Every finding on record at Northcrest Specialty Care

Based on observation, staff interview, and facility policy review the facility failed to ensure medications were kept secured when medication and treatment carts were unlocked out of staff sight for 2 of 4 hallways observed. The facility reported a census of 88 residents. Findings include:On 8/12/26 at 11:28 AM, observed an unlocked medication cart along the wall on the 300 hallway with its lock pushed out into an unlocked position. No staff remained present in the 300 hallway. Resident #7 sat next to the unlocked medication cart on top of a 4-wheeled walker. On 8/12/26 at 11:36 AM, Staff I, Registered Nurse (RN), exited a resident room on the 300 hallway and returned to the medication cart. On 8/13/26 at 9:12 AM, witnessed an unlocked treatment cart along the wall towards the middle of the 400 hallway with its lock pushed out. The top drawer of the treatment cart contained insulin (blood sugar medication) pens and insulin needles. Physical Therapy staff walked through the 400 hallway and entered a resident room, leaving the cart unattended. On 8/17/26 at 9:12 AM, observed an unlocked treatment cart along the wall at the end of the 300 hallway with its lock pushed out. The top drawer of the treatment cart contained insulin pens and insulin needles. No staff remained present in the 300 hallway. On 8/17/26 at 1:24 PM, Staff I stated staff should keep medication carts and treatment carts locked unless in sight. On 8/17/26 at 1:50 PM, Staff G, Registered Nurse (RN), stated staff should lock medication carts and treatment carts at all times when not in use. Staff G explained treatment carts stored insulin and needles and wouldn't want anyone getting hold of these items. On 8/17/26 at 4:15 PM, Staff C, Assistant Director of Nursing (ADON), stated staff should keep medication carts and treatment carts locked anytime staff aren't watching them. On 8/17/26 at 4:30 PM, the Director of Nursing (DON) revealed an expectation for medication carts and treatment carts to always remain locked when not in use. The DON stated treatment carts contained insulin and prescription topical (skin) medications. The Administering Medications policy dated April 2019 instructed staff to keep medication carts closed and locked during medication administration when out of sight of the medication nurse or aide. The policy permitted placing the cart in the doorway of a resident room with open drawers facing inward and all other sides closed, prohibiting medications on top of the cart. The policy required personnel administering medications to keep the cart clearly visible, with all outward sides inaccessible to residents or passersby.

Based on resident interview, staff interview, clinical record review and facility policy review, the facility failed ensure safe smoking practices and storage of smoking supplies were followed for 1 of 1 residents (Resident #4) reviewed for smoking. The facility reported a census of 88 residents. Findings include:Resident #4's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses included anxiety disorder (feeling anxious), depression (persistent sadness), Post Traumatic Stress Disorder (PTSD) (mental health condition), asthma/Chronic Obstructive Pulmonary Disease (COPD) (chronic lung disease), and nicotine dependence (tobacco addiction). Resident #4 required staff supervision or touching assistance to transfer (move positions). The MDS indicated Resident #4 fell in the month prior to admission and experienced two or more falls without injury since admission. Review of Resident #4's care plan revealed the following focus areas and interventions:Smoker non-compliant (non-adherent) with smoking policy, history of smoking in undesignated areas, and non-compliant with safe storage of smoking materials, created and revised on 8/13/26. Interventions created on 8/13/26 instructed staff to:Educate Resident #4 not to wear a nicotine patch if choosing to smoke.Educate Resident #4 on signing out and leaving property to smoke.Educate Resident #4 on available smoking cessation (quitting) aids.Instruct Resident #4 about smoking risks and hazards.Remind Resident #4 to store smoking materials properly.Smoker, created on 8/4/26, non-compliant with facility policy on smoking location, created on 8/12/26. Interventions instructed staff to:Instruct Resident #4 about the non-smoking facility policy, created on 8/12/26.Notify charge nurse immediately if suspecting Resident #4 violated facility smoking policy, created on 8/4/26.Observe Resident #4's clothing and skin for signs of cigarette burns, created on 8/4/26.Tobacco use, created on 8/4/26. Interventions created on 8/4/26 instructed staff to:Conduct a smoking evaluation on admission and as needed (PRN).Educate Resident #4 and responsible party on facility tobacco and smoking policy.Address Resident #4 going outside frequently alone due to non-compliance with smoking policy.Risk for falls, created on 8/4/26. Review of the Smoking Evaluation dated 8/4/26 identified the facility as a smoke-free facility. The evaluation documented the following, in part:Section B. Cognitive: Resident #4 demonstrated ability to communicate understanding of standard smoking procedures (prohibiting possession of cigarettes, e-cigarettes, pipes, tobacco, or other smoking articles, permitting only disposable safety lighters stored with smoking articles, and prohibiting matches or other lighters) and demonstrated ability to make daily decisions.Section C. Dexterity: Resident #4 demonstrated ability to hold a cigarette safely, maintain control if physically distracted, light a cigarette safely, use an ashtray appropriately, let go of and retrieve a cigarette appropriately, and extinguish a cigarette appropriately.Section D. Safety: Resident #4 didn't use Oxygen (O2) (breathing gas) and demonstrated non-compliance with smoking policy requirements.Section E. Assessment: Described Resident #4 as an independent smoker.Section F. Adaptive Equipment: Specified Resident #4 couldn't leave facility grounds independently and remained non-compliant with smoking policies. Review of a Care Plan Conference Note dated 8/12/26 at 9:41 AM identified under the Social Service Summary that Resident #4 didn't follow facility smoking policy, remained non-compliant, and frequently self-transferred (moved without staff assistance). Review of the facility sign-out sheet revealed Resident #4 went outside on an unknown date at 8:26 AM, 10:10 AM, 12:40 PM, 12:45 PM, 3:55 PM, and 6:20 PM. The sign-out sheet indicated Resident #4 went outside on 8/14/26 at 12:35 PM, 12:35 PM, 3:50 PM, and 4:30 PM. Review of Resident #4's incident reports revealed Resident #4 fell on the following dates and times:On 8/4/26 at 9:11 AM, witnessed fall in Resident #4's room.On 8/4/26 at 4:00 PM, unwitnessed fall in Resident #4's room.On 8/8/26 at 6:30 PM, unwitnessed fall in Resident #4's room.On 8/10/26 at 8:30 PM, witnessed fall outside.On 8/11/26 at 8:00 PM, unwitnessed fall in Resident #4's room.On 8/12/26 at 4:00 PM, unwitnessed fall in Resident #4's room. Review of an Incident Report dated 8/10/26 at 8:30 AM revealed Resident #4 experienced a witnessed fall outside the facility. A staff member pulling into the facility witnessed Resident #4 slowly and safely lower himself to the ground from a wheelchair without hitting his head. Resident #4 reported leaning too far left and sliding out of the wheelchair. The report documented weakness/fainting as a predisposing physiological factor and wheelchair positioning as a situational factor. On 8/17/26 at 11:07 AM Resident #4 stated he exits through the back door of the 400 hallway to smoke unsupervised, including earlier that morning. Resident #4 stated receiving a lockbox for cigarettes and a lighter on the morning of 8/17/26, but reported previously keeping smoking supplies on his person or in his wheelchair. On 8/17/26 at 1:24 PM Staff I, Registered Nurse (RN), stated Resident #4 signs himself out and must leave facility grounds to smoke. Staff I stated never seeing smoking supplies lying around, but felt unaware where Resident #4 stored smoking supplies. On 8/17/26 at 1:34 PM Staff H, Certified Nursing Assistant (CNA), stated feeling unaware where Resident #4 could smoke, but believed Resident #4 went outside the front door to smoke on the sidewalk. Staff H confirmed Resident #4 received a lockbox in his room for smoking supplies on the morning of 8/17/26, but reported no knowledge of where Resident #4 stored smoking supplies prior to 8/17/26. On 8/17/26 at 4:45 PM Staff J, CNA, stated Resident #4 smoked unsupervised outside the facility front door and presented a high risk for falls. Staff J stated Resident #4 required one-staff assistance for transfers, propelled himself in a wheelchair, and previously stored boxes of cigarettes in a bag inside his room. On 8/17/26 at 2:58 PM the Social Service Worker (SSW) stated the facility maintains a non-smoking policy, requiring residents to sign themselves out and leave facility property to smoke. The SSW reported Resident #4 didn't always comply with going off property to smoke, adding staff should redirect Resident #4 if seen smoking on facility grounds. On 8/17/26 at 4:15 PM Staff C, Assistant Director of Nursing (ADON), stated educating Resident #4 against smoking in his room, smoking while wearing a nicotine patch, and smoking on facility property. Staff C stated staff must lock up smoking supplies, especially lighters, in the medication cart. On 8/17/26 at 4:30 PM the Director of Nursing (DON) stated residents who wish to smoke must undergo an evaluation ensuring smoking safety and demonstrate ability to sign out and leave facility premises safely. The DON stated staff should educate and redirect any resident seen smoking on facility grounds. The DON confirmed smoking supplies require locked storage and stated Resident #4 stored supplies in a bag in his room for a period after refusing to yield smoking supplies to staff. The Smoking Policy - Residents policy dated July 2017 instructed staff to establish and maintain safe resident smoking practices. The policy instructed, in part:Inform residents upon admission of the facility smoking policy, designated smoking areas, and accommodation capabilities for smoking preferences.Permit smoking only in designated outdoor smoking areas, prohibiting indoor smoking under any circumstances and restricting electronic cigarettes to designated areas.Prohibit oxygen use in smoking areas, provide self-closing metal containers, and empty ashtrays only into designated receptacles.Evaluate residents upon admission to determine smoking status and ability to smoke safely with or without supervision using a Safe Smoking Evaluation.Consult with the attending physician and the DON to determine necessary safety restrictions based on the evaluation.Re-evaluate a resident's ability to smoke safely quarterly, upon a significant change, or as determined by staff.Document smoking privileges, restrictions, and care plan concerns, alerting all care personnel.Impose smoking restrictions if determining a resident cannot smoke safely with available support, requiring direct supervision during smoking for monitored residents.Prohibit residents from keeping cigarettes, e-cigarettes, pipes, tobacco, or other smoking articles in their possession, permitting only disposable safety lighters while prohibiting matches or other lighters.Prohibit residents from giving smoking articles to other residents, allowing only designated staff to purchase or provide smoking articles.Maintain the right to confiscate smoking articles in violation of policy, itemizing confiscated property for ultimate return to the resident or legal representative.

Based on observation, record review, facility policy review, and interview, the facility failed to ensure staff provided timely dressing assistance for a resident with visibly wet clothing for approximately one hour for 1 of 3 residents (Resident #8) reviewed for dignity. The facility reported a census of 88 residents. Findings include:Resident #8's Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Active diagnoses included cerebral palsy (movement disorder), anxiety disorder (chronic worry), and depression (persistent sadness). Resident #8 displayed verbal behaviors without rejecting care. Resident #8 depended on staff assistance for lower body dressing, toilet transfers, and toileting hygiene. Resident #8 always experienced bladder incontinence (accidental urine loss) and frequently experienced bowel incontinence without receiving a trial toileting program. Review of Resident #8's Care Plan revealed focus areas and interventions:Focus Area 1: Fall risk related to cerebral palsy, weakness, impaired mobility, tremors, and anxiety, with a fall history, knees giving out during transfers, impulsive behaviors, and non-compliance with call light use for toileting assistance (initiated 1/3/12 and updated 6/16/25). Interventions included:Offer toileting before and after meals (initiated 4/27/22).Place a sign in the bathroom reminding Resident #8 to use the call light for toileting assistance (initiated 9/20/23).Staff to increase toileting offers (initiated 6/16/25).Focus Area 2: Activities of Daily Living (ADLs) assistance needs (initiated 10/10/23). Interventions included:Assist Resident #8 with a one-staff stand pivot transfer (assisted standing turn) for toileting (initiated 10/10/23).Assist Resident #8 with lower body dressing using one staff member (initiated 10/10/23).Focus Area 3: Total urinary incontinence (initiated 12/1/23). Interventions included:Assist Resident #8 with perineal cleansing (private area washing) as needed (initiated 12/1/23).Observe Resident #8 for acute behavioral changes indicating a urinary tract infection (UTI) (bladder infection) (initiated 12/1/23).Observe Resident #8's skin daily for irritation and redness (initiated 12/1/23). On 8/13/26 at 9:31 AM, Resident #8 sat in a wheelchair on the 100 hallway with shorts visibly wet in the middle and over the left thigh. On 8/13/26 at 9:33 AM, Staff A, Licensed Practical Nurse (LPN), approached Resident #8, provided gum, and returned to the medication cart while Resident #8 self-propelled the wheelchair toward the nurse's station/common area to visit a staff member. On 8/13/26 at 9:59 AM, Resident #8 continued sitting near the nurse's station/common area in the wheelchair visiting two staff members, with the front of the shorts remaining visibly wet. On 8/13/26 at 10:49 AM, Staff B, Certified Nursing Assistant (CNA), exited Resident #8's room holding soiled clothing in a plastic bag. Staff B confirmed providing incontinence care (bladder and bowel hygiene) to Resident #8 and acknowledged seeing wet pants. On 8/17/26 at 2:55 PM, Staff A stated Resident #8 experienced urinary incontinence, sometimes requested clothing changes, occasionally refused care during offers, and sometimes pushed the call light before leaving the room. On 8/17/26 at 4:16 PM, the Assistant Director of Nursing (ADON) stated Resident #8 experienced frequent urinary incontinence, used the call light or entered the hallway to request clothing changes, and sometimes refused care offered during scheduled activities. On 8/17/26 at 4:46 PM, the Director of Nursing (DON) stated staff must change Resident #8's pants when visibly wet or soiled. The DON added Resident #8 refused care offered during activities, directing staff to offer toileting prior to activities. The Activities of Daily Living (ADLs), Supporting policy dated March 2018 instructed staff to provide necessary services for residents unable to perform ADLs independently to maintain good nutrition, grooming, personal hygiene, and oral hygiene. The policy specified providing appropriate care and services according to the plan of care and resident consent, including support for hygiene (bathing, dressing, grooming, oral care), mobility (transfers, ambulation), elimination (toileting), dining, and communication.

