerebrovascular accident (CVA) with right-sided weakness, recent right femur fracture status-post repair. (Initiated: 2/24/25) ~ R12 has actual impairment to skin integrity of the bilateral buttocks related to MASD. (Initiated: 2/17/25) ~ Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the Medical Doctor (MD). (Initiated: 2/24/25) ~ Diet, supplement/vitamins/protein to promote wound healing. (Initiated: 2/24/25) ~ Enhanced Barrier Precautions-Gown and gloves should be worn while providing wound care. (Initiated: 1/31/25) On 2/26/25 at 8:21 AM, Surveyor observed Restorative Aide (RA)-R in R12's room with the door open. Surveyor interviewed RA-R when RA-R exited R12's room. RA-R confirmed RA-R had just assisted R12 and was aware that R12 was on EBP. RA-R confirmed RA-R had initially donned PPE to assist R12 with restorative services, but removed PPE to exit and renter R12's room. RA-R confirmed RA-R did not don a gown prior to propping R12's legs up with pillows. RA-R indicated RA-R should have worn PPE to touch R12. On 2/26/25 at 11:34 AM, Surveyor interviewed Therapy Program Manager (TPM)-S who indicated if a resident is on EBP, restorative staff should follow PPE requirements for transfers, cares, and touching the resident. On 2/26/25 at 11:34 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should be aware of and follow the facility's EBP policies and procedures.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 3 sampled residents. On 11/4/24, staff witnessed Licensed Practical Nurse (LPN)-C verbally abuse R1. The facility did not report the verbal abuse to local law enforcement. Findings include: The facility's Abuse Neglect and Exploitation Policy, revised 9/20/24, indicates: Abuse means the willful infliction of . intimidation .pain or mental anguish, which can include staff and resident abuse .it includes verbal abuse .and mental abuse .Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .A. The community will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse . On 1/9/25, Surveyor reviewed R1's medical record. R1 received Hospice services and had diagnoses including dementia, anxiety, and depression. R1's Minimum Data Set (MDS) assessment, dated 12/23/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R1's health care decisions. On 1/9/25, Surveyor reviewed a facility-reported incident (FRI) regarding an allegation of verbal abuse that involved R1 and LPN-C. The FRI indicated on 11/4/24 at approximately 7:45 AM, R1 was in a common area crying out for help. Staff observed LPN-C yell at R1. Staff reported LPN-C stated Stop and Shut up and Stop being a fool. You should be ashamed of yourself. On 1/9/25 at 11:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who confirmed CNA-E witnessed the verbal abuse on 11/4/24. CNA-E indicated LPN-C was more than 20 minutes late for work and LPN-C's behavior was abnormal. CNA-E was providing care in a resident's room when CNA-E heard LPN-C yelling loudly in the central area. CNA-E went to the central area in response to LPN-C's raised voice and observed R1 seated and crying out for help. CNA-E observed LPN-C repeatedly yell Be quiet at R1. On 1/9/25 at 11:35 AM, Surveyor interviewed Housekeeper (HK)-D who confirmed HK-D witnessed the verbal abuse on 11/4/24. HK-D indicated HK-D observed LPN-C yell Shut up with a raised voice in response to R1 calling out for assistance. HK-D expressed concern that LPN-C was under the influence of alcohol at the time because LPN-C had an unsteady gait, a raised voice, and unusual behavior. On 1/9/25 at 1:34 PM, Surveyor interviewed LPN-F who indicated LPN-F witnessed the verbal abuse on 11/4/24. LPN-F indicated LPN-C reported to work approximately 30 minutes late. LPN-F attempted to give (nursing) report to LPN-C, however LPN-C was disruptive, yelled, cussed, slurred LPN-C's words, and swayed when standing. LPN-F observed LPN-C yell and say inappropriate things to R1. On 1/9/25 at 2:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the incident between LPN-C and R1 on 11/4/24 constituted verbal abuse. NHA-A verified law enforcement was not notified of the incident. NHA-A indicated the local police department have been notified of the allegation of abuse.

Based on observation, interview, and record review the Facility did not ensure 2 (R17 & R27) of 2 Residents reviewed received the necessary treatment and services to prevent the development of pressure injuries. R17 was readmitted to the facility on [DATE]. The Facility contends R17 was admitted with a right heel DTI (deep tissue injury) from the hospital due to hospital note dated 3/14/18. The Facility did not develop a potential for skin integrity care plan until 4/3/18 and an impaired skin integrity care plan until 4/25/18. There were no revisions in R17's care plan after the pressure injury declined. Observations were made of R17's left heel not being offloaded during the survey. R27's heels were not offloaded according to her plan of care. Findings include: 1.) R17 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. R17 was readmitted to the facility on [DATE]. The initial care plan dated 3/23/18 documents N/A (non applicable) GOAL: Prevent/Heal Pressure Sores Other Pressure Ulcer/Skin at Risk Interventions 'is blank' Pressure Ulcer/Skin at Risk Notes/Comments 'is blank.' The Braden assessment dated [DATE] has a score of 12 which indicates high risk for the potential development of pressure injuries. The skin risk evaluation dated 3/28/18 answers no for the question Resident has a Stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device. The Resident summary dated 3/28/18 for section FYI (for your information): Resident is High Risk for Pain Skin breakdown. Under reminders and notes documents Has paralysis to LE (lower extremity). The admission MDS (minimum data set) with an assessment reference date of 3/29/18, signed as complete on 4/3/18, has a BIMS (brief interview mental status) score of 15 which indicates R17 is cognitively intact. R17 requires extensive assistance with two plus person physical assist for bed mobility and transfer. R17 is at risk for developing pressure ulcers and is coded as R17 not having any pressure ulcers. The pressure ulcer CAA (care area assessment) dated 4/3/18 under care plan considerations documents Skin score is 7, R17 is at risk for pressure related skin break down. He is on renal diet, his [MEDICATION NAME] and total protein levels are subnormal, he is receiving proheal protein supplements at this time. He has a good appetite RD (Registered Dietitian) will monitor closely. Will care plan for assessment and management of fragile skin status d/t (due to) multiple wound indicated during hospital stay, including history of multiple pressure areas. R17 frequently incontinent of bowel and bladder, and needs to extensive assist with bed mobility. The nurses note with an effective date of 3/30/18 and entered date of 4/3/18 documents Writer was called to assess suspicious area on right heel which was not observed from original admission or prior to hospitalization on ,[DATE]. Upon assessment writer noted a 1.2 x (times) 1.6 x 0.2 cm (centimeter) wound with a dark red dry bloody base and white, dry, hard flap attached at 3oc (o'clock) which flaked off during NS (normal saline) cleanse, edges intact, no drainage, no s/s (signs/symptoms) infection, non-tender. Surrounding tissue blanchable and presents as extreme dry cracked skin, white in appearance, to BLE (bilateral lower extremity) with [MEDICAL CONDITION]; right greater than left. Resident Re-admitted [DATE] after 10 day hospital stay dx (diagnoses) [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) with excess volume and SOB (shortness of breath). According to report resident spent a few days during the hospital stay in ICU (intensive care unit) d/t (due to)[MEDICAL CONDITION] r/t (related to) [MEDICAL TREATMENT] CVC. Writer requested any wound documentation from 03/12 hospital stay and per final progress note on 03/14 resident had a dti (deep tissue injury) to the right heel measuring 1.0 x 1.0 cm. Conclusion reached based on hospital documentation and Re-admission body check it was determined that dti was hidden under white dry flaky skin and not visualized until the dry flaky skin dislodged itself. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x 2 to total assist with ADLs (activities daily living)/transfers; independent with eating. Upon readmit low air-loss mattress initiated along with pillows and cushion to assist with turning/repositioning in bed and in w/c (wheelchair) and grab bars to assist with bed mobility. Tx (treatment) to include NS (normal saline) cleanse, skin prep surrounding tissue, Apply [MEDICATION NAME] to wound base, Cover with foam border dressing q (every) 3 days and PRN ( as needed); and [MEDICATION NAME] to BLE (bilateral lower extremities) bid (twice daily). Will continue to monitor. The at risk of skin breakdown care plan with an effective & created date of 4/3/18 has interventions effective & created 4/3/18 of: Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Perform nutritional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown. Use pillows, pads, or wedges to reduce pressure on heels and pressure points Turn/reposition between w/c (wheelchair), recliner, bed and side to side where ever he is frequently - every 1-2 hours and PRN (as needed). Do not massage skin over pressure areas. Check skin daily. Assist R17 with turning and positioning a minimum of every 2-3 hours and PRN. Pressure relieving device on bed and chair. Dietary consult, assist nutrition and hydration needs, encourage consumption of high protein foods on meal trays and all fluids provided. Skilled PT (physical therapy), OT (occupational therapy) to improve functional mobility. Assess R17 on admission for skin risk and current condition. Instruct/assist R17 in methods of reducing friction and shear (i.e. lifting vs sliding) and Barrier cream to peri area as needed. Intervention effective & created 4/3/18 and changed on 4/13/18 documents Use pillows, pads, or wedges to reduce pressure on heals (heels) and pressure points. Turn/reposition. The nurses note with an effective date and entered date of 4/13/18 documents Previous noted DTI to Right heel now appears more like a Stage 3 PRl (pressure injury) measuring 1.0 x 1.6 x 0.2 cm wound base includes 80% moist red center, 10% scattered gray slough and 10% yellow slough at 12-2oc, edges intact, no c/o (complaint of) pain with palpation, no temperature changes bilaterally. Dry flaky skin resolved. Surrounding tissue blanchable with [MEDICAL CONDITION]; right greater than left. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility. Tx to include NS cleanse, skin prep surrounding tissue, Apply [MEDICATION NAME] to wound base, Cover with foam boarder dressing q3 days and PRN; and [MEDICATION NAME] to BLE bid. Will continue to monitor. Surveyor noted this assessment is 14 days after being initially discovered, the wound was not assessed weekly. The nurses note with an effective date of 4/23/18 and with an entered date of 4/24/18 documents Stage 3 Prl measuring 1.6 x 1.5 x 0.2 cm, wound base includes 80% moist red center, 20% gray slough in center, edges intact with slight maceration, no c/o pain with palpation, no temperature changes bilaterally. Surrounding tissue blanchable with [MEDICAL CONDITION]; right greater than left. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility and heel protector boot on as much as R17 can tolerate as he tends to rest his heel on the w/c foot rest pedal. Tx changed to include NS cleanse, skin prep surrounding tissue and wound edges well, Apply collagen alginate with silver to wound base, Cover with foam border dressing q 3 days and PRN; and [MEDICATION NAME] to BLE bid. Will continue to monitor. Surveyor noted this assessment is 10 days after the previous assessment. The impaired skin integrity care plan effective and created on 4/24/18 documents interventions effective & created dated 4/24/18 of: Apply lotion to intact skin with personal care. Do wound care or dressing changes as ordered. Initiate pressure relieving measures as needed. Keep skin clean and dry. 0 Maintain adequate nutrition and hydration. Monitor and document skin integrity with each bath. Notify physician of any changes/abnormal findings. Perform skin treatments as ordered. Protect skin from moisture with barrier cream and Provide measures to decrease pressure/irritation to skin using: low air-loss mattress; pressure redistributing cushion to w/c; heel protection boot to right foot or heel lift cushion per R17's preference. An intervention with an effective & created date of 4/24/18 and changed 5/22/18 of Provide measures to decrease pressure/irritation to skin using: low air-loss mattress; pressure redistributing cushion to w/c; heel protection boot to right foot. The nurses note with an effective date of 4/30/18 and entered on 5/8/18 documents Stage 3 Prl measuring 1.2 x 1.5 x 0.4 cm, wound base includes 50% moist red center, 50% gray slough in center, edges intact with slight maceration, no c/o pain with palpation, no temperature changes bilaterally. Surrounding tissue blanchable with [MEDICAL CONDITION]; right greater than left. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility and heel protector boot on as much as R17 can tolerate as he tends to rest his heel on the w/c foot pedal. Tx includes NS cleanse, skin prep surrounding tissue and wound edges well. Apply collagen alginate with silver to wound base, Cover with foam border dressing q3 days and PRN; and [MEDICATION NAME] to BLE bid. Will continue to monitor. The nurses note with an effective date & entered date of 5/8/18 documents Stage 3 Prl measuring 1.0 x 1.2 x 0.4 cm deep at visible wound bed, wound base includes 60% gray slough and 40% moist red base from 8-12oc, edges intact with slight maceration, no c/o pain with palpation, no temperature changes bilaterally. Surrounding tissue blanchable with firm [MEDICAL CONDITION]. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility and heel protector boot on as much as R17 can tolerate as he tends to rest his heel on the w/c foot pedal. Tx change to include NS cleanse, skin prep surrounding tissue and wound edges well, Apply [MEDICATION NAME] gel to wound base f/b silver alginate, Cover with foam border dressing qod (every other day) days and prn; and [MEDICATION NAME] to BLE bid. Will continue to monitor. The nurses note with an effective date & entered date of 5/14/18 documents Stage 3 Prl measuring 1.0 x 1.1 x 0.4 cm deep at visible wound bed, wound base includes 70% gray slough and 30% moist red base from 8-12 oc, edges intact with maceration from 12-3 oc, no c/o pain with palpation, no temperature changes bilaterally. Surrounding tissue blanchable with [MEDICAL CONDITION] to bilateral feet. Resident is non-ambulatory; incontinent of bowel and bladder; and extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility. Offering heel protector boot as much as R17 can tolerate as he tends to rest his heel on the w/c foot pedal. Writer was told resident was refusing heel boot protectors over the weekend. Offloading device use reinforced by offering heel lift cushion when in bed and encouragement of heel protection boot when in wheelchair. Tx to include NS cleanse, skin prep surrounding tissue and wound edges well, Apply [MEDICATION NAME] gel to wound base f/b (followed by) silver alginate, Cover with foam border dressing qOD (every other day) days and PRN and [MEDICATION NAME] to BLE bid. Will continue to monitor. The nurses note with an effective date & entered date of 5/22/18 documents Stage 3 Prl measure slightly bigger today 1.1 x 1.4 x 0.4 cm wound bed, wound base includes 20% gray/light brown/yellow slough and 80% moist red base, edges intact with increased maceration circumferentially, no c/o pain with palpation, no temperature changes bilaterally. No s/s infection. Surrounding tissue blanchable with [MEDICAL CONDITION] +2 to bilateral feet and hemosiderin staining noted to BLE. Resident is non-ambulatory; mostly incontinent of bowel and occasionally incontinent of bladder; extensive assist x2 to total assist with ADLs/transfers; independent with eating. Current interventions include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility. Offering heel protector boot or heel lift cushion which ever R17 is more comfortable in bed. Offloading device use re-inforced (sic) along with encouragement elevation and off-loading out of w/c. R17 was able to see his wound for the first time last week and was surprised at how it looks. Writer explained wound healing and how the wound is actually showing healing progress. Writer also re-educated about the importance of protein consumption and adherence to his fluid restriction. R17 has [MEDICAL CONDITION] and HD ([MEDICAL TREATMENT]) 3x weekly at an outpatient clinic. Tx to include NS cleanse, skin prep surrounding tissue and wound edges well. Apply [MEDICATION NAME] gel to wound base and gently pack wound with silver alginate, cover with foam border dressing 3 x weekly (M-W-F) (Monday-Wednesday-Friday) and prn ; and continue [MEDICATION NAME] to BLE bid. The nurses note with an effective date & entered date of 5/30/18 documents R Heel weekly Stage 3 Prl improving measuring 0.9 x 1.4 x 0.3 cm. Wound bed 100% beefy red, scant bloody drainage with cleansing. Edges intact but slightly macerated from 12-4oc, surrounding tissue pink and blanchable, no malodor, tender to touch, no s/s of infection. Pitting [MEDICAL CONDITION] to right dorsal foot seems less than previous noted. Current Tx to continue and performed without complication and R17 tolerated it well. Additional interventions continue to include low air-loss mattress, frequent repositioning with pillows and cushions to assist with turning/repositioning in bed, recliner, and in w/c and trapeze and grab bars to assist with bed mobility. Offering heel protector boot or heel lift cushion which ever R17 is more comfortable with in bed. Offloading device use re-enforced along with encouragement of elevation and off-loading out of w/c. On 5/30/18 at 7:45 a.m. Surveyor asked LPN (Licensed Practical Nurse)-H if she had any treatments to do. LPN-H replied no and explained DON-B and another nurse completed R17's treatment. Surveyor asked LPN-H if R17 was admitted with his pressure injury. LPN-H replied yes and explained he places pressure on the back of his heel when he is sitting in the wheelchair so they gave him a boot. On 5/30/18 at 9:11 a.m. Surveyor asked R17 how he developed the pressure injury to his right heel. R17 informed Surveyor he got it here and it goes deep. R17's wife who was also in the room informed Surveyor they said it was from laying in the bed. On 5/31/18 at 8:15 a.m. Surveyor observed R17 awake in bed on his back. Surveyor asked R17 if Surveyor could look at his feet. After R17 gave Surveyor permission, Surveyor observed there is a heel lift pad under R17's right foot which also has a prevalon boot on but the left heel is resting directly on the mattress. On 5/31/18 at 10:04 a.m. Surveyor observed morning cares for R17 with CNA (Certified Nursing Assistant)-S and CNA-U. CNA-S removed the bedding off R17 and Surveyor observed R17's left heel continues to be resting directly on the mattress. On 5/31/18 at 10:38 a.m. Surveyor asked CNA-U if she has taken care of R17 prior to today. CNA-U replied yes. Surveyor asked CNA-U if she knew how R17 received the pressure injury on his right heel. CNA-U replied, From digging in and explained he puts pressure on the mattress informing Surveyor guess the air mattress didn't do it's job. Surveyor asked CNA-U when R17 was given the pressure boot and heel lift pad. CNA-U informed Surveyor after he got the pressure ulcer and informed Surveyor it's not getting worse. On 5/31/18 at 11:17 a.m. Surveyor asked CNA-U if they used pillows before R17 had the right heel pressure injury. CNA-U informed Surveyor they used to put pillows under his legs the long way but R17 would scoot down in the bed so they didn't work. On 6/4/18 at 7:31 a.m. Surveyor entered R17's room with ADON (Assistant Director of Nursing)-C and DON (Director of Nursing)-B to observe R17's right heel pressure injury treatment. Surveyor observed R17 is wearing the blue prevalon boot on his right foot. Surveyor observed the ball of R17's left foot is pressing against the footboard and the left heel is resting directly on the mattress. At 7:35 a.m. ADON-C stated they should boost R17 up in bed prior to starting the treatment. R17 held onto the trapeze and ADON-C & DON-B repositioned R17 up in bed. Surveyor then observed R17's right heel treatment which was completed according to physician's orders [REDACTED]. ADON-C informed R17 it looked better on Friday and they may have to change the treatment and will speak with the physician. On 6/4/18 at 11:16 a.m. Surveyor met with ADON-C to discuss R17's right heel pressure injury. Surveyor asked who is responsible for developing skin integrity care plans. ADON-C informed Surveyor MDS (minimum data set)-V, herself and others. Surveyor informed ADON-C R17 was readmitted on [DATE] but the potential for skin integrity care plan wasn't developed until 4/3/18 which is after ADON-C's assessment dated [DATE]. The impaired skin integrity care plan is dated 4/24/18 which is 25 days after ADON-C's assessment dated [DATE]. Surveyor informed ADON-C Surveyor noted after R17's pressure injury declined there was no change in the plan of care. ADON-C looked at R17's electronic health record stating this can't be right. ADON-C informed Surveyor she was going to look into this and get back to Surveyor. Surveyor inquired how often wound rounds are done. ADON-C replied weekly and explained they may not be necessarily every 7 days but they are done during the week. Surveyor informed ADON-C the first assessment of R17's right heel pressure injury is on 3/30/18 but the next note isn't until 4/13/18. ADON-C informed Surveyor she has to look because it has to be there, referring to the assessment. On 6/4/18 at 1:19 p.m. ADON-C informed Surveyor she doesn't understand why the care plan isn't there after R17 was readmitted . ADON-C informed Surveyor her normal process is to update the resident summary for the CNA's, write a note and update the care plan. The nurses note with an effective date & entered date of 6/4/18 documents, Wound care/dressing changes performed, resident tolerated tx well. No s/s of infection. Blister are (area) to right lateral lower leg resolved. Will continue to monitor. The nurses note with an effective date & entered date of 6/5/18 documents, Addendum note Wound care/dressing changes performed, resident tolerated tx well. No s/s of infection. Blister are (area) to right lateral lower leg resolved. Will continue to monitor. Stage 3 Prl to R (right) heel malodorous, wound bed 80% dark red mixed with 10% gray and 10% yellow slough, and wound edges increased maceration circumferentially. MD updated 06/04/18 at 1630 (4:30 p.m.) via telephone and new treatment to include 0.5% acetic acid soaks qd (every day) x 7 days f/b skin prep and lightly packed with silver alginate to slightly overhand wound edges daily x 7 days, then will re-evaluate. Will continue to monitor. 2.) R27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of 5/3/18 documents a BIMS (brief interview mental status) score of 5 which indicates severe cognitive impairment. R27 requires extensive assistance with two person physical assist for bed mobility and transfer, is at risk for pressure ulcer development and is coded as not having any pressure ulcers. The at risk for impaired skin integrity care plan effective 5/6/18 includes an intervention also dated 5/6/18 of Use pillows, pads, or wedges to reduce pressure on heals and pressure points. Turn/reposition. On 5/29/18 at 12:53 p.m. Surveyor observed R27 in bed on her back with mats on the floor. Surveyor observed R27's heels are not being offloaded. On 5/30/18 at 9:53 a.m. Surveyor observed R27 in bed on her back with her eyes closed. Surveyor observed R27's heels are resting directly on the mattress and are not being offloaded. On 5/30/18 at 11:42 p.m. Surveyor observed R27 continues to be in bed on her back with her eyes closed. Surveyor observed R27's heels are resting directly on the mattress and are not being offloaded. On 5/30/18 at 1:31 p.m. Surveyor observed R27 in bed on her back yelling out. Surveyor observed R27's heels are resting directly on the mattress and are not being offloaded. On 5/31/18 at 8:56 a.m. Surveyor observed R27 in bed on her back yelling out she has to pee. Surveyor observed R27's heels are resting directly on the mattress and are not being offloaded. On 5/31/18 at 1:26 p.m. Surveyor observed R27 in bed on her back with her eyes closed holding onto the call light. Surveyor observed R27's heels are resting directly on the mattress and are not being offloaded. On 5/31/18 at 1:28 p.m. Surveyor asked CNA (Certified Nursing Assistant)-S if they ever use a pillow to float R27's heels. CNA-S informed Surveyor they use a pillow at night. On 6/5/18 at 8:51 a.m. Surveyor asked CNA-T if they offload R27's heels. CNA-T replied yes and explain they place a pillow. Surveyor asked CNA-T if she ever refuses. CNA-T informed Surveyor she refuses her hearing aide and with her dentures you have to promise to give them back. Surveyor asked if R27 ever refuses a pillow to offload her heels. CNA-T replied no, never with me. On 6/5/18 at 9:17 a.m. Surveyor asked Licensed Practical Nurse (LPN)-H if R27's heels should be offloaded. LPN-H replied yes but sometimes she likes her shoes on. Surveyor asked if R27's shoes aren't on? LPN-H replied then they should be elevated. On 6/5/18 at 10:34 a.m. Surveyor informed DON (Director of Nursing)-B of the observations of R27's heels not being offloaded.