Based on observation, resident interview, staff interview, clinical record review and facility policy review, the facility failed to observe medication administration for 3 of 3 residents reviewed for medications (Resident #2, Resident #3, and Resident #9) who lacked medication self administration assessment when pills were left at bedside unattended to self administer (Resident #2 and Resident #3) and inhalers were left unattended in the bed to self administer (Resident #9). The facility reported a census of 88 residents. Findings include:1. Resident #2's Care Plan initiated on 8/1/26 identified a focus area for chronic and acute pain related to prior injuries or procedures. Interventions instructed the following, in part:Administer pain medication Hydrocodone/Tylenol (Lortab) per orders 30 minutes before treatments or care, initiated 8/3/26.Monitor and document probable causes of each pain episode, removing or limiting causes where possible, initiated 8/3/26.Monitor and document side effects of pain medication, observing for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria (state of unease), nausea, vomiting, dizziness, and falls, reporting occurrences to the physician, initiated 8/1/26.Resident #2's medication contained a black box warning (strict safety warning), initiated 8/3/26. Resident #2's Electronic Health Records (EHR) lacked an assessment determining safety for self-administration of medications. On 8/12/26 at 1:10 PM, Resident #2 stated staff often dropped off medications in a cup on his bedside table for self-administration. Resident #2 reported feeling unsure which medications staff left in the cup, adding he'd eventually take them. On 8/13/26 at 2:50 PM, Resident #2 asked Staff E, Registered Nurse (RN), for a pain pill to take prior to leaving for an appointment. On 8/13/26 at 3:00 PM, Staff D, Registered Nurse (RN), entered Resident #2's room holding a white tablet in a medication cup, stating she had his pill. Resident #2 asked Staff D to identify the pill, and Staff D responded it represented his pain pill. As Resident #2 began moving from a reclined position to sit upright, Staff D exited the room before Resident #2 took the pill. Resident #2 then self-administered the pill, stating he didn't know the pill's identity. Resident #2's August 2026 Medication Administration Record (MAR) revealed the following orders, in part:Oxycodone Hydrochloride (HCl) (opioid pain medication) 5-milligram capsule, giving one capsule orally every 4 hours as needed for moderate to severe pain, start date 8/4/26. Documentation indicated staff didn't administer Oxycodone on 8/13/26.Methocarbamol 500-milligram oral tablet (muscle relaxant), giving one tablet orally four times daily for muscle stiffness, start date 8/3/26. Documentation revealed Staff D administered the scheduled evening dose to Resident #2 on 8/13/26.Acetaminophen 500-milligram oral tablet (Tylenol) (pain reliever), giving two tablets orally three times daily for pain, start date 8/3/26. Documentation revealed Staff D administered the scheduled evening dose to Resident #2 on 8/13/26. 2. Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses included Schizophrenia (severe mental disorder), seizure disorder (brain electrical disturbance), and thyroid disorder (glandular condition). Resident #3's Care Plan initiated on 7/30/26 revealed a focus area for hypothyroidism (underactive thyroid) treated with daily Levothyroxine (thyroid hormone replacement). Interventions instructed the following:* Give thyroid replacement therapy as ordered, monitoring for and documenting side effects and effectiveness, initiated 7/30/26.* Resident #3's medication contained a black box warning (strict safety warning), initiated 7/30/26. Resident #3's Electronic Health Records (EHR) lacked an assessment determining safety for self-administration of medications. On 8/13/26 at 9:15 AM, Resident #3 stated taking an early morning medication, reporting staff sometimes wake him to administer it, but nearly every day he wakes to find a pill in a cup left on his bedside table. Resident #3 reported feeling unsure about the medication's purpose, though confirmed taking it. Resident #3's Medication Administration Record (MAR) dated August 2026 revealed a daily 5:00 AM medication order for Levothyroxine Sodium 175-microgram oral tablet, instructing staff to administer one tablet orally daily for hypothyroidism (underactive thyroid), start date 7/30/26. On 8/17/26 at 9:45 AM, Staff F stated finding a pill in a medication cup on Resident #3's bedside table multiple times upon arriving at work at 6:00 AM. Staff F stated comparing bedside pills to Resident #3's early morning thyroid medication to confirm identity before giving them to Resident #3. Staff F stated the prior shift signed off the early morning thyroid pill as administered in the Medication Administration Record (MAR). Staff F reported having no way of knowing how long the pill remained on Resident #3's bedside table. On 8/17/26 at 1:34 PM, Staff H, Certified Nursing Assistant/Certified Medication Assistant (CNA/CMA), stated noticing a medication cup with a pill inside on Resident #3's bedside table while delivering a breakfast tray on an unknown date. Staff H stated Resident #3 asked to identify the pill, prompting Staff H to call Staff F into the room, where Staff F identified the item as Resident #3's thyroid pill. 3. Resident #9's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (chronic lung disease), heart failure (weakened heart pumping), pulmonary embolism (blood clot in lungs), and pulmonary hypertension (high blood pressure in lung arteries). Resident #9's Care Plan initiated on 1/27/26 revealed a focus area for altered respiratory status and breathing difficulty related to Chronic Obstructive Pulmonary Disease (COPD) (chronic lung disease). Interventions instructed the following:Administer medication/puffers as ordered, monitoring for effectiveness and side effects, initiated 1/27/26.Encourage sustained deep breaths using demonstration, emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation; use an incentive spirometer (breathing exercise device) placed close for convenient use; and ask Resident #9 to yawn, initiated 1/27/26.Maintain oxygen settings: Oxygen (O2) via nasal cannula (nasal breathing tube) at 2 liters continuous, initiated 5/13/26. Resident #9's Electronic Health Records (EHR) lacked an assessment determining safety for self-administration of medications. On 8/17/26 at 9:17 AM, Resident #9 slept in bed with two unattended inhalers sitting on the bedsheets on the left side of Resident #9's bed. Staff A, Registered Nurse (RN), stood at a medication cart down the 100 hallway, out of sight from Resident #9's room. On 8/17/26 at 9:26 AM, Staff A denied knowledge of any residents self-administering medications. When asked if Resident #9 could self-administer inhalers, Staff A reported unawareness of residents self-administering pills, but stated Resident #9 could manage inhalers independently. Resident #9's Medication Administration Record (MAR) dated August 2026 revealed Staff A signed off administering the following scheduled morning inhalation medications on 8/17/26:Tiotropium Bromide Monohydrate (Spiriva) 18-microgram capsule (long-acting lung inhaler), instructing oral inhalation daily to prevent bronchospasm (airway constriction), start date 1/28/26.Budesonide Formoterol Fumarate Inhalation Aerosol 160-4.5 micrograms per actuation (combination steroid/bronchodilator inhaler), instructing two puffs orally twice daily for Chronic Obstructive Pulmonary Disease (COPD) (chronic lung disease), start date 1/27/26. On 8/17/26 at 10:00 AM, Staff F denied knowledge of any residents capable of self-administering medications. On 8/17/26 at 1:24 PM, Staff I, Registered Nurse (RN), denied knowledge of any residents capable of self-administering medications. On 8/17/26 at 4:00 PM, Staff D denied knowledge of any residents capable of self-administering medications. On 8/17/26 at 4:16 PM, the Assistant Director of Nursing (ADON) stated no current residents self-administered medications. The ADON stated facility self-administration protocol required obtaining a physician's order, completing a safety assessment with the resident, and care planning the resident's capability for self-administration. On 8/17/26 at 4:30 PM, the Director of Nursing (DON) outlined expectations for nursing staff to follow these medication administration steps:Prepare the medication as ordered.Administer the medication to the resident.Observe the resident taking the medication to ensure administration occurs without issues.Document medication administration.The DON stated no current residents possessed the ability to self-administer pills or inhalers. The facility policy titled Administering Medications dated April 2019 directed staff to administer medications in a safe, timely manner as prescribed. The policy instructed, in part:As required or indicated for a medication, the individual administering the medication records in the resident's medical record:The date and time of medication administration;The dosage;The route of administration;The injection site (if applicable);Any complaints or symptoms for which staff administered the drug;Any results achieved and observation timing; andThe signature and title of the person administering the drug.Residents may self-administer medications only if the attending physician, alongside the interdisciplinary care planning team, determines decision-making capacity to do so safely.

Based on observation, staff interviews, resident interviews and policy review, the facility failed to provide resident call light access for alerting staff of needs or in the event of an emergency for 3 of 24 residents reviewed for call light access (Residents #42, #69, and #73). The facility reported a census of 87.Findings include: 1. Resident #73's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview of Mental Status (BIMS) scored 14, indicating intact cognition. The MDS included diagnoses of heart failure, orthostatic hypotension, high blood pressure, and kidney failure. The Care Plan Focus initiated 1/24/26 identified Resident #73 had a risk for falls. The Interventions directed to encourage him to use the call light for assistance. On 2/9/26 at 2:44 PM Resident #73 relayed he came to the facility for therapy. He had low blood pressure and repeat falls. He reported the call light worked when he arrived, then it became unpredictable. It didn't work on Saturday 2/6/26 and he alerted staff who looked at it. He stated the light would come on in the room but, not on the board that alerted the staff. He added he didn't know if it worked like it is supposed to. On 2/9/26 at 2:46 PM Resident #73 agreed to test to call light and pushed the button, observed a small red light came on at the cord outlet. After 15 minutes without no one responding, the surveyor stepped out of the room to check the staff board. On 2/9/26 at 3:02 PM observed the call light board used to alert staff of resident calls; the board did not indicate Resident #73 pushed the call light. On 2/9/26 at 3:09 PM Resident #73 pushed the call light again, a red light went on and then off. Resident #73 relayed at times staff fiddled with the reset button to make the light work. On 2/9/25 at 3:45 PM Staff A, Certified Nursing Aide entered Resident #73's room, reported they didn't know his call light didn't work. Staff A pushed the call light button, the red light came on. Staff A left the room, came back in and confirmed the alert didn't show on the staff board. Staff A queried about the process when it didn't work, Staff A replied they would submit a work order. Staff A added all staff could submit a work order. Staff A summoned Staff C, Registered Nurse (RN), to the room On 2/9/25 at 3:50 PM RN, Staff C entered Resident #73's room and pushed the call light. Staff C left the room to view the staff board. Staff C came back, confirmed the call light did not work to alert staff on the board. Staff C reported they would submit a request to maintenance. Staff C gave Resident #73 a bell to shake to alert staff as needed. On 2/10/25 at 1:15 PM Resident #73 explained while in his room the Maintenance staff hadn't looked at the call light. Resident #73 pushed the button and reported the call light didn't work at all. The observation revealed no red light came on and confirmed it didn't show up on the staff alert call board. On 2/10/26 at 1:47 PM Staff B, CNA, explained several residents on other halls that have bells to ring due to call lights not functioning properly. They said no one told them Resident #73's call light didn't work and instead used a bell. Staff B confirmed Resident #73 preferred to keep his room door closed. On 2/10/26 at 2:05 PM Staff F, Maintenance Supervisor, reported he didn't know of any call lights not working. He explained the process used for concerns or repair needs. Staff F relayed the staff should put in a work order to alert maintenance as soon as they identify a problem. Staff F reported they had a tracking application of work orders on the phone and currently had no work orders. Staff F showed his phone that displayed 0 work orders. Staff F reported the facility just purchased the current call light system July of last year. They had replaced several cords under warranty that didn't' function. Staff F reported they expected the staff to alert maintenance and submit a work order for concerns. On 2/10/26 at 3:15 PM the Administrator relayed frustration with the new system and expected staff to first provide a bell to ring if the call light didn't function and submit a work order to maintenance. On 2/10/26 at 4:14 PM Staff D, CNA, explained the new call system function like a new one should. When a call light didn't work, the staff should give residents bells. They didn't know Resident #73 had a bell nor that his call light didn't work. On 2/10/26 at 4:16 PM Staff E, CNA, queried about the call light system and shared several residents on another hall have bells to ring due to ongoing issues with their call lights. They found sometimes the remedy is to hold the reset button longer, or unplugged it and plugged it back in to get it to work. 2. Resident #69's MDS assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS included diagnoses of non-Alzheimer's dementia, repeated falls, unsteadiness on feet, weakness, abnormalities of gait and mobility. The Care Plan Focus initiated 10/7/24 indicated Resident #69 had a risk for falls related to limited mobility. The Interventions instructed to encourage them to use their call light for assistance. On 2/9/25 at 10:20 AM Resident #69's family shared Resident #69 stayed at the nursing facility for support by staff and memory concerns. Observed Resident #69 sitting in her chair with no call light within reach. On 2/10/26 at 9:25 AM witnessed Resident #69 sitting in a bedside chair next to the window, with the door open, and no call light within reach. The call light cord hung from wall, behind the bedside dresser, down to the floor, curled under the bed. On 2/10/26 1:59 PM observed Resident #69 sitting her room with their door open. They welcomed the surveyor in. The observation revealed no call light in reach, the cord hung from wall behind bedside table on the floor under the bed. On 2/11/26 at 9:52 AM saw Resident #69 in their room with the door closed. Resident #69 welcomed a visit and relayed sometimes they liked to keep the door closed. Resident #69 queried if they needed staff assistance how would get help in an emergency. Resident #69 responded they could get up and thought could press a button. As they said that, they reached the reset button on the wall that did not activate the call light. Resident #69 relayed they didn't know where the call light cord was. Observed the call light cord hanging alongside the wall behind the bedside table, curled on the floor under the bed. Resident #69 relayed they wanted the door kept closed that day, resulting in them not in view of staff. On 2/11/26 at 10:15 AM the Director of Nurses, (DON) reported they expected the call light to be accessible to all residents. The DON entered Resident #69's room and confirmed they didn't have their call light available. She added she would ensure to provide staff education. The Policy titled, Answering the Call Light, revised March 2021 documented, upon admission and periodically as needed explain and demonstrate use of the call light to the resident. Be sure the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly, and when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 3. Resident #42 MDS dated [DATE] identified a staff assessment for mental status indicating she had severely impaired cognitive skills for daily decision making. Resident #42 needed supervision or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) for eating. The MDS listed Resident #42 dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity.) for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair to bed/bed to chair transfer and toilet transfers. The MDS included diagnoses of a stroke, hemiplegia (a severe form of paralysis affecting one side of the body), post-traumatic stress disorder (PTSD), and depression. The Care Plan Focus initiated 7/11/23 identified Resident #42 as a risk for falls related to a history of a stroke with hemiplegia affecting her right dominant side. The Interventions directed staff to encourage Resident #42 to use her call light for assistance. On 2/9/26 at 10:30 AM, observed Resident #42 sitting up in bed watching TV. Her call light cord wrapped around the middle of the headboard of the bed, not within reach of Resident #42. On 2/11/26 at 11:01 AM, observed Resident #42 lying in bed in a raised position. The call light laid coiled up on the floor behind the left side of the headboard of the bed, not within reach of Resident #42. On 2/11/26 at 11:03 AM, Staff G, Certified Medication Aide (CMA), verbalized the residents should have call lights placed within their reach. On 2/11/26 at 11:06 AM, Staff H, CMA, verbalized residents should have call lights within their reach. On 2/11/26 at 11:08 AM, Staff G and Staff H acknowledged Resident #42 didn't have her call light within reach. On 2/11/26 at 1:36 PM, the Director of Nursing (DON) verbalized all of the residents must have their call lights within reach of them at all times.