Based on observation, interview and record review the facility did not ensure that it identified and evaluated hazards and risks and implemented interventions to reduce hazards and risks for 1 (R1) of 3 sampled residents reviewed for falls. -R1 fell from his wheelchair on 11/21/17. The facility did not complete an investigation to determine a root cause analysis of the fall or implement interventions to reduce hazards and risks after R1 fell from his wheelchair. On 2/12/18 R1 was noted by nursing staff to not be making safe choices related to his electronic wheelchair operation, however, no safety interventions were noted to be implemented despite knowledge that R1 was not making safe choices. On 2/14/18 R1 had a subsequent fall from his wheelchair, was admitted to the hospital, and suffered a subdural hematoma (a pool of blood between the brain and its outermost covering). On 2/16/18 R1 was assessed by occupational therapy to not be safe to operate his electronic wheelchair. On 2/21/18 R1 was observed self-operating his electronic wheelchair without staff assistance or observation. A non-staff visitor was also observed having to assist R1 to turn off his wheelchair; R1 was not offered assistance by staff. On 2/21/18 R1 was observed with his call light not within reach per his plan of care. Findings include: R1 has [DIAGNOSES REDACTED]. The facility's Fall Prevention and Management policy and procedure, undated, states Steps following a fall: 1. Head to toe assessment by a licensed nurse completed before the resident is moved. 2. Emergency care will be provided to the resident following appropriate procedures. 3. Documentation will include incident report/event report completion, the nurse's notes, and a fall investigation. 4. Referral to Therapy after a fall to prevent repeat occurrences should be considered. 5. Review and update causative factors, interventions, care plan and fall assessment will be completed .7. Nursing staff will make appropriate interventions upon the completion of the report to prevent reoccurrence of a fall or to minimize injury. Clinical notes by RN-C on 11/21/17 at 12:58 am document Resident has fall out of w/c (wheelchair) at approximately 1930 (7:30 pm). The way writer was alerted to fall out of resident's w/c was (another resident's family member) alerted writer and CNA (CNA's first name) (we were in the Nurses station) that '(R1) is on the floor!' Writer and (CNA) ran down to (R1's) room where we witnessed resident on his back on the floor aside his motorized w/c. We asked (resident's wife) what had happened. She was in the room at the time of the resident's fall. (Resident's wife) stated 'he tried to reach for his nebulizer mask that dropped on the floor and I told him he should call for help, but he did it anyway and fell out of the w/c. Resident stated 'I didn't fall out of my chair, I slid out of it.' Writer had (CNA) support resident's head while writer ran to 2 east to get assistance in getting (R1) off of the floor. (CNA) ran with writer back to (R1's) room to assist with the hoyer lift in getting resident off of the floor and into his bed. Us three staff members .got resident off of the floor and into bed with success. Resident reported no pain at the time. Writer told resident that he may have pain later in the shift from the fall. VS (vital signs) were stable. BP (blood pressure) 140/82, P (pulse) 88, R (respirations) 20, O2 sat 94% ra (room air) 0/10 pain. Later in the shift, at approximately 2230, resident's wife alerted staff that resident felt short-of-breath and that his pulse felt high. (A different nurse) went to get resident's VS. VS at approximately 2245 (10:45 pm) were BP 152/92 P129, R24, O2 sat 66% ra (room air). (A different nurse) alerted writer of vitals. Writer and (nurse) got STAT O2 on 2L per NC continuous and called resident's PMD (primary medical doctor) for order to send to (hospital) for evaluation and treatment . R1 was admitted to the hospital with [REDACTED]. RN-C is no longer an employee at the facility. The surveyor was unable to interview RN-C. There is no documentation that a head to toe assessment was completed in the medical record. The surveyor reviewed R1's care plan provided from the facility for R1's (MONTH) and (MONTH) (YEAR) admission. The surveyor noted all interventions on the fall care plan were created 11/17/17. The surveyor noted no new interventions to prevent falls were created following R1's fall on 11/21/17. The surveyor asked Director of Nursing (DON)-B for a fall investigation related to R1's fall on 11/21/17. On 2/22/18 at 11:13 am DON-B informed the surveyor she was unable to find a fall investigation related to R1's fall on 11/21/17. DON-B stated they were unable to contact RN-C. DON-B stated she usually gets called (if a resident has a fall) and that she did not have a voicemail from that fall. DON-B stated she was not sure if RN-C had been focused on R1's change of condition. The surveyor shared the concern to DON-B related to the lack of an investigation to determine root cause analysis to prevent future falls. The surveyor asked for any additional information. No additional information was provided. Clinical notes on 2/12/18 document He is very pleasant but is very confused towards the end od (sic) the shift. Daughter came to visit and brought him some fries from Culver's he was asking for. Daughter and Wife left at 9:50pm and he was gong (sic) to go down to the lobby to say good by (sic) but the daughter told him to stay up here as he was taking too long and she had to get to Walgreens before it closed in 10 minutes, he still went down the elevator after them. Staff had to go downstairs and get him back up, and once back up stairs and in his room he was coming down the hall and when asked where he was going he realized he was already upstairs and went back to room to watch Olympics. When writer walked past his room did not see him and he was in the corner of the room by his night stand away from the wall and he bounced forward so quickly in the electric scooter he ran his chair right into his bed and backed up. Then he realized that the chair was set on full speed for hallway and not slow for in the room. He left a black mark on the carpet from burning rubber trying to get out of the spot he got himself into and he ran into his bed. Assessed his legs did not see any new injuries as writer was behind him did not see what or if any body part hit the bed. He denies any problems. He is not making safe choices. On 2/16/18 at 9:20 am the surveyor interviewed DON- B. The surveyor informed DON-B of the above clinical note. The surveyor asked if anything had been done at that point after staff became aware that R1 was not making safe choices. DON-B stated she was not aware of that note. The surveyor asked for any additional information. No additional information was provided. On 2/14/18 at 4:27 pm clinical notes document At approx.(approximately) 1215 (12:15 pm) resident was in dining room at table waiting for lunch to be served, he leaned forward in hid (sic) electric wc to drink from a straw, upon leaning forward his L (left) arm pushed against the joystick on the wc arm causing him to first hit the table then cont (continue) turning left while angling downward and dumped resident onto floor in prone position hitting head first. Writer was called over, CNA helped turn resident over onto back to examine, found hemotoma (sic) w/ (with) slight abrasion (9.0 x 7.0 x 3.0) rapidly forming to resident ant (anterior) R (right) cranium, resident very confused and unable to answer questions coherently, vital taken w/ BP elevated, resident did not express any physical pain, no other abnormality observed on body other that (sic) the hematoma on cranium. Men from therapies lifted resident back into ewc (electronic wheelchair), confusion decreased as resident sat w/ ice pack on head. MD contacted, order to send out to (hospital) for eval tx (evaluation/treatment), (daughter) notified at approx. 1230 (12:30pm). Resident taken to (hospital emergency room ) via ambulance at approx. 1300 (1:00 pm). Admissions called ER (emergency room ) for update at approx. 1400 (2 pm), resident was admitted w/ a brain bleed. Hospital notes document that Patientt (sic) presented with a mechanical fall and a resultant subdural hematoma. Neurosurgical consultation notes on 2/14/18 document a recommendation for intensive care unit observation and starting an anti-[MEDICAL CONDITION] drug. R1 was readmitted to the facility on [DATE]. The facility's event report related to R1's fall on 2/14/18 documents the investigation summary as Resident drove electric w/c to dining room + (and) didn't turn power off when @ (at) table. He reached for something on table + pushed joystick propelling into table + then fell out. Sent to ER. Therapy eval (evaluation) electric scooter use-trial having staff propel std (standard) w/c vs (versus) electric w/c. A Power Mobility Screen completed by occupation therapy on 2/16/18 indicates No to the following questions if resident can do safely: drive forward, back up, negotiate environmental obstacles, operate controls, select and maintain safe operational spend, attend to surrounding environment, park device in room, dining room, other community locations, enter and exit elevator safely, and demonstrate ability to problem solve situations with 100% efficiency and safety. The screen documents Pt. (patient) unsafe to operate w/c at this time. A SCOOTER DRIVING SCREENING CHECK-LIST documented as completed by occupational therapy on 2/16/18 documents No to Has adequate UB/LB (upper body/lower body) strength to operate scooter. The screening documents Delayed to able to carry out sequential tasks needed to operate scooter. The screening documents No to Cognition intact and uses good judgement. The screen documents No to Demonstrates safe use of scooter in and around the facility. The screening documents Delayed to Able to start and stop scooter upon command. The screening documents No to Able to turn scoot to L and/or R upon command and remain in appropriate 'lane.' On 2/21/18 at 11:45 am the surveyor observed R1 self-operating his electric wheelchair down the hallway from his bedroom. The surveyor noted that no staff were assisting R1 to operate his electric wheelchair or supervising his use of the electric wheelchair. The surveyor observed R1 operate his electric wheelchair down the hallway to the dining room to a table with no staff assistance. On 2/21/18 at 11:51 pm the surveyor observed a visitor of another resident assist R1 to turn off his electric wheelchair. The surveyor noted no staff was observed to assist R1 to turn off his wheelchair. The surveyor reviewed R1's fall care plan. The care plan includes an intervention with a created date of 2/21/18 for Staff or family to assist (R1) with propelling his electric scooter for safety. On 2/26/18 at 9:20 am the surveyor interviewed DON-B. The surveyor informed DON-B of the observation on 2/21/18 of R1 self-operating his wheelchair. DON-B confirmed that R1 should not have been self-operating his wheelchair. The surveyor asked why the intervention for staff or family to assist R1 with propelling his electric scooter for safety was not put into place on the care plan until 2/21/18. DON-B stated that information was placed into the resident summary binder that staff utilize on the floor on 2/16/18. R1's fall care plan includes an intervention to Keep nurse call light within easy reach. Instruct (R1) to use call light or call out for assistance. A complaint received to the Southeastern Regional Office states that sometimes staff left R1's call light far away or on the side that R1 can't use. On 2/21/18 at 10:36 am the surveyor observed R1 in his room in his wheelchair with his call light on his bed and not within reach of R1. On 2/21/18 at 2:34 pm the surveyor observed R1 in his wheelchair and his call light clipped to his bed and not within reach of R1. On 2/26/18 at 9:20 am the surveyor interviewed DON-B. The surveyor shared the observations of R1's call light not within reach. DON-B stated Everyone's (call light) should be in reach. On 2/26/18 at 2:38 pm the surveyor shared the above information with Administrator-A. The surveyor asked for any additional information. No additional information was provided.

Based on review of a Facility self-report investigation, closed record review and interview the Facility did not provide adequate supervision and assistance devices to prevent accidents for 2 of 4 (Resident 1 and 4) Residents reviewed for falls. The Facility did not have effective measures in place to prevent/limit falls and injury to Resident #1 who was at risk for serious injury due to her history of falls. The Facility's failure to have a system in place to provide supervision in the beauty salon for Residents at risk for falling created an Immediate Jeopardy situation, which began on 3/2/16. On 5/11/16 at 2:00 p.m. Administrator-A and DON (Director of Nursing)-B were notified of the immediate jeopardy. The immediate jeopardy was removed on 5/11/16. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement their removal plan and based upon the example below related to Resident #4. Resident #4 was observed being transferred without a gait belt and was observed with oxygen on while having her hair dried with a bonnet type hair dryer. Findings include: 1.) Surveyor # reviewed Resident #1's closed medical record from 5/9/16 to 5/11/16. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurses note dated 2/18/16 documents Orders verified via fax with Physician-J. Ok for bilateral grab bars for repositioning .Resident found on floor in room at 1740 (5:40 p.m.) on her knees. Writer contacted MD (medical doctor) Physician-I on call for Physician-J and updated at 1755 (5:55 p.m.) daughter-H aware at 1750 (5:50 p.m.). Monitor per protocol and encourage resident to be in common areas after dinner for closer supervision. The nurses note dated 2/22/16 documents Alert. Very confused. Wanders in peers rooms. Needs cont. (continual) cues and redirection. Pushes staff. Does not want to change clothes and bathe. Gets on elevator and sets off alarms. Speech is often non-sensical. The Resident Summary, which is used by the CNA's, dated 2/24/16 documents under FYI (for your information) Resident is at high risk for Elopement Fall. Under reminders and notes documents Resident #1 is not hard of hearing please talk slow and not loud, startles easily. Res. (Resident) has Parkinson's disease. When ambulating res. has a shuffled gait. The admission MDS (minimum data set) with an assessment reference date of 2/25/16 and signed as complete on 2/27/16 documents a BIMS (brief interview mental status) total score of 8, which indicates moderately impaired. Resident #1 requires limited assistance with one person physical assist for bed mobility, transfer, toilet use and ambulation. Resident #1 is occasionally incontinent of bladder and always continent of bowel. Resident #1 is coded as having a fall in the last 2-6 months prior to admission and since admission has had 1 fall with no injury. The fall CAA (care area assessment) dated 2/27/16 under care plan considerations documents will care plan for mobility support on unit, therapy intervention and nursing follow through. vision field deficit may be present re: (regarding) [DIAGNOSES REDACTED]. She continues to be at risk for falls, it is unclear if she has had falls at home since discharge as she is not able to remember them. Has had one fall since admission 2/18. The social service note dated 2/26/16 documents Meeting held with Resident #1's dtr. (daughter)-H, we discussed that Resident #1 will moving to the Harrison house. Therapy reported continued progress but that she will always have safety issues and fall risk due to poor safety awareness and dementia. We discussed a dc (discharge) date of 3/8/16. The at risk for falls care plan created 2/27/16 has interventions also dated 2/27/16 of: -Assess and document cause and pattern of previous falls and act upon resolvable factors. - Assist with activities as needed. Invite resident to public area to increase supervised time. - Bed in lowest position. Nite lite at noc (night) encourage/remind frequently to use call lite. Clip call lite to nite gown at noc (resident in agreement. - Check on resident at least every 2 hours to identify and meet needs as well as note location and safety status. Keep in view as much as possible as indicated. - Encourage or remind to use assistive devices daily: walker when ambulating transfer bars in bathroom, handrails in hallways, side rail(s) in bed. - Ensure resident wears appropriate footwear: nonskid shoes, slippers, socks. - Fall Committee to review all fall per policy and provide appropriate interventions as indicated. - Fall risk assessment quarterly and PRN (as needed). - Keep floors in room/hallways clean, dry and free of clutter/obstacles that may impede safety while ambulating or in w/c (wheelchair). Keep mats on floor when in bed. - Keep frequently used personal items within reach and in same familiar location. - Maintain call light within reach in room for assistance. Remind to use of call light as needed. - Monitor reviews by pharmacist or physician to identify medications that may increase falls. - Provide adequate, non-glare lighting. Adjust lighting in room as indicated via over bed light, open drapes, nightlight in bathroom etc. - Encourage or remind to use assistive devices daily: walker when ambulating, transfer bars in bathroom and handrails in hallways. The nurses note dated 3/1/16 documents, At 1830 (6:30 p.m.) Resident found in hall sitting on floor in front of room L27. Resident stated she heard someone coughing and she is going to check on them to make sure they were okay. Neuro checks WNL (within normal limits). No injury noted. Denies any pain or discomfort. Daughter-H made aware. An intervention of After dinner offer resident fluids with an activity in common room dated 3/2/16 is on the at risk falls care plan that was created on 2/27/16. The fall risk evaluation dated 3/2/16 documents a fall risk score of 14. Total scores of 10 or more represent high risk for fall. The nurses note dated 3/2/16 documents At 1430 (2:30 p.m.) Writer went to assist with resident after falling in the beauty shop during her hair appointment. Writer observed resident lying flat on the floor with the left leg appearing shorter than right and foot externally rotated. Arms were at her side; left side was toward the hair-dryer with w/c (wheelchair) under it; next to the w/c was a desk on wheels with a stool underneath with legs sticking out slightly. Hair cutting area and hostess desk to the right. Resident was wearing non-slip shoes. Resident had rollers in her hair and glasses were not on her face. Resident was calm and alert, and oriented x (times) 1. Resident reported pain in left hip at 9/10, with nonverbal displays of pain of guarding with left hand holding left hip area. Initial neuro checks WNL (within normal limit). Vital signs 114/70 p (pulse) 68, PO2 95% RA (room air), R (respirations) 20. Writer asked other day shift nurse to call for order to send resident to ED (emergency department) for eval and tx (treatment). Writer asked resident what happened and resident stated I saw her wave, into running toward to greet her, whoever the person was who greeted before me. Writer as SS (Social Service) to assist with call EMS (emergency medical services) (Lifestar) at 1430 (2:30 p.m.); PCP (primary care physician) Physician-J and Daughter-H notified via phone between 1430 (2:30 p.m.) and 1445 (2:45 p.m.); Daughter-H to meet Resident at AG ED (Aurora Grafton Emergency Department). Lifestar arrived at 1445 (2:45 p.m.) and left with resident at 1512 (3:12 p.m.) to go to Aurora Grafton. An intervention of Ensure resident does not go to the beauty salon until the beautician is ready/alone dated 3/3/16 is on the at risk falls care plan that was created on 2/27/16. The hospital physician discharge summary dated 3/6/16 documents under discharge [DIAGNOSES REDACTED]. Dementia/cognitive decline. The nurses note dated 3/6/16 documents, Resident arrived @ (at) 1230 on 3/6/16 via Lifestar ambulance from Aurora Grafton after a fall resulting in surgery to insert L (left) hip rod. L hip roding was done on 3/3/16. New orders were verified with the on call doc Physician-K. Resident is not A & O (alert and orientated), and is immobile. Was using the sit to stand in the hospital. Resident's diet was changed to cardiac and she is now a feeder. Resident is incontinent of B & B (bowel and bladder). Resident is still confused. Daughter was present when she arrived from Aurora Grafton. The Resident Summary, which is used by the CNA's, dated 3/7/16 documents under FYI (for your information) Resident is at high risk for Elopement Fall Pain Skin breakdown Swallowing precautions. Under reminders and notes documents Resident #1 is not hard of hearing please talk slow and not loud, startles easily. Res. (Resident) has Parkinson's disease. When ambulating res. has a shuffled gait. WANDERGUARD BRACELET RIGHT WRIST. L (left) hip fracture, roding done in hospital. Very confused, not oriented. Needs to be fed, swallow precautions. Sit to stand to transfer. Incontinent. According to the following statements and interviews, PTA (physical therapy aide) - L brought Resident #1 to the beauty salon on 3/2/16 and told the beautician not to leave Resident #1 alone. When the beautician went to take another resident back to her room, she asked the receptionist to watch Resident #1, even though the receptionist sits with her back to the beauty salon and is about 15 feet away. On 5/9/16 Surveyor # reviewed the Facility's self report investigation for Resident #1's fall on 3/2/16. Surveyor # noted PTA (Physical Therapy Assistant)-L's statement dated 3/3/16 documents, I had finished with Resident #1 physical therapy treatment at 2:00 p.m. Resident #1 was sitting in wheelchair, the lady from the beauty shop came up to the floor/room to get Resident #1 for her hair appointment. She wheeled her in the wheelchair to the elevator. I was walking with her and told her make sure you do not leave Resident #1 alone by herself she is a fall risk. She then proceeded to take Resident #1 down to the beauty shop getting on the elevator. Resident #1 was wheeled down to the beauty shop in the wheelchair. On 5/9/16 at 3:14 p.m. Surveyor # asked PTA-L if she remembers what she said to the beautician on the day that Resident #1 fell in the beauty shop. PTA-L informed Surveyor # that she remembers that Resident #1 was in her wheelchair with the beautician who was wheeling her. PTA-L informed Surveyor # that she told the beautician make sure you don't leave Resident #1 by herself. She is a fall risk because she will get up. Surveyor # asked PTA-L how does she know that the beautician heard what she said. PTA-L informed Surveyor # that she believes the beautician said ok. PTA-L informed Surveyor # that the beautician heard what she said. The Facility's self report investigation for Resident #1's fall on 3/2/16 contained a statement from Receptionist-F dated 3/2/16 that states, Salon asked me to Keep an eye on Resident #1 while taking another client back to apartment. On 5/9/16 at 3:19 p.m. Surveyor # spoke with Receptionist-F regarding Resident #1's fall in the beauty shop. Surveyor # asked Receptionist-F to explain to Surveyor # what happened on 3/2/16 when Resident #1 fell in the beauty shop. Receptionist-F explained that the beautician asked her to check in on Resident #1. Surveyor # asked what that meant. Receptionist-F replied, I don't know because I usually don't. It's not possible. Receptionist-F explained that she is very busy at the receptionist area but that day it was a slower day so she was able to get up from behind the desk. Receptionist-F indicated that she saw Resident #1 walking out half way out of the beauty shop room, Resident #1 started turning and got tangled up with her own feet. Resident #1 grabbed onto a rolling table and that kind of slowed her down as she fell to the floor. Receptionist-F informed Surveyor # that she was too far from Resident #1 to grab her. Surveyor # asked Receptionist-F if it is normal for her to check on Residents in the beauty shop. Receptionist-F replied, No. Surveyor # asked Receptionist-F if this was the first time that the beautician asked her to check on a Resident. Receptionist-F replied no and explained that she had been asked in the past but that doesn't mean she was able to check on the Resident and that if she was busy she wouldn't be able to go to the beauty shop. Surveyor # asked Receptionist-F if checking on Residents in the beauty shop was one of her regular duties. Receptionist-F replied no and explained that it wasn't in her job description. On 5/9/16 at 3:31 p.m. Surveyor # observed the area from where Receptionist-F sits to the beauty shop. Surveyor # noted that Receptionist-F or any other staff sitting at the receptionist desk would have their back