Based on observation, clinical record review, policy review, family, and staff interviews, the facility failed to maintain a homelike environment free of odors. The facility identified a census of 87 residents.Findings include:On 2/9/26 at 10:41 AM smelled a slight urine odor outside Resident #53's room door. The nurse entered Resident #53's room to administer medications and returned to the medication cart parked outside in the hallway just up from Resident #53's room. Another staff member stood at a treatment cart in hallway approximately 3 doors down from Resident #53's room door talking to another resident.On 2/9/26 at 10:46 AM observed Resident #53 lying in bed. Upon entrance to the room noted a strong, stale urine type odor throughout the room. Resident #53 sat up in bed and stated they didn't smell an odor in the room. She explained when she tried to stand up urine just runs out of her. Resident #53 admitted if she had wet linens or brief, she would throw them on the floor. She stated she really didn't use her call light and the staff eventually come clean it up. She just didn't have control of her urine. Further observation revealed a small blue wet blanket to the right side of the bed lying on the floor. The Care Plan Focus related to activities of daily living (ADLs) initiated 8/27/25 included an Intervention initiated 9/16/25 that described Resident #53 as non-compliant with toileting, using the call light, and she would throw soiled briefs on the floor. The Care Plan lacked further direction for the staff on what to do for Resident #53 or how to address the odor in her room. On 2/10/26 at 2:33 PM approximately 3 feet outside Resident #53's room door, smelled a stale, musty urine type odor. At the time several second shift staff and the maintenance man stood in the hallway outside of the doorway. Interview on 2/11/26 at 7:59 AM Staff P, Housekeeping Aide, reported generally the facility had a housekeeper for each hallway. They check first to see if there are any hotspots that need addressed. Each resident's room is cleaned daily Monday through Friday. On the weekend the facility schedules 2 housekeepers. One housekeeper has to clean two hallways each; (100 and 200 hallways) (300 and 400 hallways). Staff P explained on the weekends, one day they just do a wipe down in the room and empty garbage. Then the other day, they do a full cleaning of the room, including mopping. They only mop resident's rooms once on the weekends. Staff P stated they didn't have any rooms that require more cleaning. If the odor comes from a commode the Certified Nursing Assistants (CNA's) clean that, housekeeping didn't. The aides need to clean the mattress if the resident had incontinence through the mattress. Sometimes the aides come get their disinfectant spray and take care of it. Housekeeping cleaned the mattresses after a resident's discharge. They didn't clean the mattresses on their baths days unless the CNA's asked them too. No one has asked to special clean any mattresses for a long time. On 2/11/26 at 8:07 AM observed Staff M, CNA, and Staff Q, CNA, in the hallway outside of Resident #53's room passing breakfast trays to that area's rooms. Noted a stale, musty urine type odor waft approximately 2 feet outside of the room. At 8:08 AM Staff N, Assistant Director of Nursing (ADON), took a breakfast tray into Resident #53's roommate and assisted her roommate to sit up for breakfast. As Staff N exited the room a prominent urine type odor came into the hallway. On 2/11/26 at 8:11 AM the observation revealed no environmental aides on the hallways cleaning rooms at the time. During an observation on 2/11/26 at 8:13 AM Resident #53 sat upright in bed finishing her breakfast. At 8:14 AM watched Staff M and Staff N enter Resident #53's room to work with Resident #53's roommate. They exited the room at 8:16 AM, the room continued to have a lingering stale urine odor. On 2/11/26 at 8:22 AM witnessed 1 housekeeper down the D hallway and 1 housekeeper cleaning in the public areas. No other housekeepers observed cleaning in the A, B, C hallways at that time. During an interview on 2/11/26 at 9:09 AM Staff M explained Resident #53 has an incontinence problem and she starts to go the minute she stands up. She added that is why the floor gets wet and sticky in the room. When queried about room odor, Staff M stated, yes ma'am, lots of urine odor which she thinks is starting to seep into the floor. They have talked to management about the situation and the smell. Management didn't really know anything about the situation until recently. Staff M reported the wet, sticky floors to Staff N about a month ago. They clean the commode as part of every few hour rounds, but it is hard. They wash out the commode pan with soap and water, but they don't have any products to do a deep clean of the commode pan. In addition, Staff Q verbalized an constant odor to Resident #53's room. On 2/11/26 at 9:31 AM smelled a stale, musty, urine type odor approximately 2-foot outside of Resident #53's room into the hallway. Witnessed the Director of Nursing (DON) walked by Resident #53's doorway to another resident's room. Interview completed on 2/11/26 at 9:35 AM Resident #53's Family Member reported having a conversation with the charge nurse last Saturday (2/7/26). The Family Member came to visit Resident #53 and reported being devastated she had piss stains all over the sheets, with a urine filled soaker pad on the floor. The Family Member voiced talking to the facility before about the situation and it got better for some time, but they noted it getting worse again. Observation on 2/11/26 at 9:54 AM revealed a housekeeping cart on the 300, C-hallway starting to clean rooms. Staff R, Housekeeping Supervisor reported on the weekend they staff 2 housekeepers who are responsible for cleaning two hallways each. The weekend housekeepers did room cleaning one day on one hallway and then the next day clean resident rooms on the other wing. On the weekend day, the room didn't get a full cleaning, the housekeepers sweep the floor, empty the garbage and clean the bathrooms if needed. They cleaned the resident's rooms daily Monday through Friday. The Housekeeping Supervisor reported one other random resident, not included in the sample that required more room cleaning. They didn't identify Resident #53's room as needing additional cleaning. During an interview on 2/11/26 at 10:22 AM the Housekeeper Supervisor explained they cleaned the resident rooms daily and as needed. When they attempt to clean Resident #53's room, she would refuse as she didn't like the staff to touch her things. They added they would always have the smell there at that rate. She reported she couldn't be responsible for what happened when she left for the day. On 2/11/26 at 10:27 AM the DON reported Resident #53's room odor smelled much worse when the resident resided on a different hallway. The Administrator voiced they were in Resident #53's room all the time and running the carpet cleaner daily. They moved Resident #53 to a room with laminated flooring to make it easier to maintain. Staff R reiterated she didn't know when someone cleaned Resident #53's mattress. They clean the mattresses when the resident takes a shower or discharges. Staff M voiced they would report to the hallway housekeeper when Resident #53's needed cleaning due to urine on the floors. Staff M voiced the housekeeper usually just did the routine daily room cleaning and didn't go right down to the room to address it right away. Staff M then started to backtrack her statement as the Housekeeping Supervisor gave her a look. Staff M repeated 3 times, I'm sorry. The DON voiced to Staff M it was okay. On 2/11/26 at 10:35 AM the Administrator reported they had several conversations about Resident #53's room and maybe it was time that they needed to revisit it again. On 2/11/26 at 10:36 AM the Housekeeping Supervisor stated the aides need to get Resident #53 out of the room so they can do a deep clean of the room. The Housekeeping Supervisor identified the commode bucket had a lot of urine odor and needed to be changed out of the room. On 2/11/26 at 10:40 AM the Administrator voiced they may have to get Resident #53 a new mattress. On 2/11/26 at 11:16 AM the Housekeeping Supervisor reported they deep cleaned the room and described the smell of the urine in the room as even worse now. Observation at this time revealed the middle 1/3 of the mattress with a strong musty urine smell and the floor with a strong, musty urine smell. The floor exhibited a tacky texture. The Housekeeping Staff's shoes stuck to the floor as they walked in the room. Staff S, Housekeeping Aide, reported the room had a stuck down slightly blackened stain that ran from where the commode sat, then down the floor underneath the closet cabinet (approximately 4 feet) that she mopped up. The Housekeeping Supervisor reported she would try to go over the floor again, but each time they tried to clean the urine smell it just kept getting worse and worse. A 2/11/26 review of Resident #53's Shower Skin Cheek Sheet provided by the DON revealed the resident had refused her bath in January 2026 on the 14, 21, 24.On 2/11/26 at 1:21 PM Staff X, CNA, reported her room had a strong odor to it many times. They try to empty her bedside commode regularly. They dump and rinse the commode pan, but they don't really clean the commode pan as they usually use a garbage bag liner in it. Staff X voiced she thought the odor came from needing her bed changed or from urine contacting the floor. When they mop the floor, the odor is better. A review of the Housekeeping Deep Cleaning a Room Record for January and February 2026 lacked documentation of more than daily cleaning for resident rooms. The Housekeeping Deep Cleaning a Room Record dated 2/6/26 Staff P documented crossed out squiggles for rooms 301-316 and included hand written at the top of the Record, they swept the rooms, mopped and emptied the garbage. The Record dated 2/7/26 documented rooms 301-316 had been cleaned daily. The Record dated 2/8/26 contained a large X through the whole document by Staff T, Housekeeping Aide. During an interview on 1/12/26 at 11:35 AM the Administrator reported they tried to provide a clean homelike environment. He agreed the average person wouldn't like their room to have a urine odor present.The Homelike Environment Policy, revised 2021, provided by the facility directed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment;b. clean bed and bath linens that are in good condition;c. pleasant, neutral scents. The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include institutional odors.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed complete the Minimum Data Set (MDS) Assessment within 14 days of admission for 1 of 2 resident reviewed for new admission (Resident #39). The facility identified a census of 87 residents.Findings include:An Electronic Medical Record (EMR) Census documented Resident #39 admitted to the facility on [DATE].Resident #39's MDS 3.0 Summary Page showed the admission MDS signed off as completed late on 9/5/25. During an interview on 2/12/26 at 11:50 AM Staff L, MDS Coordinator, reported the facility completed Resident #39's MDS late. They look at the MDS list and spend time everyday working on them, looking to see where they are at. Staff L stated she has a calendar made up that she used to track when the MDS are due. Staff L voiced they have one week to get the MDS done and she utilized a Paper Document Titled Section GG Collection Dates which specified the day of admission counted as day 1 of the residents stay. Staff L reiterated they utilize the RAI manual for the MDS. The LTC RAI 3.0 User Manual, directed the admission MDS completion date is required no later than day 14 of the resident's stay.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed encode and transmit Minimum Data Set (MDS) documents to the CMS system in the appropriate time frames for 3 of 4 records reviewed for MDS timing requirements (Residents #36, #39 and #61). The facility identified a census of 87 residents.Findings include:1. Resident #36's Electronic Healthcare Record (EMR) Census documented a discharge date of 8/7/25. Resident #36's MDS Discharge Return Anticipated Assessment documented a discharge date in A2000 of 8/7/25. Section Z0400 related to the signature of persons completing the assessment or entry/death reporting reflected a completion date of 8/24/25.The MDS 3.0 Summary Page documented a MDS Discharge Return Anticipated Assessment completed late on 8/24/25, 24 days after their discharge.During an interview on 2/12/26 at 11:50 AM Staff L, MDS Coordinator, reported they look at the MDS list and spend time everyday working on the MDS schedule. Staff J, MDS Coordinator, stated she made up a MDS calendar that she used to track the MDS due dates, evaluation dates and Care Plan dates. Staff L voiced she tried to batch MDS documents to the (CMS) database every week and thought they had one week to transmit the records in. Staff L reported they follow the RAI for completing the MDS. The RAI 3.0 User Manual directed Discharge Assessments must be completed within 14 days of the discharge date and transmitted 14 days from the completion of the discharge assessment date to the CMS data base.2. Resident #39 EMR Census documented an admission date of 8/12/25 and a discharge date of 8/18/25. A Discharge Return Not Anticipated Assessment documented a discharge date of 8/18/25 in A1600. Section Z0500 related to the signature of the Registered Nurse, RN, reflected a completion date of 9/5/25.Resident #39's MDS 3.0 Summary Page documented the Discharge Return Not Anticipated Assessment as completed late on 9/5/25. 3. Resident #61's EMR Census documented a discharge date of 9/30/25.A MDS Tracking Page documented a 9/16/25 Entry Tracking Form and a 9/22/25 admission MDS Assessment. The MDS Tracking page lacked documentation of the completion of a Discharge Assessment. A review completed on 2/12/25 of the MDS Tracking Page documented a 9/30/25 Discharge Return Not Anticipated Assessment completed and waiting for transmittion to the CMS data base.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interviews, the facility failed to accurately code the Preadmission Screening and Resident Review (PASRR, an assessment for serious mental illness or intellectual or developmental disability for appropriate services) on the Minimum Data Set (MDS) assessment for 2 of 2 residents sampled (Resident #6 and #10). The facility identified a census of 87 residents.Findings include: 1. Resident #6's Notice of PASRR Level 1 Screen Outcome dated 10/2/25 documented a Determination of Level 1 Positive, No Status Change. The PASRR Outcome Explanation documented Resident #6 had evidence of a serious mental illness. The previous PASRR Summary of Findings remains valid for your stay. The Explanation further detailed the facility should mark yes for question A1500 on the MDS, Is the resident currently considered by the state level II PASRR process to have serious mental illness. Also, the PASRR condition(s) should be checked in question A1510, Level II PASRR Conditions. Resident #6's MDS assessment dated [DATE] documented in Section A1500 Resident #6 didn't have a serious mental illness and/or intellectual disability related condition. Section A1510 was blank. The MDS listed diagnoses of anxiety, depression, and post-traumatic stress disorder. The MDS reflected Resident #6 utilized antipsychotic, antianxiety and antidepressant medications during the lookback period. Resident #6's Notice of PASRR Level II Outcome dated 11/22/24 documented Resident #6 required specialized services for behavioral health. A review conducted on 2/11/26 of the Electronic Medical Record Profile Page documented Resident #6 as a level 1 under the PASRR Level. Interview completed on 2/11/26 12:36 PM Staff K, Social Service Coordinator explained they list the resident PASRR level of the Profile Page. Staff K pulled up Resident #6 Profile page and listed her as a PASRR level 1. During an interview on 2/11/26 at 12:42 PM Staff L, MDS Coordinator, reported Resident #6 is a level 1 for PASRR. Staff L explained when coding the PASRR status she looked at the resident's profile page and sometimes looked at the resident's PASRR in the documents area (of the medical record). After reviewing the 10/2/25 PASRR she stated she didn't know Resident #6 had a level II PASRR. She verified the annual MDS as not coded correctly. Staff L explained they follow the RAI manual to code the MDS assessments. The CMS LTC RAI 3.0 User's Manual, October 2025, Version 1.20.1, Page 1-4 documented the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require the assessment accurately reflects the resident's status. 2. Resident #10's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #10 is not a level II PASRR. Resident #10's PASRR dated 12/16/25 documented a Positive level I, no status change (positive Level II on file, a new Level II is generally not required unless they experience a significant change in condition). Resident #10's PASRR dated 3/26/24 documented a Level II approved with specialized services. On 2/12/26 at 11:02 AM Staff J, MDS Coordinator, confirmed the Annual MDS as coded wrong as Resident #10 is a level II PASRR.

Based on observation, record review, facility records, policy review, and staff interviews, the facility failed to utilize infection control standards to prevent cross contamination when they placed gauze that dropped on a bed pad directly on a wound for 1 of 2 residents reviewed (Resident #65). The facility reported a census of 87 residents. Findings include:Resident #65's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #65 as frequently incontinent of urine and bowel during the lookback period. The MDS listed active diagnoses of wound infection, diabetes mellitus and chronic obstructive pulmonary disease (COPD - an ongoing lung condition caused by damage to the lungs). The MDS identified Resident #65 required surgical wound care and application of a nonsurgical dressing. A Progress Note dated 2/6/25 at 6:35 PM documented the surgical incision site measured 7.03 centimeters (cm) in length and 9.97 cm in width with an area of 9.65 cm. The wound had 10% exudate (a fluid rich in protein, cells, and solid materials that leaks from blood vessels into nearby tissues, usually due to inflammation or injury). The note described the exudate type as serosanguineous: a mixture of serous and sanguineous fluid, typically pale, red, and watery.A Physician Order dated 2/7/26 instructed staff to change spinal dressing daily and as needed. The order directed to apply dry gauze to incision site and tape, don't cleanse with anything or put any creams, ointments, etc. on incision site. The Care Plan Report initiated on 9/30/25 identified Resident #65 had a surgical incision/wound to the lower back. The Care Plan Report instructed staff to weekly evaluate wound healing and provide incision care as ordered by the physician. The Care Plan Report revised on 10/30/25 identified Resident #65 had impaired skin due to a surgical incision. The Care Plan instructed staff to use Enhanced Barrier Precautions (an infection control strategy in nursing homes requiring staff to use gowns and gloves during high-contact resident care-such as dressing, bathing, or transferring-to prevent the spread of multidrug-resistant organisms MDROs). On 2/11/26 at 1:21 PM, observed Resident #65 sitting up in bed. Resident #65 used the bed control to lower the head of her bed. Resident #65 removed the top sheet and rolled onto her right side. Resident #65 had an incontinent brief and was positioned on a linen bed pad on the fitted sheet of the bed. Staff I, Licensed Practical Nurse (LPN), sanitized her hands, donned (applied) a gown and gloves. Staff I, raised Resident #65's shirt and lowered the top of the incontinent brief. Staff I removed the dressing on her spine and threw it away. Staff I, removed her gloves, sanitized her hands and donned new gloves. Staff I opened gauze and folded the gauze in half, staggering 3 gauze pads. Staff I attached 2 sections of the staggered gauze to the tape. The third folded gauze fell onto the surface of the bed pad. Staff I picked up the folded gauze off the incontinent bed pad and placed it on the tape. Staff I placed the gauze and tape on the spinal wound of Resident #65's lower back.On 2/11/26 at 1:30 PM, Staff I, LPN acknowledged a gauze pad fell on the bed pad and they placed directly on the wound. Staff I verbalized they shouldn't have used that gauze. The DON verbalized she didn't see the gauze drop onto the bed pad, but if it did, they shouldn't have used the gauze.On 2/12/26 at 9:45, Staff G, Certified Medication Aide (CMA), verbalized they changed resident bedding when a resident received a shower/bath. Staff G didn't know when they changed Resident #65's bedding.Resident #65 bath records revealed the following:1/26/26 bath completed1/29/26 bath not completed - Resident on leave of absence/ at appointment2/2/26 resident not available2/5/26 resident refused2/9/26 not applicableThe personnel file for Staff I, LPN reflected a hire date of 12/12/23. The Job Description signed by Staff I on 12/12/23 included essential functions of:Follow established standards of nursing practices and implement facility policies and procedures. Administer and document direct resident care, medications, external nutrition, treatments per physicians' orders and accurately record all care provided. The Orientation Checklist: Licensed Nurses documented wound care had been reviewed on 12/18/23 signed by Staff I on 12/20/23. The personnel file documented Staff I successfully completed all requirements and received a Wound Care Certification on 7/17/25.The Dressings, Dry/Clean policy revised September 2013 directed staff to: Position resident and adjust clothing to provide access to the affected area.Wash and dry hand thoroughly.Put on clean gloves. Loosen tape and remove soiled dressing.Pull glove over dressing and discard into plastic or biohazard bag.Wash and dry your hands thoroughly. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface.Label tape or dressing with date, time and initials. Place on clean field.Using clean technique, open other produces (i.e. prescribed dressing; dry, clean gauze).The policy failed to direct staff of what to do if gauze/dressing comes into contact with a contaminated surface.