towards the direction of the beauty shop and that the beauty shop is approximately fifteen feet away from the receptionist desk. Surveyor # also observed that if Receptionist-F turned to head to the side she would not be able to see inside the beauty shop and would have to walk out of the receptionist area and down the hallway to where the beauty shop is located. On 5/9/16 at 3:28 p.m. Surveyor # asked Beautician-G how she knows if a Resident is safe to be left alone in the beauty shop. Beautician-G explained to Surveyor # that she has been here for [AGE] years and if a Resident is independent then they can be left alone. Beautician-G informed Surveyor # that Administrator-A asked that they not leave anyone alone. Beautician-G informed Surveyor # that if they are alert she isn't going to treat them as if they are babies. On 5/10/16 at 8:15 a.m. Surveyor # asked CNA (Certified Nursing Assistant)-D if she knew Resident #1 and if she had ever provided cares to Resident #1. CNA-D informed Surveyor # that she did. CNA-D informed Surveyor # that they always told Resident #1 to put her light on in the room but would get up herself and in the dining room she was always trying to get up and walk by herself. CNA-D informed Surveyor # that they needed to keep Resident #1 in eye sight. Surveyor # asked CNA-D how would the beautician know that Resident #1 is at risk for falls and should not be left alone. CNA-D informed Surveyor # that they should be telling the beautician she's at risk for falls. CNA-D informed Surveyor # that it was her understanding that the beautician had to go and do something. CNA-D informed Surveyor # that Resident #1 almost needed a one to one because she was always trying to get up and if she had this she may not have fractured her hip. On 5/11/16 at 10:26 a.m. Surveyor # spoke to LPN (Licensed Practical Nurse)-E regarding Resident #1. Surveyor # inquired if Resident #1 ambulated independently. LPN-E replied, No, because of her Parkinson's she was so unsteady when she walked. LPN-E informed Surveyor # that Resident #1 was a helpful person and wanted to help other Residents. LPN-E stated that if there was a Resident in the dining room that didn't have butter Resident #1 would stand up and try to walk to get the butter. LPN-E informed Surveyor # that she used to be a school teacher. LPN-E informed Surveyor # that after lunch Resident #1 would start to sundown, would get angry, she wasn't nice to people and got mean at times. LPN-E stated that at times Resident #1 would have night mares that were very vivid to Resident #1 and it was hard to convince her otherwise and that she was very hard to redirect when she was sundowning. LPN-E stated that at times they had to do one on one to make sure she was safe as she thought she could get up and walk. LPN-E stated that mornings were good for Resident #1 and she would go to activities but in the afternoon they tried activities but that didn't work so well. Surveyor # asked LPN-E how she would know if a Resident had an appointment with the beauty shop. LPN-E explained that they would have to call the beauty shop or the beauty shop would call them or families would let them know. LPN-E stated that all different people tell them. Surveyor # asked if there was a list in the beauty shop of Residents that shouldn't be left alone. LPN-E informed Surveyor # that she didn't know. On 5/10/16 at 3:22 p.m. Surveyor # spoke with Beautician-G again to clarify how she knows if a Resident can be left alone or if they have behaviors of trying to get up by themselves. Beautician-G explained that a lot of times it happens in the beauty shop and that staff will tell them if they went to get a Resident. Surveyor # asked what would happen when she went to get a Resident and didn't see any staff to speak with. Beautician-G stated then she sees how they are in the chair. Beautician-G stated that basically they don't leave them in the beauty shop. Beautician-G explained that if she has to go to the bathroom she will go to the memory care unit and ask a staff member to come to the beauty shop. Surveyor # noted that the memory care unit is down the hall from the beauty shop and while Beautician-G is going to get a staff member the Resident would be left alone. On 5/11/16 at 7:40 a.m. Administrator-A informed Surveyor # that after Resident #1 fell in the beauty shop the stylists were told not to leave any residents by themselves and if they need to leave the room then someone would come in. Surveyor # asked who that would be Administrator-A informed Surveyor # it could be himself, DON (Director of Nursing)-B or the Receptionist because they are close by. Surveyor # asked Administrator-A if he asked the Beautician why she left Resident #1 alone. Administrator-A informed Surveyor # that she was going to get another Resident and that she should have called one of us or call the floor where the Resident resided and have staff come down. Surveyor # asked Administrator-A how does the nursing staff know when a Resident has an appointment at the beauty shop. Administrator-A informed Surveyor # that the Resident would tell nursing, or the beautician goes up to the floor and tells the staff the Resident has an appointment. The Salon Fall Prevention Procedure (not dated) documents, Please ensure that residents are not left alone in the Beauty Salon. Contact the floor staff to bring each resident when you are ready for them if you already have another client in the salon. If you have finished caring for someone and they want to be transported back to their apartment or room, contact that nurse's station for a staff member to come and pick the resident up. On 5/11/16 at 10:41 a.m. Surveyor # showed Administrator-A the Salon Fall Prevention Procedure and asked when this was implemented as the procedure is not dated. Administrator-A informed Surveyor # a day or 2 after the event referring to Resident #1's fall in the beauty shop. Subsequent to Resident 1's return to the nursing home, she continued to experience falls. On 3/10/16 at 1:23 a.m. the nurses note documents Writer called by staff to resident's room at 2030 (8:30 p.m.), resident found lying on back on floor next to bed. Writer asked resident if she could state what happened resident replied I was going to work on radio wires under the bed. Resident denied hitting head, no injuries noted, ROM (range of motion) wnl (within normal limits) for resident, VS (vital signs) taken with assessment immediately after, denied no signs of pain/discomfort during assessment and ROM, assisted into bed with two assist/gait belt, resident TTWB (toe touch weight bearing) pivot d/t (due to) recent fall resulting in left hip fx (fracture) s/p (status [REDACTED]. Daughter-H called at 2100 (9:00 a.m.) to update, dtr. (daughter) will check tomorrow when at facility as to any thoughts/plans for her mother, on call MD called at 2115 (9:15 p.m.) to update, MD aware and to continue monitoring, will pass on in report to update surgeon 3-10-16 on day shift PCP (primary care physician) sent fax to update, facility DON (Director of Nursing) updated, intervention of 15 minute checks started, will continue to monitor. An intervention of 15 minute checks by staff when resident in room/bed dated 3/9/16 is on the at risk falls care plan that was created on 2/27/16. On 5/11/16 at 11:34 a.m. Surveyor # met with DON (Director of Nursing)-B and ADON (Assistant Director of Nursing)-C to discuss Resident #1's fall in the beauty shop and additional falls. DON-B informed Surveyor # that when the beautician comes up to the unit the nursing staff should communicate with the beautician any behaviors such as trying to get up and ambulate. Surveyor # inquired if the beauty shop had a list of Residents that should not be left alone. DON-B replied no. Surveyor # informed DON-B & ADON-C that after Resident #1 fell and broke her hip, Resident #1 had a fall on 3/9/16 and the intervention implemented was 15 minute checks. Surveyor # noted after the 3/9/16 Resident #1 had additional falls on 3/26/16, 4/12/16 when Resident #1 sustained a left wrist fracture and 4/17/16. Surveyor # informed DON-B and ADON-C that Surveyor # was unable to locate the 15 minutes checks after they were initiated on 3/9/16. DON-B informed Surveyor # that they identified that 15 minute checks were not being done and this needed to go to their quality assurance committee. On 5/11/16 at 12:10 p.m. DON-B informed Surveyor # that she has the 15 minute checks from 4/1/16 to 4/17/16. Surveyor# reviewed these 15 minute checks and noted on 4/12/16 when Resident #1 fell and fractured her wrist these 15 minute checks were not consistently completed as 1600 (4:00 p.m.), 1615 (4:15 p.m.), 2245 (10:45 p.m.) and 2300 (11:00 p.m.) are blank. On 5/11/16 at 3:13 p.m. Surveyor # asked DON-B if she was able to locate any of the 15 minute checks from 3/9/16 to 3/26/16. DON-B informed Surveyor # that she is not able to locate them. The Medicare 30 day MDS (minimum data set) with an assessment reference date of 4/3/16 and signed as complete on 4/4/16 documents a BIMS (brief interview mental status) score of 8, which indicates moderately impaired. Resident #1 requires extensive assistance with one person physical assist for bed mobility, transfer and toilet use. (Previously, this had been limited assistance.) Resident #1 did not ambulate in corridor and is frequently incontinent of bowel and bladder. (Previously, she had ambulated and had been occasionally incontinent of bladder.) The failure to ensure that the facility had an effective system for ensuring proper supervision of residents brought to the beauty salon created a finding of immediate jeopardy. The immediate jeopardy was removed on 5/11/16 when the Facility implemented a plan where a facility nursing staff member will be present in the salon during the time Health Center Residents are receiving salon services to ensure safety and supervision of the resident, regardless of the contracted salon staff presence. The oversight will be provided during the entire duration that the Resident receives services. No Health Center resident will be left unattended while having salon services provided. The deficient practices continues at a scope/severity of D (potential for harm/isolated) as Resident #4 was observed being transferred without a gait belt and was observed with oxygen on while having her hair dried with a bonnet type hair dryer. 2.) Surveyor # reviewed Resident #4's medical record on 5/9/16 & 5/10/16. The hospital history and physical dated 12/10/15 includes under past medical history femur fracture, left, fracture of humerus, and history of falls. The quarterly MDS (minimum data set) signed as complete on 3/5/16 documents a BIMS (brief interview mental status) total score of 14 which indicates cognitively intact. Resident #4 requires extensive assistance with two plus persons physical assist for transfers, extensive assistance with one person physical assist for bed mobility and ambulating in the room. Resident #4 has not had any falls since the prior assessment period. The Resident Summary, which is utilized by the CNA's (Certified Nursing Assistant), dated 5/6/2016 under the section transferring and assistance needed documents Extensive assist Assist x (times) 1 Full weight bearing Gait belt Requires bed to chair assist Requires chair to bed assist. On 5/10/16 at 9:14 a.m. Surveyor # observed Resident #4's call light on. On 5/10/16 at 9:15 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-D answer Resident #4's call light and ask Resident #4 if she can help her with anything. Resident #4 informed CNA-D that she needed to go to the bathroom. CNA-D washed her hands, moved the bedside commode, and then moved the wheeled walker over near the bed. CNA-D assisted Resident #4 with sitting on the edge of the bed. CNA-D placed the wheeled walker in front of Resident #4 and Resident #4 stood up holding onto the walker. CNA-D asked Resident #4 if she had her balance and if she was steady enough on her feet. Resident #4 replied I think enough. CNA-D ambulated behind Resident #4 holding onto the oxygen tubing with her left hand. As Resident #4 and CNA-D entered the bathroom, Surveyor # observed a gait belt hanging on the inside of the bathroom door. Resident #4 and CNA-D ambulated into the bathroom, Resident #4 turned so her back was facing the toilet, CNA-D placed gloves on and pulled down Resident #4's pajama bottoms & pull up incontinence product. CNA-D then assisted Resident #4 to sit on the toilet. CNA-D removed her gloves, asked Resident #4 if she wanted a minute, informed her to put on the light and closed the bathroom door. At 9:22 a.m. while standing outside the bathroom door, CNA-D informed Surveyor # that Resident #4 moves slow and is cautious which is good because of the oxygen tubing. CNA-D then left with Resident #4's breakfast tray. At 9:28 a.m. CNA-D answered Resident #4's bathroom call light, washed her hands, and placed gloves on. CNA-D asked Resident #4 if she should get dressed while on the toilet, asked Resident #4 what she wanted to wear, wet a washcloth and handed the washcloth so Resident #4 could wash her face. CNA-D removed the pajama bottoms and pull up incontinence product and placed Resident #4's clothing on the walker. At 9:34 a.m. LPN (License Practical Nurse)-E knocked on the door and informed CNA-D that she needed to assist another Resident. CNA-D informed Resident #4 to start doing her top, she would be right back, and left the bathroom at 9:36 a.m. At 9:39 a.m. CNA-D entered Resident #4's bathroom, placed her shirt on, informed Resident #4 that she was going to change her brief and get her washed up. CNA-D placed a pull up incontinence product & pants on Resident #4 and asked Resident #4 to stand up. CNA-D washed Resident #4's frontal perineal area, buttocks, applied selan cream, removed her gloves and pulled up Resident #4's incontinence product and pants. CNA-D held onto the oxygen tubing with her right hand and ambulated with Resident #4 out of the bathroom and into her room. CNA-D assisted Resident #4 with sitting on the bed, and swung her Resident #4's legs so Resident #4 was laying in bed. Surveyor # noted that CNA-D did not use a gait belt according to Resident #4's Resident summary. On 5/10/16 at 9:57 a.m. Surveyor # informed CNA-D that Surveyor # had observed a gait belt hanging on the back of Resident #4's bathroom door and asked CNA-D if they use the gait belt with Resident #4. CNA-D replied no and informed Surveyor # that she hasn't used a gait belt on Resident #4 in a long time. On 5/10/16 at 11:20 a.m. Surveyor # observed CNA-D ambulating with Resident #4 out of the bathroom with her right hand on Resident #4's back to the wheelchair in Resident #4's room. Surveyor # observed that Resident #4 did not have a gait belt on. On 5/10/16 at 11:41 a.m. Surveyor # asked ADON (Assistant Director of Nursing)-C if staff should be using a gait belt when ambulating with Resident #4. ADON-C replied yes according to her care plan. Surveyor # informed ADON-C of the observations of CNA-D not using a gait belt and when asked CNA-D informed Surveyor # that she doesn't use a gait belt with Resident #4. ADON-C informed Surveyor # that staff should be using a gait belt unless it was changed and the care plan was not updated. Surveyor # inquired who would make the change. ADON-C replied if there was a therapy assessment. Surveyor # informed ADON-C that Resident #4 does not participate in therapy and inquired if it is the expectation that staff follow the Resident's plan of care. ADON-C replied yes and then informed Surveyor # that she will look to see if there was a change. On 5/10/16 at 3:39 p.m. during the daily exit conference with Administrator-A and ADON-C Surveyor # asked if there was any change with staff having to use a gait belt with Resident #4. ADON-C informed Surveyor # that there was no change. Surveyor # asked for the Facility's transfer policy and procedure. On 5/11/16 at 7:33 a.m. Administrator-A provided Surveyor # with the Facility's Transfer with gait belt policy and procedure. Surveyor # asked Administrator-A when this policy and procedure became effective as it is not dated. Administrator-A informed Surveyor # that the policy has been in place since 2003. Surveyor # noted the purse documents To transfer resident safely, utilizing good body mechanics. 3.) DQA (Division Of Quality Assurance) Memo 16-006 Revised Guidance for the Safe Use of Oxygen - Use of Hair Dryers dated April 4, 2016 documents The purpose of this memorandum is to provide updated guidance regarding the safe use of hair dryers by residents who are receiving oxygen therapy in residential and health care facilities. Life Safety code regulations state that the resident nasal cannula or face mask must be at least one foot away from the heating element (NFPA (National Fire Protection Association) 99 section 8-2.1.2.3.). As a result, resident nasal cannula or face mask oxygen use is permitted when the heat source of the hair dryer is located on or near the floor, i.e., at the base of the hair dryer. This memo replaces DQA Memo 12-005. Hair dryers that have the heating element in the base of the hair dryer are safer for resident use as opposed to when the heating element is located within the bonnet of the hair dryer. Under Quality of Life - Alternatives documents The majority of residents in nursing homes and assisted living facilities do not rely on oxygen for life support, and therefore are not reliant on continual access to oxygen. For these residents the facility should verify the physician order [REDACTED]. Oxygen can be intermittently discontinued to minimize the fire hazard exposure to the resident. Note: Oxygen remains in the air and on a person's clothes, hair and body for a period of time after the oxygen is turned off. Manufacturers recommend a wait time of 15-20 minutes before using the hair dryer. Facilities should also instruct salon staff to keep hair dryer settings on low heat to minimize a potentially hazardous situation. Surveyor # reviewed Resident #4's medical record on 5/9/16 & 5/10/16. The quarterly MDS (min

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Residents # 5 and #6) of 8 sampled residents at risk for falls. On 10/11/15, Resident #5 was a 2 person transfer with a gait belt and was transferred with 1 person and gait belt. Resident #5 needed to be lowered to the floor and sustained a fracture of the left tibia. On 7/20/15, Resident #6 was not positioned properly on the bed and when resident was turned in bed she rolled out of the bed onto the floor. Example #1 rises to a scope and severity level of G, actual harm. Findings: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12-9-15 at 2:05p.m., Surveyor # observed the treatment to Resident #5's left lower leg due to pressure ulcers. During the observation of treatment Licensed Practical Nurse (LPN)-D asked Resident #5 if her pain medication was still working. Resident #5 stated the pain medication was still working. Resident #5 stated to Surveyor # that she had a fall a little while ago and broke her leg when she was transferred and it still hurts. On 12-14-15 at 1:10p.m., Surveyor # requested the fall investigation regarding Resident #5's broken leg from the Director of Nursing (DON)-B. Surveyor # was provided the Event Report dated 10-11-15 from DON-B. This report states the number of staff that was on duty at time of incident, which was 1 nurse and 1 CNA (Certified Nursing Assistant). The Event Report dated 10-11-15 states that Resident #5 described what happened: Transferring to recliner, my left leg felt weak. It states the description: Certified Nursing Assistant (CNA) in room assisting with transfer resident lowered to floor when resident's left leg gave out. The Event Report states: Describe Injury: No injury noted, c/o (complained of) chronic Lt (left) knee discomfort. B/P (blood pressure) 128/50, P (pulse) 67, R (respirations) 22, T (temperature) 98.6, O2 (oxygen) 93, Pain (1-10) 2. On this report it notes that the Nurse Practitioner was notified and ordered an X-ray. It notes that Resident #5's daughter was notified directly. Under: What Action Nurse initiated immediately in response to this event to prevent a reoccurrence it states, Resident assisted with Hoyer to bed, dtr (daughter) in room shortly after, legs elevated, ice to lt (left) knee d/t (due to) discomfort to area, open sandal shoe removed. Signed and dated 10-11-15. Under Additional Investigative Data: Section 2 it notes under Mobility, W/C (wheelchair) staff assist and gait problems. Under, Was the care plan followed? it is checked NO. The Root Cause Determination by charge nurse at the time of the event the following were circled: Balance problem while standing/ambulating, Staff performance, Pain LLE (left lower extremity) discomfort. Under Investigation Summary it states: Resident transferred with assist of 1 CNA and her knee gave out resulting in her being lowered to the floor. CNA reeducated on following care plan/resident summary This portion of the investigation was signed and dated on 1-14-15 by the Administrator-A and DON-B. On 12-14-15 at 1:30p.m., Surveyor # reviewed the medical record of Resident #5. Review of the nurses notes dated 10-11-15 states: Resident toileted at approx. 1500 (3:00p.m.) with staff, assisted from wc to recliner. Staff assisting resident to transfer, resident felt left leg buckling/weak, gait unsteady, lowered to floor with staff assist. Witnessed Fall to floor. Resident alert and oriented x2, forgetful, confusion. Assessment/VSS (vital signs stable) immediately after. Has chronic left leg and knee pain, 2/10 at time of incident. Assisted into bed with 3 assist and Hoyer lift. Dtr (Daughter) arrived at facility at approx, 1530 (3:30p.m.) and updated. Ice pack applied to left knee d/t discomfort per resident. Resident wearing sandal shoe to Lt (Left) foot per therapy (no shoes/open toe), message left with therapy to update on fall incident and resident feeling sandal shoe not helping in transfers. Scheduled pain meds during shift, legs elevated, ice pack to left knee, c/o increased pain to left ankle/foot, writer called dtr to update, writer calling MD to request order for left tib/fib/ankle/foot Mobilex X-ray. Dtr in agreement and would like update in morning. Nurse Practitioner with MD called at 2115 (9:15p.m.) NOR (new order received). Mobilex X-ray called, d/t increased pain STAT request. Mobilex arrived approx 2300 (11:00p.m.), results pending, will be fax'd to MD. Reviewed the Addendum Radiology Report dated 10-11-15 at 11:25p.m. (Mobilex x-ray report). Which states under conclusion for Left Tibia/Fibula: Acute, nondisplaced distal tibia and fibula fractures as noted. Under Left Foot Conclusion it states: Acute, minimally displaced 1st metacarpal neck fracture. Under Addendum it states: In the body and conclusion this is the 1st metatarsal (the left great toe) not metacarpal. Surveyor # reviewed the Admission MDS (Minimum Data Set) dated 9-25-15 which notes that Resident #5 had history of falls prior to facility admission. On 12-14-15 at 2:00p.m., Surveyor # interviewed the DON-B regarding Resident #5's fall which occurred on 10-11-15. DON-B stated, Resident #5 was a 2 person assist with gait belt for transfers, prior to the fall on 10-11-15. DON-B stated CNA (Certified Nursing Assistant)-C transferred Resident #5 alone with a gait belt. DON-B stated CNA-C observed the physical therapist transfer Resident #5 in her room by pivoting with a gait belt, so in CNA-C's mind she felt she could also do a pivot transfer with a gait belt. DON-B stated CNA-C gave a return demonstration of transfer by transferring the DON-B and was re-educated along with all CNA's regarding transfers and following the care plan. DON-B stated Resident #5 ended up with a fracture of the left tibia bone (Lower Leg). On 12-15-15 at 7:50a.m., Surveyor # reviewed the Resident Summary for Resident #5 dated 10-9-15 (prior to being lowered to floor). This summary is the CNA's care plan for resident. Under Transferring and Assistance Needed it states: Extensive assist, Assist x2, Gait belt, Requires bed to chair assist, Requires chair to bed assist. Under Ambulation and Assistive Devices it states: Extensive assist, Assist x2, Gait belt, Standard or pick-up walker, Wheelchair - staff propelled. Also reviewed the Nursing Evaluation Form dated 9-18-15. Under Fall Risk it notes that Resident #5 had a history of [REDACTED]. Fall Risk Score was a 12. Total scores of 10 or more represent high risk for fall. On 12-15-15 at 8:40a.m., Surveyor # interviewed CNA-C by phone. CNA-C stated at that time she was the only aide on the floor, and Resident #5 needed to go to the bathroom NOW, so I took her to the bathroom. CNA-C states she observed the physical therapist transfer resident with a pivot transfer with 1 therapist and gait belt. When CNA-C observed this, CNA-C thought she could transfer Resident #5 by herself with a gait belt. CNA-C stated that Resident #5 was in her recliner and CNA-C placed a gait belt on resident and transferred her to her wheelchair then transferred resident to the toilet. CNA-C stated that Resident #5 had to sit for a while on the toilet, then resident put the call light on and CNA-C went into the bathroom to assist resident. CNA-C stated she transferred Resident #5 from the toilet to her wheelchair then CNA-C was going to transfer Resident #5 to her recliner. Resident #5 stated her left leg was hurting and CNA-C couldn't move Resident #5's left leg. CNA-C stated she heard a POP and then CNA-C told Resident #5 she couldn't transfer her and told Resident #5 that CNA-C needed to lower her to the floor. CNA-C stated when she lowered Resident #5 to the floor, Resident #5's legs were bent and resident was sitting on her left leg. CNA-C stated she got the nurse immediately. CNA-C stated that the RN came in and assessed Resident #5 and then we used the Hoyer lift and 3 staff to get Resident #5 up and put her into bed. CNA-C stated that about a half hour later Resident#5 put her call light on and that CNA-C and the RN entered Resident #5's room and she complained she had pain in her left leg. The above information was shared with the facility. 