Based on observation, facility records, record review, policy review, resident and staff interviews the facility failed to follow their smoking policies to ensure resident safety for 1 of 1 resident reviewed (Resident #70). The facility failed to complete a smoking assessment or safety assessment to ensure a resident could safely smoke alone in the designated smoking area off the facility's property. In addition, the facility failed to ensure the facility grounds remained smoke free as declared by the staff with 50 cigarette butts on the facility's ground near the area of a resident observed smoking. The facility reported a census of 87 residents.Findings include:Resident #70's Minimum Data Set (MDS) assessment dated [DATE], documented an admission date of 12/20/25. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #70 used a walker and a wheelchair during the 7-day lookback period. The MDS listed Resident #70 as independent to wheel himself in a manual wheelchair. The MDS documented Resident #70 as a current tobacco user. The MDS documented active diagnoses of amputation, atrial fibrillation, heart failure, and peripheral vascular disease (PVD).Review of the facility provided Smoking Policy - Residents revised July 2017 reflected the following: Upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include: ability to smoke safely with or without supervision.The staff shall consult with the attending physician and the DON to determine if safety restrictions need to be placed on a residents smoking privileges based on the Safe Smoking Evaluation.The resident's ability to smoke will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. Resident #70's Safe Smoking Evaluation completed on 2/9/26 at 10:23 AM documented the facility was a smoke free facility. The Safe Smoking Evaluation documented the following: Ability to hold cigarette safelyAbility to maintain control of cigarette if physically distractedAbility to light his/her cigarette safelyDemonstrate appropriate use of an ashtrayDemonstrate ability to let go of cigarette and then retrieve it appropriatelyDemonstrate ability to appropriately extinguish cigaretteThe Safe Smoking Evaluation documented the resident had not demonstrated non-compliance with the smoking policy requirements. The Safe Smoking Evaluation identified Resident #70 as an independent smoker with no adaptive equipment required. The Safe Smoking Evaluation lacked evaluation of the resident's ability to walk, wheel, or propel oneself off property to smoke if a resident chose to exit the facility without going out with family. The Safe Smoking Evaluation lacked evaluation of the resident's ability to maneuver outside in inclement weather including rain, snow or ice. Resident #70's clinical record lacked a smoking evaluation prior to 2/9/26.The Service Agreement effective 12/23/24 for the facility related snow removal, deicing, and lawn maintenance services. Snow removal and deicing services directed the following service requirements related to snow:Plow level 2: snow removal for 2.1-4 inches accumulationPlow level 3: snow removal for 4.1-6 inches accumulationShovel walks level 2: snow removal for 2.1 -4 inches of accumulationShovel walks level 3: snow removal for 4.1 - 6 inches of accumulationDeicing Services included deicing lot and sidewalks.The Care Plan Focus initiated 2/9/26 identified Resident #70 as non-compliant with the facility's smoking policy and didn't leave the property to smoke. The Interventions direct the staff to:Conduct Safe Smoking Evaluation at admission and as neededEducate resident/responsible party on the facility's tobacco/smoking policyStaff will educate resident on the facility's smoking policy, including where and when smoking is permittedStaff will redirect Resident #70 to appropriate locations when non-compliance is observedStaff will remind Resident #70 in a calm and respectful manner, that smoking is only allowed off facility property.The Care Plan Report lacked direction of where to keep smoking supplies, such as cigarettes and lighter. In addition, the Care Plan Report lacked identifying where facility property ended and where it would be permissible to smoke. The Encounter Note dated 1/8/26 at 12:00 AM documented Resident #70 as a daily smoker who continued to smoke.The SPN - Skilled Evaluation dated 1/15/26 at 2:32 PM indicated Resident #70 had a chronic cough related to smoking.Review of the Release of Responsibility for Leave of Absence form for Resident #70 revealed he didn't sign out of the facility on the morning of 2/9/26. On 2/9/26 at 9:30 AM, observed Resident #70 sitting in his wheelchair smoking on the sidewalk on the north sidewalk between a bench and the north side of the parking lot. On 2/9/26 at 9:45 AM, the Administrator declared the facility as a smoke-free facility. They listed no residents as current smokers. The Administrator verbalized if a resident wanted to smoke, they would need to do so off property when they went out with family.On 2/9/26 at 2:11 PM, observed Resident #70 seated in his wheelchair outside the Director of Nursing's (DON) office. The DON identified Resident #70 as a smoker. On 2/9/26 at 2:15 PM observed the area where Resident #70 smoked revealed more than 50 cigarette butts lying on the ground around a bench, under a mature evergreen tree, and on the north side of the facility parking lot. The facility didn't have a receptacle to place cigarette butts in. On 2/10/26 at 7:47 AM, observed Staff O, Maintenance, outside on the facility sidewalk. He reported he picked up the cigarette butts. Staff O verbalized he saw cigarette butts on the ground after winter when the weather warmed up. On 2/10/26 at 8:30 AM, the Administrator denied knowing Resident #70 currently smoked. The Administrator added Resident #70 didn't smell like smoke. The Administrator reported residents needed to sign out of the facility if they leave when they went outside to smoke. The Administrator acknowledged the facility had a lot of cigarette butts on the ground where they observed Resident #70 smoking on facility property. The Administrator acknowledged Resident #70 didn't sign out of the facility on the morning of 2/9/26.On 2/10/26 at 1:07 PM Resident #70 verbalized he smoked. Resident #70 confirmed he smoked on the sidewalk between the bench and the parking lot on the morning of 2/9/26. Resident #70 reported someone chewed him out for it already. Resident #70 explained they told him he had to go out by the road to smoke. On 2/12/26 at 10:47 AM, Staff W, Rehab Director/Certified Occupational Therapy Assistant (COTA), verbalized she knew Resident #70. Staff W reported the smoking area as off property. Staff W explained therapy hadn't assessed Resident #70 abilities to transfer himself safely off the facility property to smoke in good or inclement weather such as rain, snow or ice. On 2/12/26 at 10:49 AM, Staff U, Doctor of Physical Therapy (PT), verbalized she knew Resident #70. Staff U acknowledged Resident #70 currently smoked. Staff U reported she didn't have any idea the location of the designated smoking area. Staff U explained she observed people on the sidewalk by the street smoking. Staff U reported PT didn't assess for wheelchair mobility. On 2/12/26 at 10:53 AM, Staff V, Occupational Therapist (OT), verbalized she knew Resident #70 currently smoked. Staff V reported she saw people smoking on the sidewalk by the bench and parking lot in the afternoons when she leaves the facility. Staff V reported she didn't know if anyone assessed Resident #70 for safety getting to an area to smoke in good weather or inclement weather. On 2/12/26 at 10:57 AM, Staff L, MDS Coordinator acknowledged she completed the MDS dated [DATE] for Resident #70 which identified him as a current smoker. Staff L verbalized any of the nurse managers could complete the Safe Smoking Evaluation. Staff L reported someone should have completed the Safe Smoking Evaluation sooner. Staff L verbalized residents who choose to smoke had to do so off property on the sidewalk by the road. Staff L verbalized no one assessed Resident #70 safety in getting himself to a smoking area off the property in inclement weather such as rain, snow or ice. On 2/12/26 at 11:07 AM, the DON acknowledged the Safe Smoking Evaluation lacked an evaluation of a resident's abilities to safely maneuver oneself off the property to smoke.

Based on observations, interviews, and record review, the facility failed to provide adequate grooming for 1 of 4 residents reviewed (Resident #1). An observation revealed Resident #1 still wore his t-shirt from bedtime, the following day. In addition, Resident #1 had hairs remaining on his shirt after his visit to the barber, the day before. The facility reported a census of 82 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS listed Resident #1 as dependent on staff with upper and lower body dressing. The MDS included diagnoses hemiplegia (extreme weakness on half of the body) following a cerebral infarction (stroke) and depression. On 6/3/25 at 12:46 PM, Resident #1's Sister reported Resident #1 wore the same shirt as he did the day before (6/2/25). She reported Resident #1 received a haircut the day before (6/2/25) and his shirt still had hair from his haircut. On 6/3/25 at 1:20 PM, observed Resident #1 in bed wearing an orange t-shirt and noted short hair on the shirt. Resident #1 acknowledged he didn't have his shirt changed the night before. Resident #1 allowed an up close picture of the hair on his shirt. On 6/4/25 at 11:06 AM, Staff A, Certified Nurse Aide (CNA), explained he got Resident #1 ready for bed on Monday, 6/2/25. He added he checked and changed Resident #1. Staff A reported Resident #1 already laid in bed, so he changed his brief during the shift. Staff A stated he didn't remember changing Resident #1's shirt that night. He stated 9 times out of 10, day shift changed him into his gown. He would already have his gown on for the night, when Staff A went into Resident #1's room. When asked who normally puts Resident #1's gown on, Staff A stated that sometimes day shift does it, otherwise he did. He added at times, Resident #1 refused to wear a gown because he preferred a t-shirt. When told Resident #1 wore the same t-shirt the following day, Staff A acknowledged the statement. He acknowledged he didn't remember if he wore a t-shirt or if Resident #1 refused to change into a gown. On 6/4/25 at 11:30 PM, Staff B, Assistant Director of Nursing (ADON), stated Resident #1 had a haircut on Monday. She remembered he wore a gray sweatshirt on Monday, but he could have worn the orange t-shirt under his sweatshirt. When shown the picture, Staff B acknowledged Resident #1 had hair on the t-shirt in the picture and it looked like hair from a haircut. An ADL (Activity of Daily Living), Supporting policy revised March 2018, directed the following: The facility would provide residents with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who can't carry out their ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Policy Interpretation and Implementation instructed the following: a. Residents will receive care, treatment and services to ensure that their ADLs didn't diminish unless the circumstances of their clinical condition(s) demonstrate diminishing ADLs are unavoidable. a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. b. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: i. Hygiene (bathing, dressing, grooming, and oral care)

Based on observation, interviews, and record review the facility failed to remove expired foods from storage, to maintain a sanitary environment, and to date opened food during 2 of 2 observations. The facility reported a census of 87 residents. Findings include: During the initial kitchen tour and observation on [DATE] at 9:36 AM the dry storage area contained an undated and nearly full clear bin of rice with a blue lid. The shelf below the rice contained two round snack bins without lids with prepackaged snacks. The bin on the left held 6 items, cheese puffs out of the wrapper, and crumbs. The bin on the right held 11 items, corn chips out of the wrapper, and chip crumbs. Another shelf contained an open, undated package of chicken and herb stuffing. The bottom shelf of the next unit contained 3 boxes of lemon bar mix. One of the boxes had two sides crumpled, and the tops of the other two had a film of dust and food particles. The boxes had expiration dates listed on the boxes as [DATE], [DATE], and [DATE]. On the top shelf of that unit contained a box of gluten free chocolate chip cookies that expired [DATE]. Further investigation of the kitchen included the walk-in refrigerator and freezer. The freezer contained an open, undated package of fajita vegetable blend. Another shelf contained a cardboard box of southern style biscuits. The front and side flaps of the box were open, and the plastic holding the biscuits was open to the freezer air (-3 degrees). The box had a delivery date, but didn't have an open date. The box looked approximately half full, and some of the biscuits had small ice crystals on them. The floor in the freezer had 3 half dollar size ice chunks stuck to the surface, tater tots, green beans, and other unidentified food particles. On [DATE] at 9:45 AM the Dietary Manager (DM) stated they had the snack bins from the day before. She didn't know why they had them in the dry storage room because they're not to be stored there. When asked when the last time they served lemon bars for a meal, the DM thought the spring and summer menu (2024) had them. During an interview on [DATE] at 4:11 PM the Administrator reported he recently audited the kitchen for expired items and didn't know how or why they still had those items there. During a second observation on [DATE] at 9:32 AM, saw a cart of clean dishes against the wall in the food preparation area. A metal surrounded floor drain approximately 5 6 inches deep with a mesh drain cup in the bottom sat approximately 9 inches from the cart. Food particles, bits of foil, and dust webs with food caught in them covered the metal-surrounded drain and the drain cup. Staff E, Assistant Dietary Services Manager (ADSM), stated they used the drain when the facility had a portable steam table, she didn't think they used it for anything at the time of survey. On [DATE] at 11:27 AM the DM reported she audited for expired food on a regular basis, and usually checked for shelf life on Mondays when she put the new food shipment away. When asked how the facility managed expired items, she stated they tossed expired food. She expected staff who opened food for meals to label items with an 'O' for opened with the date. On [DATE] at 11:45 AM the DM provided a document titled Cleaning Schedule for the week of the survey. Morning staff initialed that they swept and mopped the floors, cleaned refrigerator spills, and checked for outdated food daily. Evening (PM) staff initialed they cleaned refrigerator spills daily, swept, and mopped the floors.