2. Surveyor # reviewed Resident #6's medical record from 12/9/15 to 12/15/15. Resident #6's [DIAGNOSES REDACTED]. The nurses note dated 7/20/15 documents, Called to see resident at 0230 (2:30 a.m.). CNA (Certified Nursing Assistant) stated she turned resident to check for incontinence and resident rolled oob (out of bed) onto floor. Resident on floor near bed on window side of room laying on the left side facing bathroom door. CNA stated she didn't think she hit her head. Bruise noted to left dorsal wrist area. Bruise and abrasion noted to right knee, ice pack applied. Resident denies pain. No scalp injuries noted, PERRL (pupils equal round reactive to light) neuro assessment wnl (within normal limits). See flow sheet. ROM (range of motion) without discomfort. No other apparent injuries noted. Resident transferred back to bed with Hoyer lift and two assist. B/P (blood pressure) 148/80, t (temperature) 96.4, p (pulse) 66, r (respirations) 18, POX (pulse oxygen) 90%. The Event Report dated 7/20/15 for describe injury (size, depth, color, pain, bleeding, limitation in ROM (range of motion) results of head-to-toe assessment & VS (vital signs) documents, Resident found lying on left side facing bed. Bruise abrasion to (R) (right) knee, bruise to (L) (left) dorsal hand. Under what action nurse initiated immediately in response to this event to prevent a reoccurrence documents, Instructed CNA to properly align residents before turning them. CNA stated she was too far over to edge of bed. Under investigative summary documents, Resident rolled out of bed during cares. check position in bed prior to any cares. Nurse to do competency with return demo (demonstration). SW (Social Worker)-L's interview with CNA-F dated 7/21/15 documents, She began her 1st round around 11:50-12am. She pointed out she has not worked this unit and was not familiar with the residents. When she got to Resident #6's room she entered and noted a fall matt next to the bed on the side of the grab pole. She decided to go to the other side so as not to make much noise or wake up Resident #6. She (CNA-F) noted Resident #6 to have a pull up depend on and pajama pants. She was dry at this time but CNA-F thinks in pulling and twisting the pull up over to check she may have not put it back on securely to prevent leaking. When she went around for her 2nd round at 2:20am she could smell the urine in the room and noted Resident #6's pants were wet. She (CNA-F) did tell Resident #6 she was there to change her and Resident #6 was sleepy at the time. CNA-F was now standing on the side of the bed with the fall matt. She (CNA-F) moved the fall matt to perform cares. She was pulling Resident #6 toward her and trying to hold her with her right hand and pull the pants and pad down with her left. She was able to rip one side of the brief and when turning Resident #6 to the other side to pull the brief out this is when she continued to roll out of the bed and sustained the bruise and the abrasion. CNA-F feels this was an accident and states she felt very badly about what happened. When Resident #6 began to roll she tried to grab her shirt but could not catch her in time. She then reported it to RN (Registered Nurse)-J. The Facility's corrective action notice dated 7/21/15 documents, She did not properly position the resident in bed prior to turning her for incontinence cares and as a result the resident rolled out of bed and sustained several injuries including bruising of the arm, knee, and head. It is the expectation at Newcastle Place that residents are properly positioned in bed for safety purposes and that when rolling a resident to provide cares the resident is rolled towards the caregiver to ensure resident safety. Per your report you failed to positioned Resident #6 before turning her which caused her to fall. The radiology report dated 7/22/15 documents, Conclusion: Acute fracture of the trapezium. The significant change MDS (Minimum Data Set) with an assessment reference date of 7/27/15 documents a BIMS (Brief Interview Mental Status) total score of 9 which indicates moderately impaired. Requires extensive assistance with two plus person for transfer, toileting, and bed mobility. The falls CAA (Care Area Assessment) dated 7/26/15 under analysis of findings for care plan considerations documents, Resident had a roll out of bed during cares which resulted in bruising to her head and left hand ROM (range of motion) and no observation or statements of pain. Resident was still using hand. Due to mild swelling, X-ray obtained which showed diffuse OP, severe degenerative joint changes and an acute fx (fracture) at the base of the trapezium (carpol bone found within the hand). Left hand splint ordered resident refuses to wear. Therapy order obtained for OT (occupational therapy) and PT (physical therapy). Fall risk issues will be maintained ongoing and support/assistance provided for safe mobility on and off unit. On 12/15/15 at 7:11 a.m., Surveyor # spoke with RN (Registered Nurse)-J regarding Resident #6's fall on 7/20/15. RN-J informed Surveyor # that she was called to Resident #6's unit and observed Resident #6 on the floor. RN-J stated that CNA-F was honest telling her how Resident #6 fell and that CNA-F didn't usually work on that unit. RN-J indicated that CNA-F informed her that Resident #6 was near the edge of the bed when she turned Resident #6 and Resident #6 rolled out of bed. RN-J stated, The CNA shouldn't have turned her when she was so close to edge of bed. I redirected her. RN-J indicated that she told CNA-F residents need to be in the middle of the bed prior to being turned. RN-J explained that on one side of the bed Resident #6 has a pole so they don't turn her on that side. RN-J informed Surveyor # that she told CNA-F that she should have called for help. RN-J stated, People just don't roll out of bed, she used improper technique. RN-J informed Surveyor # that CNA-F no longer works at the Facility. Surveyor # noted that Resident #6 fell out of bed due to not being properly positioned in the bed prior to being turned. On 12/15/15 at 3:00 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, interview and record review, facility staff did not provide appropriate supervision and assistive devices to prevent accidents for 2 (Resident #10 and #5) of 2 Residents who sustained falls. Resident #10, who had hip surgery prior to admission to the facility, fell from bed onto the floor. Staff did not place a fall mat on the floor as requested by the family. Resident #10 required another hip surgery when displacement of the fracture and screws was identified. Resident #10 fell again while in the facility. Neither fall was thoroughly investigated to try to identify the root cause of the falls. Getting to the root cause of the falls is necessary to then develop appropriate interventions to try to prevent future falls. Resident #5 had a fall when transferred with one staff member when the care plan called for two staff assisting. During the survey, Resident #5 was observed being transferred with only one staff member. Findings include: 1.) Resident #10 was admitted to the facility on [DATE] following a hospitalization and hip surgery after a fall at home. Resident #10's Discharge Summary from the hospital states the Principle [DIAGNOSES REDACTED]. Resident #10 is also noted to have advanced dementia and advanced Parkinson disease. Surveyor # reviewed a Nursing Evaluation Fall Risk dated 2/5/14 indicating Resident #10 scored "21." Total scores of 10 or more represent high risk for falls. Resident #10 was noted to have had 1-2 falls in the past 3 months; is chair bound; poor vision; not able to perform gait or balance tests; and takes 3-4 medications that may contribute to falls; and has 3 or more pre-disposing diseases. Resident #10's Admission MDS dated [DATE] notes Resident #10 had fallen in the month prior to admission, had fallen in the 2-6 months prior to admission, and sustained a fracture related to a fall within the 6 months prior to admission. NURSES' NOTES Surveyor # reviewed Resident #10's Nurses' Notes which indicate Resident #10 was admitted to the facility on [DATE] at 5:00 p.m. The Admission Note states Resident #10 is very frail and has contractures of the left hand. Notes dated 2/6/14 indicate Resident #10 had anxiety, restlessness and pain to right hip as evidenced by facial grimacing, crying out during bed mobility, while assessing right hip and repositioning. Right hip dressing clean, dry and intact. Right hip incision well approximated with 5 intact staples. Pain and anxiety medications given. A note dated 2/7/14 at 8:57 p.m. states "Resident very anxious and crying, needs frequent reassurance from staff...mat applied next to bed, bathroom side of bed per husbands request..." A note on 2/9/14 indicates Resident #10's family member transferred Resident #10 by himself without a gait belt against the advice of staff. Nurses' Notes on 2/10/14 at 1:05 p.m. state "Resident was found on floor next to bed at 12:00 p.m. Stated she hit her head-forehead was reddened and painful. Pain meds were given which relieved pain..." CARE PLAN Surveyor # reviewed Resident #10's Care Plan dated 2/7/14 stating "At risk for falls related to poor safety awareness, history of falls. The Goal is Resident #10 will have no falls through the next 90 days. Interventions include: -Asses and document cause and pattern of previous falls and act upon resolvable factors; -Assist with activities as needed; -Bed in lowest position; -Check on resident at least every 2 hours to identify and meets needs as well as note location and safety status. Keep in view as much as possible as indicated; -Cue, reorient, and supervise activities as needed to ensure safety; -Encourage or remind to use assistive devices daily: walker when ambulating, transfer bars in bathroom, handrails in hallways, side rail(s) in bed; -Ensure resident wears appropriate footwear: nonskid shoes, slippers, socks; -Fall Committee to review all falls per policy and provide appropriate interventions as needed; -Fall Risk Assessment quarterly and prn (as needed); -Keep floors clean, dry and free of clutter; -Keep frequently used items within reach and in same familiar location; -Maintain call light within reach, remind of use of call light as needed; -Medication review by pharmacists to identify medications that may increase falls; -Provide adequate lighting. There was no mention of Resident #10's family member request to put a mat on the floor, as documented in the Nurses' Notes on 2/7/14. NURSES' NOTES Notes on 2/14/14 indicate Resident #10's family member again transferred Resident #10 without a gait belt by himself. Resident #10 requires assist of 2 and gait belt for transfers, per Care Plan dated 2/7/14. A Note on 2/18/14 states "Call received from (orthopedic office) stating that Resident is being discharged to hospital right from his office for surgery on right hip..." Surveyor # reviewed a Consultation Report dated 2/18/14 from the orthopedic surgeon's office stating "Findings: X-rays show cut out of screws and displacement of femoral neck fracture. Recommendations: Admit to (hospital) -plan to remove screws and convert to hemiarthroplasty" (replaces half of the hip joint with a prosthetic joint). Resident #10 was readmitted to the facility on [DATE]. Another Nursing Evaluation Fall Risk assessment was included in Resident #10's medical record; it was not signed or dated, but again indicates Resident #10 is at high risk for falls. Nurses' notes dated 4/1/14 at 11:54 p.m. state "Resident attempted three times to get out of bed, feet hanging off bed, resident laying across bed, resident positioned three times since beginning of shift. She calls out "help me, help me", repeatedly. Writer tried to redirect resident with no success. PRN (as needed) alprazolam given at 11:30 p.m., bed in lowest position, mat on floor and call light within reach. Will continue to monitor." A Note on 4/10/14 at 4:29 a.m. states Resident #10 "hanging BLE (bilateral lower extremities) over the bed at the beginning of shift, writer and CNA (certified nursing assistant) straightened her up. She was noted to be anxious, redirection provided and resident calmed down..." Notes at 12:11 a.m. on 4/16/14 state Resident #10 "was found on the floor. When first found per CNA, was on knees next to W/C (wheel chair), with her face on the night stand. Call light on chair. When writer entered room she was found lying on the floor on her right side...Resident had a black and blue bruise to the corner of right eye also bruising to patient's right cheek...Resident with complaint of pain on her chin, head and right hip. MD and family notified..." FALL INVESTIGATIONS Fall-February 10, 2014 Surveyor # reviewed the facility's Fall Investigation for 2/10/14 at 12:00 p.m. The Fall Event Report states Resident #10 "fell out of bed to carpeting." Resident #10 stated "I fell and hit my head." Resident #10's forehead was reddened, good ROM (range of motion) for all extremities. The fall happened in Resident #10's room, first aid was provided. Resident #10 was noted to be alert, disoriented and anxious before and after the fall. When the form asks "What action Nurse initiated immediately in response to this event to prevent re-occurrence?" staff wrote "Called OT (occupational therapy) and reminded to put mat next to bed when put in bed." The investigation states Resident #10 was agitated, last toileted at 10:10 a.m., last seen in bed 20 minutes prior to the fall (but does not say by whom or what Resident #10 was doing at the time- e.g., sleeping, restless, trying to get out of bed, legs over side of bed, etc.). It also notes "other data- staff in orientation;" and "what unmet need may have precipitated the fall?" Staff answered "attention seeking." "Type of footwear" was left blank. The Root Cause was noted to be behavior related, though it was almost 2 hours since Resident #10 was last toileted. Staff checked that the Care Plan was followed, but then added "Investigative Summary: Discussed with OT Supervisor to provide education to staff involved. Resident is anxious and known to have behaviors for attention. (Family member) looking into companion for when they're not here." Surveyor # reviewed the Fall Investigative Interviews "To be completed at the time of the fall-nurses and CNAs scheduled on the unit." CNA (Certified Nursing Assistant)-R's statement indicates she last saw Resident #10 asleep in bed 20 minutes after Resident #10 laid down for a nap, but it does not say when that was- since it does not say when Resident #10 laid down. It asks "What was the resident's footwear?" and CNA-R answered "Yes." It then asks "Was the resident agitated prior to the fall?" CNA-R answered "yes." "What interventions were taken at that time?"- CNA-R left that blank. The statement written by RN (Registered Nurse)-S indicates Resident #10 was resting quietly in bed at 11:00 a.m. (an hour before the fall). RN-S next observed Resident #10 "lying on the floor next to the bed on her right side." "What was the resident's footwear?"-RN-S answered "yes." "Was the resident agitated prior to the fall?" RN-S answered "yes." "What interventions were taken at that time?" RN-S left that blank. The statement written by CNA-T indicates she saw Resident #10 sleeping on the bed, but does not indicate when that was. CNA-T states she was on break at the time and did not see Resident #10 fall. Two statements indicate Resident #10 was agitated prior to the fall, but neither indicates what they did for Resident #10, such as get her up if she is agitated in bed. None of the statements indicates what Resident #10 had on her feet. The Investigation does not include any other statements- from housekeeping staff, for example, who may have knowledge regarding Resident #10 prior to the fall. While attention seeking behaviors is noted to be the root cause, the Investigation does not indicate if Resident #10 had to use the toilet, or was incontinent, which could have caused the fall, but that information was not gathered. This is the only fall documented between Resident #10's admission to the facility and her orthopedic appointment on 2/18/14 when the X-ray showed displacement of femoral neck fracture. While placing the mat on the floor next to Resident #10's bed would not have prevented the fall, it may have lessened or minimized Resident #10's injuries. Fall-April 15, 2014 Surveyor # reviewed the Fall Investigation for Resident #10's fall during the afternoon of 4/15/14. One staff statement indicates the fall was at 3:00 p.m., two statements leave the time of the fall blank, and the fourth statement documents the fall happened at 4:30 p.m. The Fall Event Report states Resident #10 was found on floor next to wheel chair on her right side, an alleged fall-unattended. Resident #10 sustained a black and blue bruise on the corner of her right eye and cheek. Resident #10 was noted to be alert and disoriented before the fall, and alert, disoriented and agitated after the fall. The Form asks "What action nurse initiated immediately in response to this event to prevent a re-occurrence?" Staff wrote "call light within reach." The Event Report indicates Resident #10 has gait problems and needs staff assist for mobility. Resident #10 was in her wheel chair, had non-skid footwear, and was last seen at 3:00 p.m. The Root Cause was noted to be "reaching, and poor safety judgement/self-directs care." The "Investigation Summary" was not completed until more than one month later, on 5/21/14, and states "Care plan reviewed and updated." (Surveyor # reviewed Resident #10's Care Plan dated 2/24/14- the date of Resident #10's readmission, but did not observe any additions to the care plan for Falls since 3/4/14). Surveyor # reviewed the 4 Fall Investigative Interviews staff wrote for Resident #10's Fall Investigation. LPN (Licensed Practical Nurse)-N documented the time of the fall was 3:00 p.m. LPN-N states when she observed Resident #10, she was "sitting in chair", but does not say when or where this observation occurred. LPN-N documents she next saw Resident #10 lying down on her right side. LPN-N notes Resident #10 was last checked at 3:00 p.m. (which is the time of the fall, but the fall was unwitnessed.) Last time toileted was left blank; Last time the resident ate or drank is also noted to be 3:00 p.m., the time of the fall. Resident #10 was noted to be wearing socks, and the call light was within reach. CNA-O's statement documents she saw Resident #10 sitting in wheel chair in room drinking water with call light in reach at 4:20 p.m. CNA-O next saw Resident #10 on her knees on the floor in front of the wheel chair, but "Time of Fall" is left blank. CNA-O states Resident #10 was wearing shoes (LPN-N stated Resident #10 was wearing socks). CNA-P's statement documents Resident #10 was last checked at 4:20 p.m. and Resident #10 was sitting in her wheel chair; Time of Fall was 4:30 p.m. (LPN-N documented Resident #10's fall was at 3:00 p.m.). Resident's footwear was noted to be "socks and shoes." CNA-Q's statement indicates she had not seen Resident #10 prior to the fall. Surveyor # reviewed the facility's Policy and Procedure "Fall Prevention and Management", adapted 1/2/13 and reviewed 1/2/14. Included under the heading "Steps following a fall", it states: ...Documentation will include incident report /event report completion, nurses' notes and fall investigation; Review and update causative factors, interventions, care plan and fall assessment will be completed...Nursing staff will make appropriate interventions upon the completion of the report to prevent re-occurrence of fall or to minimize injury. On 8/28/14, Surveyor # shared the above information at the daily exit meeting. Surveyor # asked if other staff (housekeeping, for example) were interviewed for either fall; and if Resident #10 was agitated in bed before the fall on 2/10/14, what did staff do to lessen the possibility of Resident #10 falling (get Resident #10 up out of bed, closer supervision, etc). Surveyor # asked why the family-requested intervention of placing a mat on the floor was not added to the care plan until after Resident #10 returned from the hospital on [DATE]. Surveyor # asked if they clarified if the 4 staff statements regarding Resident #10's fall on 4/15/14 all pertained to the same fall because LPN-N states the fall happened at 3:00 p.m. and Resident #10 was wearing socks, while CNA-P stated the fall happened at 4:30 p.m. and she was wearing socks and shoes, while CNA-O left the time of fall blank and noted Resident #10 was wearing shoes. Surveyor # asked why the "Action nurse initiated immediately in response to the event to prevent re-occurrence" states "Call light within reach", if the call light was already in reach per the staff interviews. Surveyor # asked why the Investigative Summary and review by DON-B and NHA (Nursing Home Administrator)-A did not take place for more than a month after Resident #10's second fall and almost a month after Resident #10 was discharged to home on 4/29/14. Surveyor # also noted the Nurses' Notes on 4/1/14 and 4/10/14 document multiple observations of Resident #10 with her legs hanging off the bed, and of Resident #10 trying to get out of bed. Surveyor # asked if they added any new interventions to address these behaviors such as closer supervision, more frequent checks, etc. On 9/2/14, Surveyor # asked DON (Director of Nursing)-B if there was any additional information regarding Resident #10's falls. DON-B stated there was no additional information. 2.) Surveyor # reviewed Resident #5's medical record on 8/26/14 to 8/28/14. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing evaluation form dated 7/31/14 under the fall risk section has a fall risk score of "6." Total scores of 10 or more represents high risk for falls. The falls evaluation dated 8/12/14 has a fall risk score of "12" and the falls evaluation dated 8/26/14 has a fall risk score of "9." The at risk for falls care plan effective 8/12/14 includes an intervention also dated 8/12/14 of "Assist Resident #5 transferring bed/chair with 2 assistance using a standard walker, roll walker, quad cane, standard pivot transfer, or slide board." Status: Active (Current). The nurses nurses dated 8/22/14 documents "Resident was lowered to the floor @ (at) 1500 (3:00 p.m.) by CNA (Certified Nursing Assistant). CNA was transferring resident alone, the resident got really weak, and had to be lowered to the floor. After physical assessment, no injuries. Denies pain. Currently resting in recliner. CNA stated that the resident did not hit his head. VSS (vital signs stable). Will continue to monitor and follow care plan." The event report dated 8/22/14 under resident statement or describe what happened documents "Resident was being transferred to toilet. Resident let go of grab bar and was lowered to the floor by CNA." Under the investigation summary documents "Care plan not followed by CNA. Clearly indicates requires assist of 2. Education and discipline to be provided." On 8/26/14 at 11:58 a.m. Surveyor # observed Resident #5's call light on. Surveyor # entered Resident #5's room with CNA-I. Surveyor # observed Resident #5 sitting on the toilet. CNA-I placed a gait belt on Resident #5, placed gloves on, and locked Resident #5's wheelchair. CNA-I then assisted Resident #5 to stand by holding onto the gait belt and placed Resident #5's left hand on the wheelchair. CNA-I then pulled up Resident #5's incontinence product and pants stating "I got you." CNA-I then assisted Resident #5 with sitting in the wheelchair. CNA-I removed the gait belt, removed her gloves, cleansed her hands and placed the foot pedals on Resident #5's wheelchair. CNA-I wheeled Resident #5 out of the bathroom and then Resident #5's wife wheeled Resident #5 out of the room to the dining room. On 8/28/14 at 10:14 a.m. Surveyor # asked LPN (Licensed Practical Nurse)-L how Resident #5 should be transferred. LPN-L informed Surveyor # that she didn't know and would have to check Resident #5's care plan. Surveyor # showed LPN-L Resident #5's computer printed care plan and LPN-L informed Surveyor # that Resident #5 is a 2 assist, 2 people. On 8/28/14 at 10:17 a.m. Surveyor # asked CNA-I how should Resident #5 be transferred. CNA-I informed Surveyor # that for the bathroom they use two people and that sometimes Resident #5 can stand very good and other times he can't. Surveyor # asked CNA-I if Resident #5 is suppose to be transferred with two why did she transfer Resident #5 by herself on 8/26/14. CNA-I informed Surveyor # that it was just her and the nurse and the nurse was busy. On 8/28/14 at 2:34 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.