Based on observation, clinical record review, Center for Disease Control and Prevention (CDC) Guidelines, policy review and staff interview, the facility failed to implement Enhanced Barrier Precautions when providing high contact care for assessing a fistula (dialysis access site), working with a gastrostomy (G) tube (feeding tube) and emptying a Urinary catheter drainage bag for 3 of 3 resident sampled (Resident #10, #128 and #132). In addition, the facility failed to provide adequate infection control prevention and practices to prevent touching medication with bare hands or dirty gloves during medication administration for 3 of 4 resident observed (Resident #34, #43 and #63). The facility identified a census of 87 residents. Findings include: 1. Resident #132's Clinical Census listed an admitted [DATE]. A Brief Interview for Mental Status (BIMS) Evaluation dated 1/14/25 listed a score of 15, indicating intact cognition. Resident #132 Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of malnutrition. The MDS documented Resident #132 had a feeding tube while a resident. She received 26 50 percent of her total calories and 501 cubic centimeters (CC, a unit of measurement 30 cc equals one ounce of fluids) per day or more through the feeding tube. Resident #132 January 2025 Electronic Medication Administration Record (EMAR) listed the following physician orders: a. Start Date 1/15/25: Enteral (An alternative way of eating that bypasses the mouth) feed order one time a day formula flow rate set at 60 Milliliters (ML) per Hour (HR). Discontinued 1/23/25. b. Start Date 1/15/25: Enteral feed order two times a day. Document the enteral feeding intake every shift. Discontinued 1/23/25. c. Start Date 1/14/25: Enteral feed order two times a day. Flush feeding tube with at least 15 30 ML of water before and after the administration of feedings. d. Start Date 1/14/25: Enteral feed order two times a day. Formula Osmolyte 1.2 no fiber at 60 ML/HR from 6 PM to 4 AM. Document the feeding tube intake every shift. Discontinued 1/23/25. e. Start Date 1/14/25: Enteral feed order three times a day. Check the residual every shift if less than 30 ML note in progress note. f. Start date 1/14/25: Enteral feed order three times a day. Document the amount of water every shift. Include water given before and after the medication administration. g. Start Date 1/14/25: Enteral feed order three times a day, verify the gastric (G) tube (feeding tube) placement every shift. On 1/27/25 at 10:47 AM observed Resident #132's room door. The door didn't have a CDC Enhanced Barrier Precaution (EBP) Sign on the room door. Resident #132's January 2025 Electronic Treatment Administration Record (ETAR) documented an order dated 1/27/25 to use EBP due to her having a G tube. On 1/28/25 at 7:54 AM observed Resident #132 with a CDC EBP sign posted on her room door. The CDC Enhanced Barrier Precautions Sign directed everyone must clean their hands, including before entering the room and when leaving the room. The EBP sign further directed Providers and Staff must wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assist with toileting, device care or use: feeding tube. During an interview on 1/28/25 at 8:02 AM Staff F, Registered Nurse (RN), reported Resident #132 ate a mechanical soft diet, the nursing staff only flushed and checked the placement of the feeding tube at that time. Resident #132 just started EBP on 1/27/25. Staff F voiced that up until 1/27/25 Resident #132 didn't have EBP precautions and she just started the precautions due to having a feeding tube. Interview on 1/28/25 at 1:30 PM Resident #132 reported the nurses just started using gowns and gloves when they flushed her tube the day before (1/27/25) in the afternoon. She voiced the other day the nurse pushed the syringe and the tube just blew. She reported stomach contents landed on her and went all over. On 1/28/25 at 1:24 PM watched Staff F sanitize her hands, apply an isolation gown, and gloves. Staff F then checked residual and placement of Resident #132's feeding tube. Afterwards, she removed her gown and gloves, then performed hand hygiene. During an interview on 1/29/25 at 11:46 AM the Director of Nursing (DON) reported the facility educated the certified nurses' aides (CNAs) on EBP. They just place the CDC EBP signs on the resident doors as an extra step to remind the staff of the Personal Protective Equipment (PPE) requirements. She reported she worked on the staff with the EBP and some residents, like Resident #132 and #128 just got missed. The Enhanced Barrier Precaution (EBP) Policy revised 3/28/24 directed EBP refers to an infection intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. The Policy further directed the facility would communicate to staff to ensure staff knew of which residents required the use of EBP prior to providing high contact care activities. The Policy PPE for EBP is only necessary when performing high contact care activities which further defined included device care for central lines, feeding tubes and urinary catheters. The Policy stated EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the discontinuation of the indwelling medical device that places the resident at higher risk. 2. Resident #128's Clinical Census reflected they admitted to the facility on [DATE]. The Handoff Report dated 1/24/24 listed Resident #128 received hemodialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are no longer able to do so) at a local (renal/kidney) dialysis center. The Nursing Admission/Readmission Evaluation - V 18 dated 1/24/25 documented Resident #128 as alert, oriented to person, place, time, situation and clear communication abilities. The Evaluation noted Resident #128 didn't have short term memory impairment, confusion, forgetfulness or impaired decision making ability. The Evaluation documented Resident #128 had an arteriovenous (AV) fistula (an AV fistula is surgically created in the arm to provide easy access to a large blood flow for dialysis) present to her right (arm). Resident #128's dialysis Care Plan directed staff to use EBP. Resident #128's BIMS evaluation dated 1/24/25 listed a score of 14, indicating intact cognition. On 1/27/25 at 11:50 PM observed Resident #128's room door didn't have a CDC EBP sign on the door. Resident #128's January 2025 EMAR listed a physician order for dialysis on Monday, Wednesday and Friday, chair time at 10:45 AM. Resident #128's January 2025 ETAR listed a physician order dated 1/24/25 to assess the fistula for bruit (swish) and thrill (pulsing feeling near the fistula) every shift. The NSG: Dialysis Evaluation - V 9 dated 1/25/25 at 1:09 PM reflected the reason for evaluation as non dialysis day. The evaluation documented Resident #128 fistula as normal with bruit heard, thrill pulsation felt, and normal fistula elevation. The NSG: Dialysis Evaluation - V 9 dated 1/26/25 at 1:53 PM reflected the reason for evaluation as non dialysis day. The evaluation documented Resident #128 fistula as normal with bruit heard, thrill pulsation felt, and normal fistula elevation. The NSG: Dialysis Evaluation - V 9 dated 1/27/25 at 1:46 PM reflected the reason for evaluation as a pre-dialysis evaluation. The evaluation described Resident #128's fistula as normal with good color, bruit swish heard and thrill pulsation present with normal fistula elevation. The NSG: Dialysis Evaluation - V 9 dated 1/27/25 at 2:53 PM reflected the reason for evaluation as a post dialysis assessment. The evaluation indicated Resident #128's fistula site as normal with the bruit heard, thrill pulsation felt, and normal fistula elevation with no bleeding at the site. Interview on 1/28/25 at 8:24 AM Resident #128 reported the nurses use their stethoscope to listen to her fistula several times a day. She voiced she never saw them wear a gown and gloves when checking and touching her fistula pointing to her fistula just below the bend in her right elbow. During an interview on 1/29/25 at 11:46 AM the DON reported Resident #128 admitted on a weekend. They felt it got missed and fell through the cracks. 3. On 1/29/25 at 7:24 AM observed Staff G, Certified Medication Aide (CMA), check Resident #63's EMAR for physician orders. Staff G pulled a bottle of stock Lactaid from the medication cart drawer, shook out two tablets from the bottle into the lid, then picked up one tablet with her bare right hand and placed it back in the stock bottle and picked up the other tablet with her bare right hand and placed it in Resident #63's medication cup. Staff G removed a stock multivitamin bottle from the medication cart. She shook two multivitamins into the bottle lid. Staff G picked up 1 tablet in her bare right hand and put back in the stock bottle, then picked up the remaining multivitamin and placed it in Resident #63's medication cup. Staff G proceeded to Resident #63's room and administered the medication to them. During an interview on 1/29/25 at 7:56 AM Staff H, CMA, verbalized staff shouldn't touch resident's pills with their bare hands. She would use a clean glove or a spoon if she needed to touch a resident's oral medications. 4. On 1/29/25 at 7:58 AM watched Staff I, Registered Nurse (RN), perform hand hygiene, apply gloves to both hands, touch the computer screen to scroll through residents and opened Resident #43's EMAR. Staff I took the medication cart keys from her pocket, unlocked the medication cart, opened the drawer, and removed Resident #43's medication cards from the drawer and laid them on top of the medication cart. Staff I reviewed the physician order on the computer screen and the medication card for each medication. Without performing hand hygiene or changing her gloves, Staff I punched each medication out of the backside of the medication card to the fingertips of her gloves putting each pill into the medication cup. Staff I continued with this technique while setting up the following medications: a. Cymbalta 90 Milligram (MG) one tablet b. Baclofen 10 MG one tablet c. Lisinopril 30 MG one tablet d. Metoprolol Succinate Extended Release 50 MG one tablet At 8:00 AM without performing hand hygiene or changing her gloves, Staff I entered Resident #43's room and administered their medications. 5. On 1/29/25 at 8:08 AM observed Staff I perform hand hygiene, apply gloves to both hands, touch the computer screen to scroll through residents and opened Resident #34's EMAR. Staff I took the medication cart keys, unlocked the medication cart, opened the drawer and removed Resident #34's medication cards from the drawer and laid them on top of the medication cart. Staff I reviewed the physician order on the computer screen and the medication card for each medication. Without performing hand hygiene or changing her gloves, Staff I punched each medication out of the backside of the medication card to the fingertips of her gloves putting each pill into the medication cup. Staff I continued with this technique while setting up the following medications: a. Amlodipine 10 MG one tablet b. Carvedilol 25 MG one tablet In addition, Staff I punched a 5 MG Eliquis (blood thinner) pill out of Resident #34's medication card and the pill flipped out on top of the medication cart. Without performing hand hygiene or changing her gloves, Staff I picked the Eliquis pill up with her right gloved hand and placed the pill in Resident #34's medication cup. Staff I touched the computer screen again with her gloved hand to scroll through the medications, then removed a stock Vitamin D3 bottle from the medication cart. Without performing hand hygiene or changing her gloves, Staff I shook one Vitamin D3 2000 Unit tablet from the bottle into her right gloved hand and then placed the tablet in the medication cup. Staff I proceeded into Resident #34 room and administered the medications to Resident #34. During an interview on 1/29/25 at 8:10 AM Staff I reported they must not touch the medication with bare hands. She added the staff should do hand hygiene and use a glove if they need to touch a medication. Interview on 1/29/25 at 11:23 PM Staff I reported she could see where wearing gloves and touching things prior to touching the medications could be an issue. During an interview on 1/29/25 at 12:15 PM the DON reported she expected the staff to use a clean glove if they need to touch resident's pills. The nursing staff shouldn't touch resident pills with bare hands. The Medication Administration Policy revised April 2019 directed the staff to follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, etc.) for the administration of medications, as applicable. 6. Resident #10's MDS assessment dated [DATE] showed a BIMS score of 14, indicating intact cognition. The MDS documented Resident #10 used an indwelling catheter. The MDS included a diagnosis of obstructive uropathy (blockage affecting urination). The Care Plan revised 10/24/24 documented Resident #10 had recurrent urinary tract infections (UTIs, bladder infections). The Care Plan lacked direction to the staff to utilize EBP to minimize the potential for cross contamination of bacteria. Resident #10 Order Review History Report signed by the Provider on 1/5/25 listed the following orders: a. Foley Catheter 16 French Bulb Size 5 cubic centimeters (CC, unit of measure) change every 30 days and as needed. Start Date 6/5/24. b. Enhanced barrier precautions due to Foley catheter. Start date 12/2/24. c. Foley catheter output every shift. Start date 1/10/24. e. Gentamicin (Antibiotic) 0.04% place 60 ML in bladder, clamp Foley catheter for 20 30 minutes then drain every evening shift every Monday, Wednesday, and Friday for bladder infection. Active 1/3/2025. Resident #10's January 2025 Electronic Medication Administration Record (EMAR) documented an order for Macrobid oral capsule (antibiotic medication), give 100 milligrams (MG) by mouth 2 times a day for a urinary tract infection for 5 days from 1/14/25 1/19/25. On 1/29/25 at 1:06 PM witnessed a CDC EBP sign on Resident #10's room door. The sign directed the staff to use good hand washing in and out of the room and utilize a gown and gloves during high contact care activity for catheter care. On 1/29/25 at 1:07 PM witnessed Staff J, CNA, enter Resident #10's room. Staff J applied a pair of gloves, placed two paper towels on the floor, placed a graduate container on top of the paper towels, cleansed the urinary drainage bag drain tube with alcohol, opened the drain tube and emptied the urine out of the bag into the graduate. Staff J emptied the graduate container of urine into the toilet, then placed the graduate under Resident #10's bathroom faucet and ran water into the graduate to rinse and dumped the urine water into the bathroom sink. Staff J filled the graduate a second time with water and dumped it into the sink before storing the graduate. Staff J failed to apply an isolation gown prior to emptying the urinary drainage bag. Interview on 1/29/25 at 1:18 PM, Staff G reported when resident is on EBP, a gown and gloves are to be worn when working with the catheter or high resident care activity. On 1/29/25 at 1:35 PM Staff K, CNA, voiced residents on EBP require the use of a gown, gloves, and a mask when working with the resident for PPE. During an interview on 1/29/25 at approximately 2:30 PM the DON reported she expected the staff to use a gown and gloves for EBP when emptying a catheter bag. She voiced it wasn't appropriate for the CNA to rinse the graduate and empty into the resident's sink. She ensured someone fully cleaned Resident #10's sink.

Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to accurately reflect the medication status for 1 of 1 resident reviewed on anticoagulant (blood thinner) medications (Resident #10). The facility identified a census of 87 residents. Findings include: Resident #10's MDS assessment dated [DATE] included a diagnosis of cerebrovascular accident (CVA, stroke). The MDS reflected Resident #10 took an anticoagulant medication within the lookback period. An Order Review History Report signed by the Provider on 1/5/25 documented the following physician orders dated 1/11/24: a. Aspirin (nonsteroidal anti inflammatory and antiplatelet medication) enteric (thick coating to prevent the medicine from breaking down too soon) coated delayed release 81 milligrams (MG) give 1 tablet by mouth one time a day for nonrheumatic aortic valve stenosis (a narrowing of the aortic valve that doesn't allow it to fully open, reducing the blood flow from the aorta to the rest of the body). b. Clopidogrel Bisulfate (Plavix, antiplatelet medication) oral tablet 75 MG give 1 tablet by mouth one time a day related to insufficiency of aortic valve. Interview on 1/29/25 at 10:44 AM Staff A, Assistant Director of Nursing (ADON) reviewed Resident #10 medications and verified she didn't receive an anticoagulant medication. During an interview on 1/29/25 at 10:48 AM the Director of Nursing (DON) stated the facility used traveling MDS Coordinators. She reviewed Resident #10 medications and stated she took aspirin and clopidogrel. Interview on 1/29/25 at 10:49 AM Staff B, Reimbursement Specialist, reported Resident #10 took aspirin and someone may have miscoded it as an anticoagulant on the MDS. She voiced she would look into it. During an interview on 1/29/25 at 10:59 AM Staff B reported Resident #10's MDS assessment from 1/3/25 as incorrectly coded. She thought since they did clinical documentation on bleeding risk, the nurse that completed the MDS may have confused it with that. She voiced the facility followed the RAI manual for MDS Coding. The LTC RAI 3.0 User's Manual Version 1.19.1 October 2024 documented the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) required the assessment accurately reflected the resident's status. The Section N Medications section instructed to not code antiplatelet medications such as aspirin as an anticoagulant. Antiplatelet and anticoagulant medications are both used to prevent blood clots, but they work in different ways. Antiplatelet medications prevent platelets, which are blood cells responsible for clotting, from sticking together and forming clots. Anticoagulant medications interfere with the clotting cascade, a series of steps that leads to blood clot formation.

Based on observation, clinical record review, policy review and staff interview the facility failed to provide a timely assessment and physician notification for a resident with a history of bowel obstructions and peptic ulcer disease who exhibited nausea, vomiting, and loose stools for 1 of 1 resident's reviewed (Resident #45). The facility identified a census of 87 residents. Findings include: Resident #45's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS listed Resident #45 as dependent upon staff for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after having a bowel movement). The MDS documented Resident #45 as incontinent of bowel. The MDS included diagnoses of unspecified intestinal obstruction versus complete obstruction and esophagitis (inflammation of the esophagus) with bleeding. The Patient Report dated 2/29/24 related to Resident #45's two view abdominal x ray for excessive diarrhea and a history of (bowel) obstruction. The reviewer compared the x ray to a prior abdominal x ray completed 12/14/23. The Impression indicated Resident #45 didn't have evidence of an obstruction. The Orders - Administration Note dated 10/10/24 at 3:27 PM written by Staff L, Certified Medication Assistant (CMA), documented she administered 30 milliliters (ML) Milk of Magnesia (MOM) to Resident #45 for a stomach ache. The Orders - Administration Note dated 10/10/24 at 4:53 PM documented the MOM effectiveness as unknown. The Progress Notes lacked documentation of an abdominal assessment or notification to the nurse. The Orders - Administration Note dated 10/11/24 at 8:22 AM written by Staff M, Licensed Practical Nurse (LPN), indicated they administered Miralax 17 Grams for constipation/loose stools. The Progress Notes lacked documentation of an abdominal assessment. The Orders - Administration Note dated 10/11/24 at 9:19 PM written by Staff N, Registered Nurse (RN), reflected they administered ondansetron (anti nausea medication) 4 MG to Resident #45 for nausea and vomiting. The Progress Notes lacked documentation of an abdominal assessment or notification to the Primary Physician Provider (PPP) on 10/11/24 or 10/12/24. The Orders - Administration Note dated 10/13/24 at 6:39 PM written by Staff O, CMA, identified they administered ondansetron 4 MG to Resident #45 for complaints of nausea. The Progress Notes lacked documentation of notification to the nurse, the PPP, or an abdominal assessment on 10/13/24 or 10/14/24. The Orders - Administration Notes dated 10/15/24 at 7:00 PM written by Staff O, reflected they administered ondansetron 4 MG to Resident #45 for nausea and vomiting. The Orders - Administration Note dated 10/15/24 at 8:00 PM listed the ondansetron as ineffective for nausea and vomiting. The Nurses Note dated 10/15/24 at 10:13 PM written by Staff P, LPN, documented Resident #45 complained of abdominal pain and nausea. The assessment described Resident #45's abdomen as distended and firm. Staff P gave Resident #45 pain medication and Zofran (ondansetron) with no relief. He began vomiting a large amount of a thin light brown liquid in consistency with bits of chicken in the vomit. Resident #45 requested to go to the emergency room (ER). Staff P sent Resident #45 to the local hospital via ambulance at 10:15 PM. Resident #45's October 2024 B&B - Bowel Elimination Follow-Up Question Report from 10/9/24 - 10/15/24 list his bowel movements as: a. Formed - 10/10 b. Soft - 10/11 and 10/12 c. Loose/Diarrhea - 10/10 (2), 10/12, 10/13 (2), and 10/14 d. Watery - 10/11 and 10/13 The Weights & Vitals lacked documentation of pulses, respiration rates, blood pressures, oxygen saturations, and temperatures from 8/17/24 to 10/15/24. The eInteract Change in Condition Evaluation - V 5.1 dated 10/15/24 at 10:30 PM documented Resident #45 had uncontrolled abdominal pain, nausea and vomiting that started that afternoon with a history of GI complications. His vital signs at 9:48 PM reflected a blood pressure of 145/84 (expected normal range from 100/70 - 120/80), pulse 80/regular (expected from 60-100), respirations 19 (expected 12-20), temperature 98 degrees Fahrenheit (F) (normal body temperature range 96 to 99.9), and oxygen level 95% (expected greater than 90%). The Evaluation indicated Resident #45 had persistent nausea discomfort not associated with other acute symptoms; intermittent recurrent nausea and vomiting; mild diffuse or localized pain, unrelieved by antacids or laxatives, abdominal pain, and distention. Resident #45 had acute abdominal pain rated at an 8 out of 10 (10 being the worse pain on a 1 10 pain scale). The Evaluation documented Resident #45 went to the ER for evaluation and treatment. The Comprehensive Encounter Progress Note dated 11/4/24 at 12:00 AM completed by the Family Nurse Practitioner (FMP) detailed Resident #45 had a history of severe gastritis as well as scarring that is consistent with prior peptic ulcer disease. On 10/15/24 Resident #45 began complaining of abdominal pain and nausea, with his abdomen distended and firm. The facility nurses attempted as needed (PRN) Zofran which was unsuccessful, and Resident #45 began vomiting large amounts. According to the facility charting Resident #45 requested to go the ER. Nursing obtained an order from his PPP. In addition, to Resident #45's abdomen's distension and firmness, he also had tenderness. They took a computer tomography (CT) scan of Resident #45's abdomen and pelvis with contrast which suggested a gastric perforation (puncture), thickening of the wall of the urinary bladder with infiltration which is suggestive of cystitis (inflammation of the bladder), and colonic diverticulosis with no definite evidence of diverticulitis (inflammation of the bowel). Resident #45 underwent exploratory laparotomy (surgery done with cameras) on 10/16/24. Resident #45 had a bowel perforation fixed with a [NAME] patch, he returned to the facility and nursing had no concerns at that time. Interview on 1/29/25 at 10:23 AM Staff L reported she gave Resident #45 MOM back in October 2024 because he said he needed to poop and couldn't poop. She voiced she would have reported this to a nurse but didn't recall which nurse she reported to. At that time the CMAs reported all the as needed medications they gave to the charge nurse. The nurses were to follow up to check the effectiveness of the medication. Interview on 1/29/25 at 1:56 PM Staff I, RN, explained she didn't know CMAs couldn't administer as needed MOM. If a resident hasn't had a bowel movement (BM) in three days, then the nurses would follow the physician orders for giving as needed medications according to the physician orders for constipation. If a resident didn't have a bowel movement and complained of a stomachache that would be reportable to a nurse. She would look to see when the resident had a BM last and then they would assess bowel sounds and take vital signs to assess what is going on. If the nausea and vomiting continued over more days, it would warrant more assessment and notification to the physician. During an interview on 1/29/25 at 2:07 PM Staff M recalled Resident #45 having nausea and vomiting, but couldn't recall how long it went on, but knew it did result in a bowel obstruction. The facility required CMAs to notify the nurse if a resident requested an as needed medication and what they wanted it for. The charge nurse would direct the CMA if they could administer the medication or if the nurse needed to check the resident. If a resident had nausea and vomiting, she would look to see when they had their last BM, talk to the resident, listen to their bowel sounds, check vital signs, ask how long it has been going on and go from there. If it was a new condition, they should notify the physician. Interview on 1/29/25 at 2:18 PM Staff O reported if a resident requested an as needed medication such as for constipation, the CMAs have to report it to the nurse. The nurse will go talk with the resident, then the nurse will direct the CMAs what to give, for example MOM. The nurses follow up to see if the resident had a bowel movement. If a resident had nausea or vomiting, he would let the charge nurse know right away. He recalled the facility had a traveling Director of Nursing (DON) at that time and miscommunication happened as to who charted as needed medications. They had different direction given since that time on for the as needed medications. He recalled Resident #45 had nausea and he thought he reported it to the charge nurse at that time. Staff O commented the CMAs received new education on the administration of as needed medications since that time. He recalled signing the education sheet. Interview on 1/29/25 at 3:28 PM Staff B, Reimbursement Specialist, reported in reviewing Resident #45 he had a long history of perforations and bowel issues. During an interview on 1/29/25 at 3:41 PM Staff Q, DON Education Support Personnel, reported the facility had a Change of Condition Evaluation form they open in the Evaluations tab in the electronic health record (HER) that directed the nurses on what assessment to do. A 1/29/25 review of the EHR Evaluations revealed no Change of Condition Evaluation Form opened from 10/9/24 to 10/15/24 to monitor Resident #45 condition. The EHR Evaluations tab only contained the E Interact Change of Condition Evaluation form for 10/15/24 at 10:30 PM filled out by the nurse when they transferred Resident #45 to the ER for evaluation. On 1/30/25 at 9:02 AM Staff R, RN, reported she didn't recall any staff informing her about Resident #45 having abdominal pain. She always told the aides to report any resident issues to her. She would have assessed the resident's bowel sounds, felt his abdomen, checked his vital signs, review his medical history and report their condition to the physician. She would document the assessment and provider notification in the progress notes. Interview on 1/30/25 at 9:04 AM Staff S, LPN, reported he didn't recall any staff reporting a health change to him regarding Resident #45. If a CNA reported a resident having abdominal pain, nausea, or vomiting, he would take a full set of vitals, assess the bowel sounds, review the resident's bowel history, and contact the physician. He would document the assessment and notification of the physician in the resident's progress notes. On 1/30/25 at 9:50 AM Staff G, CMA, reported she is not allowed to give as needed medications to residents. A prior DON stated the CMAs had to stop administering as needed medications because they had just too many errors occurring. If a resident requested or complained of something, the CMAs will report it to the nurse. The nurse will go see the resident to see what is going on and go from there. The nurses do the medication follow ups on the as needed medication administration. She would alert the nurse about reports of abdominal pain, nausea, and vomiting especially with Resident #45 as he had issues in the past. Interview on 1/30/25 at 9:52 AM Staff F, RN, reported CMAs are not allowed to give as needed medications. If a resident reported symptoms or concerns, or a CNA/CMA saw a change in the resident, they are to report it to the nurse. The nurses are to go down to assess the resident by talking with them about symptoms, take vital signs, a pain assessment, abdominal assessment, review records, then give medications as needed, document the assessment either in the evaluations if a specific type of evaluation was completed or a change of in condition in the progress notes and notification of the provider in the resident's medical record. During an interview on 1/30/25 at 10:02 AM the DON reported she expected the nurses to fill out a Change of Condition Evaluation, perform a full assessment including vital signs, document the assessment and notify the physician of the change in condition. She expected a focused assessment on the area of concern to be completed every shift with vital signs until resolved. She expected the charge nurse to notify her or the Assistant DON's of the situation so they can do further monitoring as well. On 1/30/25 the DON provided In Service documentation to the CMAs from 11/11/24 directing that CMAs could no longer administer as needed medications. A 11/15/24 In Service Form provided nursing education that a resident's primary care physician must be notified of any changes and documented. An Acute Condition Change Clinical Protocol revised March 2018 directed the following: a. The physician will help identify individuals with a significant risk of having acute changes of condition during their stay. b. In addition, the nurse shall assess and document/report the following baseline information: vital signs, neurological status, current level of pain and recent changes in pain level, level of consciousness, cognitive and motional status, resident's age and sex, onset, duration and severity, recent labs, history of psychiatric disturbances, mental illnesses, depression, all active diagnosis and all current medications. c. Before contacting a physician about a resident with an acute change, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test resulting for comparison. f. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request prompt response (approximately one half hour or less). The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely response or appropriate response.

Based on observation, clinical record review, and staff interview, the facility failed to provide food to a resident while out of the facility while they received renal dialysis for 1 of 1 resident's sampled (Resident #128). The facility identified a census of 87 residents. Findings include: Resident #128's Clinical Census reflected they admitted to the facility on [DATE]. The Handoff Report dated 1/24/24 listed Resident #128 received hemodialysis (a treatment that helps remove waste products and excess fluid from the blood when the kidneys are no longer able to do so) at a local (renal/kidney) dialysis center. The Nursing Admission/Readmission Evaluation - V 18 dated 1/24/25 documented Resident #128 as alert, oriented to person, place, time, situation and clear communication abilities. The Evaluation noted Resident #128 didn't have short term memory impairment, confusion, forgetfulness or impaired decision making ability. The Evaluation listed a Dietary Care Plan indicating the facility would provide with meals within Resident #128's diet. The Evaluation documented an arteriovenous (AV) fistula (an AV fistula is surgically created in the arm to provide easy access to a large blood flow for dialysis) present to the resident's right (arm) and a Dialysis Care Plan that lacked direction for the staff to send food or meals with Resident #128 to dialysis appointments. The Clinical - Assessment included a Brief Interview for Mental Status (BIMS) dated 1/24/25 with a score of 14, indicating intact cognition. A Communication: Nursing to Dietary V3 dated 1/24/25 directed Resident #128 admitted to the facility and required a regular, no added salt diet. The Communication lacked documentation Resident #128 received renal dialysis. The NSG: Dialysis Evaluation - V 9 dated 1/27/25 at 1:46 PM reflected the reason for evaluation as a pre-dialysis evaluation. The evaluation indicated Resident #128 left the facility at 7:00 AM for renal dialysis. The NSG: Dialysis Evaluation - V 9 dated 1/27/25 at 2:53 PM reflected the reason for evaluation as a post dialysis assessment. The evaluation indicated Resident #128 returned to the facility. During an interview on 1/28/25 at 8:24 AM Resident #128 verbalized she goes to dialysis on Monday, Wednesday and Fridays. She added the transport arrived late to pick her up around 9:45 AM. She reported she had her first dialysis appointment on 1/27/25 since admitting to the facility. When she went to her appointment, the facility didn't send any food with her. Transport picked her up around 9:45 AM and she didn't return from dialysis until late afternoon. The facility didn't send any food with her to dialysis and she got really hungry. She voiced she had to call [NAME] and pay for her own lunch to be delivered to the dialysis center. During an interview on 1/29/25 at 11:26 AM Staff C, Registered Nurse (RN), reported she usually worked on the other side of the facility so she didn't see when Resident #128 left for dialysis. She reported if she asked for a meal, then the facility would send a meal with them. It depended on what the resident wanted. She wasn't sure who had the responsibility to check with the resident, dietary staff or the certified nursing aides (CNAs). On 1/29/25 at 11:30 AM Staff D, CNA, reported the kitchen usually had sack lunches set up, but if they didn't, then the aides ask the resident if they want food to go with them to dialysis or their appointment. Interview on 1/29/25 at 11:33 AM Staff E, Assistant Dietary Services Manager, reported she didn't send any lunch with Resident #128 on 1/27/25 when they went to dialysis. None of the staff informed her Resident #128 was leaving and no one communicated that she had to go out to dialysis. Staff E communicated the aides usually let them know if a resident is going out and wanted to take a sack lunch with them, then they make it for them. During an interview on 1/29/25 at 11:43 AM the Director of Nursing (DON) reported usually nursing informs the Dietary Manager know when a resident is going out so they can set things up. The DON voiced, Resident #128 was admitted over the weekend so it did not get communicated properly. She expects the dietary staff to send a sack lunch with the residents when the go out to dialysis.

Based on resident interview, record review, staff interview, and policy review the facility failed to administer the flu vaccine for 1 of 6 residents reviewed (Resident #9). The resident requested the vaccine during her admission assessment. The facility reported a census of 87 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] documented an admitted [DATE]. The MDS included diagnoses of stroke and asthma. During an interview on 1/27/25 at 12:47 PM Resident #9 reported she didn't receive any vaccines at the facility, and she wanted the flu and COVID vaccines. When asked if she spoke to the staff about it, she replied she asked for the vaccines when she first arrived. On 1/30/25 at 10:19 AM the Director of Nursing (DON) provided documentation from Resident #10's clinical record dated 9/4/24 at 11:44 AM titled Admission/Readmission Evaluation. It documented Resident #10 consented to the flu vaccine, directed staff to complete the consent form, and noted the consent entered into Resident #10's immunization tab. The DON confirmed her record didn't have documentation about why Resident #10 didn't receive the vaccine, and acknowledged the facility had a flu clinic for residents at the facility in October after Resident #9's admission. The facility didn't have an original consent or declination form. During an interview at 11:28 AM on 1/30/25 the Administrator stated they usually have a progress note that said why the resident refused or why they didn't receive the vaccine during a clinic. A policy titled Influenza Vaccine revised October 2019 documented all residents who had no medical contraindications to the vaccine would be offered the influenza vaccine annually. It further indicated that if a resident refused the vaccine it would be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.

Based on resident interview, record review, staff interview, and policy review the facility failed to administer the flu vaccine for 1 of 6 residents reviewed (Resident #9). The resident requested the vaccine during her admission assessment. The facility reported a census of 87 residents. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] documented an admitted [DATE]. The MDS included diagnoses of stroke and asthma. During an interview on 1/27/25 at 12:47 PM Resident #9 reported she didn't receive any vaccines at the facility, and she wanted the flu and COVID vaccines. When asked if she spoke to the staff about it, she replied she asked for the vaccines when she first arrived. On 1/30/25 at 10:19 AM the Director of Nursing (DON) provided documentation from Resident #10's clinical record dated 9/4/24 at 11:44 AM titled Admission/Readmission Evaluation. It documented Resident #10 consented to the flu vaccine, directed staff to complete the consent form, and noted the consent entered into Resident #10's immunization tab. The DON confirmed her record didn't have documentation about why Resident #10 didn't receive the vaccine, and acknowledged the facility had a flu clinic for residents at the facility in October after Resident #9's admission. The facility didn't have an original consent or declination form. During an interview at 11:28 AM on 1/30/25 the Administrator stated they usually have a progress note that said why the resident refused or why they didn't receive the vaccine during a clinic. A policy titled Influenza Vaccine revised October 2019 documented all residents who had no medical contraindications to the vaccine would be offered the influenza vaccine annually. It further indicated that if a resident refused the vaccine it would be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.

Based on clinical record review, staff interview, and observation the facility failed to provide appropriate assessment and intervention for one of three residents reviewed (Resident #1). The facility reported a census of 79 residents. Findings include: The admission MDS (Minimum Data Set) an assessment tool dated 2/26/2024 revealed Resident #1 had mild impaired cognitive abilities, required staff assistance to transfer from one surface to another, used a wheel chair for mobility, and had no identified skin concerns. The MDS revealed the resident had diagnoses including anemia, malnutrition, ESRD (End Stage Renal Disease), diabetes, heart failure and received dialysis. The quarterly MDS dated [DATE] revealed the resident had intact cognitive abilities, required staff assistance to transfer, and received ointment/medication application other than to feet. The Care Plan identified the resident had a skin integrity concern due to venous insufficiency dated 3/12/2024. It directed staff to monitor the resident to avoid scratching, keep fingernails short, provide good nutrition, administer treatments as ordered, and staff were to do weekly skin assessments and document width, length, type of tissue, and other notable change. The TAR (Treatment Administration Record) dated 2/22/2024 - 5/21/2024 instructed staff to complete a head to toe skin check on the 2 - 10 o'clock P.M. shift on Thursday even if a previous skin area has been noted. If a new skin concern is noted, complete a new Risk Management, skin evaluation and add or update the weekly non-pressure/pressure Good Nursing Order. The resident's May, 2024 MAR/TAR (Medication and Treatment Administration Records) revealed an order for Benadryl itch stopping external cream on 5/21/2024. The records revealed staff failed to administer the cream from 5/21/2024 through 5/29/2024. The Resident's April, 2024 Weekly Skin Evaluation revealed staff documented they performed a skin evaluation on April 4, April 11, and April 18. Staff failed to perform the skin evaluation on April 25. The Resident's May, 2024 Weekly Skin Evaluation revealed staff documented they performed a skin evaluation on May 24. Staff failed to perform the skin evaluation on May 2, May 9, and May 16 as they were instructed. The resident's clinical record included skin evaluations related to a right shin skin issue from 3/5 - 4/11/2024. On 4/11/2024 the area had no measurement, indicating the wound had healed. The resident's clinical record had no further skin evaluations related to the residents lower extremities. The Resident's Progress Notes included: 4/19/2024 - Red/pink rash to bilateral abdominal folds, groin and under bilateral breasts. Appears yeast related with foul odors, and no bleeding or open areas. Areas cleansed with soap and water, barrier applied and Impact (the resident's primary care physician clinic) notified. The resident received a new order for Nystatin powder (treats yeast or fungal infections) for ten days. 4/27/2024 - resident picking at right lower extremity this shift resulting in leg bleeding. Wrapped legs per treatment order. Family visiting and questioned if treatment had been done and about the color of bilateral legs. The writer assured family the treatment had been done and the resident's picking had caused the bleeding. The resident stated she had picked the scales on her leg. The writer educated family the color to her bilateral legs was normal and due to chronic kidney disease. The writer wrapped the legs with new roll gauze. The family indicated the resident had medication at home for pruritis (itchy skin) and would let the facility know which specific medication. 4/30/2024 - New orders from Impact: , discontinue current treatment and apply Eucerin cream and tubigrips (tubular bandage). 5/19/2024 - Resident has red, irritated rash to abdominal folds and looks like yeast rash. Impact called and requested an order for Nystatin powder BID (two times a day) until healed. Education provided to C.N.A.'s to ensure resident's abdominal folds are cleansed and dried with every check and change or incontinence episode. 5/20/2024 - New order: Nystatin to abdominal folds. 5/20/2024 - Resident complained of itching and current medications are not helping with itch relief. Impact office called and voicemail left requesting a PRN (as needed) order to help with increased itching. 5/21/2024- Resident has been complaining of itching and states she wants an itch pill. Impact called and received orders for Benadryl cream BID and PRN. They are also going to check with primary nurse practitioner about getting Benadryl tablet order for all over itching. 5/27 and 5/28/2024 - Resident refused Nystatin and Eucerin lotion. 5/28/2024 at 4:55 A.M. - bilateral lower extremities with red/weeping blisters shin to calf. Yellow/red drainage. Resident observed scratching legs. Bilateral lower extremities covered with dressing to deter resident from scratching. Impact called. 5/28/2024 at 11:16 A.M. - Changed dressing to lower legs, no bleeding but open with sanguineous fluid (containing blood). Cleaned them and placed new dressing. Called Impact and indicated the wound nurse would see the resident on 5/29/2024. Also, brought up the Hydroxyzine the resident stated she took in the past. 5/28/2024 at 1:16 P.M. - Impact wound nurse will see resident tomorrow. 5/28/2024 at 10:05 PM. - Call placed to Impact due to resident's leg wound. Unable to take a photo due to I-pad not working. Received a new order: Xeroform (dressing) to weeping areas, (ABD) absorbent dressing, wrap with Kerlix (gauze) and tubigrips. 5/28/2024 at 9:24 P.M. - Eucerin External Lotion, apply to dry skin topically every day and evening shift related to pruritis. Legs are open wounds, weeping, no dry skin. 5/29/2024 at 5:23 A.M. - Upon entering the resident's room to administer medications, resident is found to have moderate tremors, pale, alert, but unable to follow commands. Vitals were assessed. Resident is warm to touch. Call placed to Impact and order received to send the resident to the ED. Staff notified the resident's family. 5/29/2024 at 10:12 A.M., hospital notified facility resident admitted with pneumonia, metabolic encephalopathy, and fluid overload. The ED note dated 5/29/2024 reported the resident admitted with mental status change. It also revealed the resident had extensive open, blistered stasis changes to both lower extremities. Overlying wraps in place. 5/29/2024 hospital records included: Active Hospital Problems: Diagnosis - cellulitis of lower extremity, delirium, ESRD, diabetes. Clinical Impression: metabolic encephalopathy, pneumonia to left lower lobe due to infectious organism, abnormal urinalysis and abnormal lower left lung on chest x-ray. Rocephin (antibiotic) has been given. Sepsis, early detection 5/29/2024. The resident's physical exam revealed she had wounds to bilateral lower extremities, scabs to upper arms from itching and erythema to groin. The resident admitted to inpatient care on 5/29/2024 and discharged to a care facility on 6/7/2024 with hospice services. The 6/7/2024 discharge Hospital Problem list included Cellulitis of lower extremity. A facility In-Service form dated 4/4/2024 revealed nursing staff received education related to Any new skin concerns should be documented, picture taken, risk management completed by the nurse at the time of the impairment being reported and/or observed. A facility In-Service form dated 10/1/2024 revealed the facility began re-educating nursing staff regarding skin/wound assessment and intervention. On 9/30/2024 at 1:35 P.M., Staff A, RN (Registered Nurse), ADON (Assistant Director of Nursing) indicated Resident #1 complained of being itchy. Staff notified Impact and they ordered different creams. Staff A contacted Impact and informed them the resident's husband revealed she had a prescription for Hydroxyzine (for itching). Impact never ordered Hydroxyzine for the resident. The resident scratched her legs as far as she could reach, and nothing seemed to help. At 3:30 P.M. Staff A reported the resident sternly refused staff to touch her legs. She had an order for staff to do skin checks weekly and that order never stopped. The facility failed to provide skin evaluations after 4/11/2024, and the Progress Notes failed to include skin assessments including measurements. If staff found the resident had a new skin concern, they were to complete a Risk Management Evaluation, notify family and provider, and start weekly skin assessments until it's resolved. On 10/1/2024 at 10:30 A.M., Staff B, Nurse Practitioner indicated staff reported the resident was itchy, and she did not want to order Benadryl (antihistamine) tablets due to the [AGE] year old resident received dialysis. The resident had blisters on the lower extremities that opened up and she transferred to the ED. According the the resident's record available to Impact, it appeared the resident already had an order for Hydroxyzine. When Hydroxyzine is ordered, the order is good for 14 days. The facility Ulcers/Skin Breakdown policy revised 9/2017 included: Policy Statement: Physicians shall help prevent and manage pressure ulcers, consistent with established guidelines. Outcomes: 1. Incidence of new pressure ulcers will be minimized to the extent possible. 2. Healing of existing pressure ulcers will be optimized to the extent possible. 3. The facility will be able to show that failure of a pressure ulcer to heal was medically unavoidable. Procedure: Identify Risk Factors Identify Existing Pressure Ulcers Define Details of Pressure Ulcers Identify Contributing Factors Clarify Medical Factors Order Pertinent Interventions Identify Related Medical Interventions Limited Effectiveness of Nutritional Supplementation Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility and medical instability. The facility Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April, 2018 included: Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. As needed, the physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. As needed, the physician will help identify and define any complications related to pressure ulcers.

Based on record review and facility staff, hospital staff and First Responder interviews, the facility failed to provide nursing care that included accurate assessment with timely intervention, and failed to notify the physician of a resident's condition changes in a timely manner, that resulted in the resident's transfer to the hospital in critical condition for emergent care when found in an unresponsive state, for 1 of 7 resident records reviewed (Resident #6). The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had diagnoses that included traumatic brain injury, subdural hematoma (bleeding on the brain) and anemia, scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment with symptoms of delirium present, required extensive assistance of at least 1 staff for transfers to and from bed and chair, dressing, toileting, bathing and personal hygiene, a urinary catheter utilized and frequently incontinent of bowel. The assessment revealed the resident's speech was unclear, some times was able to make herself understood and some times was able to understand others. The resident sustained a subdural hematoma from a 12/26/22 fall at the facility that required hospitalization from [DATE] to 1/2/23. An alteration in neurological status related to recent subdural hematoma problem on the nursing care plan directed staff to:. 1. Monitor, document, and report to physician as needed any signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech. 2. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. A potential for urinary tract infection (UTI) related to urinary catheter use problem on the nursing care plan directed staff to: 1. Monitor vital signs/physical assessment per order/protocol/RN. Notify MD of significant abnormalities. 2. Monitor, document, and report to physician as needed any signs or symptoms of urinary tract infection: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. 3. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Fluid oral intake records recorded by Certified Nursing Assistants (CNA's) revealed the following: 1/7/23 11:05 a.m. 200 milliliters (ml) 12:47 p.m. 200 ml 1/8/23 11:15 a.m. 50 ml 11:30 a.m. 50 ml 6:49 p.m. 50 ml 1/9/23 8:00 a.m. 100 ml 11:30 a.m. 100 ml 9:31 p.m. 50 ml Urinary output recorded by CNA's revealed the following entries: 1/7/23 at 5:18 am., 650 ml 1/7/23 at 12:47 p.m., 500 ml 1/8/23 at 5:34 a.m., 0 ml 1/8/23 at 1:59 p.m., 250 ml 1/9/23 at 5:04 a.m., 400 ml 1/9/23 at 1:59 p.m., 100 ml The January, 2023 Treatment Administration Record (TAR) revealed the following urine output entries: 1/7/23 day shift (6 a.m. - 2 p.m.) 350 milliliters (ml) documented by Staff P, Licensed Practical Nurse (LPN). 1/7/23 evening shift (2 p.m. - 10 p.m.) 300 ml documented by Staff K, LPN 1/7/23 night shift (10 p.m. on 1/7/23 to 6 a.m. on 1/8/23) a 9 recorded by Staff K, LPN, directed the reader to refer to the Nurse's Notes. 1/8/23 day shift, no documentation of urine output or notation by nursing staff. 1/8/23 evening shift, 200 ml documented by Staff D, LPN. 1/8/23 night shift, 400 ml documented by Staff K, LPN 1/9/23 day shift, no documentation of urine output or notation by nursing staff. 1/9/23 evening shift, a 1 recorded indicated the resident was absent from the facility. The staffing schedule revealed Staff C, LPN, assigned to the resident on the 1/8/23 day shift (6 a.m. to 2 p.m.) and 1/9/23 day and evening shift from 6 a.m. to 6 p.m. A Nursing Progress Note entry recorded by Staff I, LPN, at 10:15 p.m. on 1/9/23 stated: Resident noted to be non responsive, unable to get pupil dilation, Vital Signs: Blood Pressure 134/74, Pulse 99, Temperature 102.9, Oxygen saturation 73 percent, applied oxygen at 6 Liters to increase resident to 83 percent, did finally rise to 90 percent on 6 Liters. Impact physician contacted and order received to send to emergency room for evaluation and treatment, notified family and Director of Nursing. Nursing Progress Notes documented between 1/7/23 and 1/9/23 did not otherwise describe the resident's condition or change in condition. The hospital ER record, dated 1/9/23 revealed the resident received at 10:18 p.m., with treatment and findings as of 1:00 a.m. on 1/10/23 that revealed the resident diagnosed with sepsis with encephalopathy and septic shock, and increased size of subdural hematoma when compared to a 12/27/22 Computed Tomographic (CT) image of the head results, and required immediate transfer to a tertiary hospital for higher level of care required by her critical condition. A Urinalysis laboratory report dated 1/10/23 at 4:11 a.m. revealed more than 180 White Blood Cells (WBC) per High Powered Field, HPF, (normal range 0 to 5 per HPF), WBC clumps present (abnormal result), Blood 1+ (normal result negative), Leukocyte Esterase 2+ (normal result negative), all indicated presence of a UTI. Staff interviews revealed: 1/18/23 at 9:58 a.m., Staff H, CNA, (assigned to the resident on the 1/7/23 day shift) stated she had to assist the resident with her cereal for breakfast, and had to keep cuing the resident to eat, which wasn't normal for the resident. The resident's urine was dark tea colored with some residue, and she notified the nurse, Staff P, of that. 1/18/23 at 8:32 p.m., Staff B, CNA (assigned to the resident on the 1/8/23 day and evening shifts) stated on 1/8/23, the resident didn't have much of an appetite, she ate very little despite a lot of encouragement, normally the resident loved to eat cookies with coffee and the resident wouldn't accept that on that day, and she informed the nurse on duty, Staff C, that something must have really been wrong for the resident not to eat her cookies or drink coffee on that day. 1/17/23 at 1:54 p.m., Staff A, CNA, (assigned to the resident on the 1/9/23 day shift) stated on 1/9/23, the resident was really out of it, she mostly slept, she tried to wake her up to eat but the resident remained half asleep and she really couldn't get her fully awake or alert, she ate very little that day. The resident could normally transfer with 1 staff assist as she held on to the walker, but that day the could not get the resident awake enough to follow cues and bare weight, so she was left in bed. The resident ate very little, and that was with a lot of staff encouragement and assistance. She did not have much for urine output, it was a low volume, and she is certain she reported the output as required to the nurse, Staff C, at the end of her shift at 2 p.m. that day. 1/17/23 at 12:55 p.m., Staff F, CNA, (assigned to the resident on the 1/9/23 evening shift) stated on 1/9/23, she was instructed by Staff A, CNA, in their change of shift report that the resident was not doing well, they had only gotten her to eat a couple of bites of food on the day shift. When she checked on her around 3 p.m., the resident would open her eyes when they spoke to her, but she wouldn't say anything and would close her eyes again when they didn't stimulate her. Around 5:30 p.m. that day, the resident was the same way, they sat the resident up in bed slightly for supper and when she tried to assist the resident with her supper meal, she wouldn't open her mouth and didn't follow her cues to open her mouth. There was about 25 to 50 ml of urine in her catheter bag, sort of dark in color. Staff F was certain she told Staff C, the nurse, that she couldn't get the resident to open her mouth to eat or awake enough to eat. 1/18/23 at 10:31 a.m., Staff D, LPN, (assigned to the resident on the 1/8/23 evening shift) stated on 1/8/23, the resident was in bed and awake, but couldn't swallow her medication whole, she had to crush her pills and put them in applesauce for the resident to be able to swallow them, and that was a definite change and decline in the resident's condition as she had never had to do that before. The resident was somewhere between awake and asleep, and not very talkative, which was also a change in her condition. The resident wasn't really eating and she instructed the aide to do what they could to get her to eat something. The resident did drink her juice that night and she was usually pretty good about drinking fluids. 1/17/23 at 2:05 p.m., Staff G, CNA and CMA, Certified Medication Aide, (assigned to the resident as a CNA on the 10 p.m. to 6 a.m. night shifts on 1/7/23 and 1/8/23, and worked as a CMA scheduled as assigned to the resident from 6 p.m. on 1/9/23 to 6 a.m. on 1/10/23) stated when she worked as a CNA on the 1/7/23 and 1/8/23 night shifts, the resident slept so soundly that she snored loudly. The resident had not woke up on those nights, and she provided was her catheter care and other routine night shift duties that night as the resident never asked for anything. She noted a difference when she first saw the resident on 1/9/23, the resident didn't snore but she made an ah sound with each breath. She was unable to wake the resident for her medication when she attempted between 9 p.m. and 9:15 p.m. She asked the aides how the resident was and was instructed the resident hadn't eaten. She then alerted the nurse, Staff I, LPN, that she couldn't wake the resident. Staff I joined her in the resident's room and attempted to wake the resident, shined a light in her eyes and tried a sternal rub (painful stimulus) which were not successful to wake the resident. Staff G stated she had medications to administer to other residents and Staff I took over from there with the resident. 1/17/23 at 1:40 p.m., Staff C, LPN (assigned to the resident on the 1/8/23 day shift, and from 6 a.m. to 6 p.m. on 1/9/23) stated on 1/9/23, the resident was her normal self, she tried to administer her medications to her that morning and received the resident's usual response, the resident turned her head away and sort of pushed the nurse away with her hand, between 7 a.m. and 7:30 a.m. A half hour later, the nurse from the next hall was available to assist her (Staff E, RN) and Staff E administered the resident's medications. The resident drank her breakfast drinks that morning but didn't eat anything, the resident would usually drink fluids but, didn't take her liquid supplement at noon that day, and that was unusual as she normally would drink it. At the time, the resident didn't say anything and moved her arms to swat her away. Staff C denied that any staff had reported the resident's refusal to eat or low urine output to her, and stated she observed yellow urine in the graduate meter attached to the catheter bag and described about 3 inches of urine in the meter (approximately 30 to 50 ml). 1/17/23 at 12:04 p.m., Staff I, LPN, (assigned to the resident from 6 p.m. to 10 p.m.) stated she normally worked on 2 different halls at the facility, she was familiar with the resident but had not taken care of the resident since her return from the hospital on 1/2/23. She received change of shift report from Staff C, LPN, and was told in report the resident was doing okay, but was sleepy, didn't really describe it as a change of condition or concern. Later that evening, the Med Aide (Staff G) told her she couldn't wake her up, she went to check the resident, it was around 9:30 - 9:35 p.m. and was the first time she had seen the resident that evening, and could not get a reaction to a sternal rub, her pupils were not responding when she shined the light in her eyes, she checked her oxygen saturation, it was low, 73 percent on room air, so applied oxygen at 6 liters per minute, took her vital signs, was able to get her saturation up to 83 percent and then called the physician for orders to transfer her to the hospital, then called for an ambulance. The resident left the facility at approximately 10:05 p.m. 1/19/23 at 10:13 a.m., Staff O, Paramedic for the local ambulance service stated he was with the crew that responded to the facility on [DATE] to transfer the resident to the hospital. Upon his initial assessment of the resident, he noted the resident's left hand and arm in a decorticate position (a contracted posture associated with increased intracranial pressure such as head trauma) and a strong foul smell of urine consistent with a UTI and the potential the resident had septic shock. Based on his observations, the resident's non-responsive status and Staff I's statement that the resident had a recent subdural hematoma from a fall, his immediate priority was to apply the electrocardiogram heart monitor, start an intravenous line for access if medications were required and transport the resident as quickly as possible to the hospital before her condition further deteriorated. 1/17/23 at 3:27 p.m., Staff N, Registered Nurse (RN) from the local hospital ER stated she was on duty in the ER when the resident arrived on 1/9/22 with contracted or decorticate positioning of her arm, the resident non-responsive to painful stimulus, an overwhelming foul urine odor and scant amount of urine in the catheter that was white, thick and had the appearance of pus. The resident was in critical condition, a CT of the head completed upon her arrival showed she had more subdural hemorrhage, lab work that included a urinalysis and Complete Blood Count (CBC) showed the resident likely septic from a UTI, they started IV antibiotics immediately and the resident required transfer to a higher level of care due to her condition and care requirements. 1/18/23 at 2:38 p.m., the Director of Nursing (DON) stated she expected nursing staff to notify the physician or provider any time a resident had negative condition change and seek appropriate treatment orders for the identified changes.

Northcrest Soecialty F686 G Exit date: 3/13/19 Based on observation, staff interview and clinical record review the facility failed to prevent the development of pressure ulcers for 1 of 2 residents reviewed. The resident developed 3 pressure ulcers areas after returning from the hospital with surgery for [REDACTED].#68) The facility identified a census of 89 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #68 dated 1/3/19 documented admission after an acute hospital stay and included [DIAGNOSES REDACTED]. The MDS documented the resident required limited staff assistance with transfers, bed mobility and ambulation with no skin concerns for pressure ulcers or injuries. The MDS documented a weight of 120 pounds. A Skin Evaluation for Non-Pressure form dated 1/6/19 showed no skin concerns except for the incision to the left closed [MEDICAL CONDITION]. A Progress Note dated 1/6/19 upon return to the facility documented the resident had no pressure areas. The Braden Scale for Predicting Pressure Sore Risks dated 1/6/19 documented the resident scored a 17 (at risk for developing pressure sores). The MDS assessment dated [DATE] included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility and extensive assistance of one for transfer, and had a Brief Interview for Mental Status score of 3 (severe memory loss). The assessment showed the resident had weight loss of 5% or more not prescribed by the physician and had 3 unstagable pressure ulcers. The MDS identified the following descriptions of pressure ulcers: -Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. -Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister. -Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. -Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The Care Plan updated 1/10/19 (after the findings of the pressure ulcers) included a focus area of increased potential for pressure ulcers and other skin breakdown related to diabetes, incontinence and impaired mobility, with pressure injuries to the coccyx and bilateral heels on 1/10/19. The problem included the following interventions: - gel overlay mattress on bed (11/08/2018). - pressure reducing cushion in wheelchair (1/09/2019). - keep heels elevated when in bed (1/10/2019). - Prafo boots to bilateral feet at all times (1/10/2019). - Treatments per physician orders [REDACTED]. A Non-Pressure Skin Evaluation dated 1/10/19 showed a new injury on the right big toe which had fluid serous intact blister to the front and bottom. The measurement showed 3.3 centimeters (cm) in length and 2.5 cm in width. A Pressure Injury Evaluation dated 1/10/19 showed a pressure ulcer to the lower coccyx with the wound bed clean. The measurements showed 0.5 cm in length x 0.5 cm in width and no depth, documenting the area as a stage II pressure ulcer. The report showed the resident's mattress upgraded to an air mattress and a gel cushioned to the wheelchair. The report also showed the resident had not experienced pain related to the pressure injury. A Pressure Injury Evaluation dated 1/10/19 showed a pressure ulcer to the resident's upper coccyx, showing 50 percent (%) with eschar and 50% with white and gray tissue to the wound bed. The measurements showed 0.8 cm in length x 0.5 cm in width and 0.1 cm in depth, documented as unstageable. The report also showed the resident had not experienced pain related to the pressure injury. A Pressure Injury Evaluation dated 1/10/19 showed a pressure ulcer to the resident's left heel described as an intact blood blister present. The measurements showed 6.5 cm in length x 4.5 cm in width and 0 depth, documented as unstageable. Staff initiated Prafo boot (heel protectors) and a pillow under both legs. The report also showed the resident had experienced pain related to the pressure injury. A Pressure Injury Evaluation dated 1/10/19 showed a pressure ulcer to the resident's right heel described as an area with purple discoloration, soft and boggy to the touch with depth unknown but skin intact. The measurements showed 4.3 cm in length x 2 cm in width and 0 depth (unknown), documented as suspected deep tissue injury. Staff initiated Prafo boot and a pillow under both legs. The report also showed the resident had not experienced pain related to the pressure injury. On 03/11/19 at 8:35 a.m., staff toileted the resident. Observation revealed a small intact dry [MEDICATION NAME] dressing covering the resident's coccyx. During observation on 3/11/19 at 10:49 a.m. Staff D, Licensed Practical Nurse (LPN) performed the prescribed treatment to the resident's heels. The right heel showed dark brown eschar on the bottom toward the outer side of the foot. The area appeared to be the size of a nickel touching into another eschar which appeared the size of a dime. The left foot had a large dark brown area on the entire bottom of the heel. Staff D stated they thought the pressure sores started from shoes. Staff O, Registered Nurse (RN) also observing, stated they showed as blisters in the beginning. Staff O then stated the resident's coccyx was nearly healed with the dressing change due for change on the evening shift. Progress Notes revealed the following: - 1/6/19 at 9:47 p.m.: the resident returned to the facility, resting in bed. - 1/7/19 at 2:17 a.m.: no concerns at the night shift. - 1/8/19 at 8:44 a.m.: the resident came out for breakfast, lost another pound and remains extremely passive. - 1/8/19 at 8:47 p.m.: the resident stayed in bed and refused to come out for supper, seems very weak and will continue to monitor. - 1/9/19 at 8:20 p.m.: resting quietly tonight. - 1/10/19 at 9:07 a.m.: the resident rested in bed and got ready for breakfast when Staff noted 2 open areas to the resident's coccyx and placed a [MEDICATION NAME] dressing at the site. -1/10/19 at 11:39 a.m.: Nurse was called to room this a.m., noted 2 small openings on the coccyx. Areas are present over coccyx (upper aspect is unstageable and lower aspect is stage 2). Area cleansed and meplex border applied. Assistant Director of Nursing (ADON)/RN manager were notified. Further assessment completed. Resident was checked for other skin alterations and noted blister to left heel and deep tissue injury to right heel. Resident also has serous fluid filled blister to top of right great toe. Resident had complained of pain to left heel when asked, but unable to rate. Had eyes closed and relaxed posture while lying in bed. Meplex border applied. Gel mattress overlay replaced with air mattress. Prafo boots applied to bilateral feet and pillow underneath lower legs. Also upgraded resident wheel chair cushion to an equi-gel cushion. See pressure ulcer and skin evaluation. IMPACT was notified and requested consult for further wound management On 3/12/19 at 9:20 a.m. Staff D, Licensed Practical Nurse (LPN), stated they usually work the residents hall. Staff D reported the nurse doing a re-admission should make sure to check the residents skin, especially their heels when coming back from the hospital. They have had problems with resident's developing pressure ulcers when returning from the hospital. Staff D stated she did not re-admit this resident and did not remember if the resident had an air mattress on the bed before the residents went to the hospital. Staff D stated she would not automatically put on heel protectors either. She reported being acutely aware of the necessity to check resident's heels when returning to the facility. She noted if the heels are soft and spongy that is a problem starting and would place preventative measures right away. If the resident's heels are intact and firm then there probably isn't a concern at that time. On 3/12/19 at 2:10 p.m. the Director of Nursing (DON), the Consultant RN, and the ADON discussed the situation during an interview. The ADON stated staff reported an opening on the resident's coccyx on 1/10/19 and she went to assess the resident. While doing that she felt the need to also assess the resident's heels. The ADON found pressure areas on the resident's heels. The DON remarked the resident had been on a repositioning schedule for the nurse aides. They all agreed the care plan showed interventions added after the pressure ulcers were identified. They did not know if the resident had the heels floated while bed, prior findings to the pressure areas, but probably didn't, as no documentation found including this prevention. The RN Consultant commented floating the resident's heels should have been implemented, if anything, right after returning from the hospital. They all verified the resident had diabetes, a small build, limited mobility after surgery and at risk to develop pressure areas. The ADON noted the area on the big toe founded as a vascular injury, as it did not display signs of a pressure area as the resident had not ambulated and did not wear shoes. The facility's policy dated 1/2015 for Prevention of Pressure Ulcers documented the purpose: to promote good skin integrity, to relieve pressure, restore circulation and promote skin protection in the affected area. The guidelines in this Policy included the following: - reposition the resident routinely and potion with pads and pillows to protect bony prominence's and maintain proper alignment. - use elbow and/or heel foot protectors if needed. NOTE: any reddened area that remains red longer than 30 minutes after pressure is relieved is at high risk for a pressure sore to develop.

Based on clinical record review, facility protocol and interviews, the facility failed to ensure one (1) of five (5) residents received adequate supervision to protect against hazards in the environment. Record review, facility protocol review and staff interviews revealed Resident #2 required the use of a personal safety alarm, pressure alarm at all times, and staff to encourage gripper socks or shoes on at all times due to fall risk. On 3/15/17, staff left Resident #2 in bed with pressure alarm in place, but failed to confirm alarm box turned on and functioning and placed socks on resident were not gripper socks. Resident #2 stood, fell and sustained a subdural hematoma (collection of blood outside the brain) and required admittance to the hospital. The facility reported a census of 92 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 2/14/17 for Resident #2 documented a score of 7 of 15 on Brief Interview for Mental Status (BIMS) test which indicated severe cognitive impairments. According to the MDS, the resident required the extensive assistance of one staff for transfers, dressing, and walking in room/walking in corridor. The MDS further identified the resident required limited assistance of one staff for bed mobility personal hygiene and toilet use. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when walking, turning around, and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had had experienced two or more falls with no injury since admission or reentry or prior assessment. Review of the Risk Assessment for Falls dated as completed on 2/13/17 identified the following risks for falls: intermittent confusion, three or more falls in past three months, chair bound, decreased muscular coordination, required use of assistive devices for gait/balance, medication use, and predisposing diseases. The Risk Assessment for Falls documented a score of 18, a score of 10 or more represented a high risk for falls. The Resident Care Plan with a problem onset date of 8/29/2014 identified a potential for injury related to fall history. The Care Plan identified a goal of no injury sustained from fall with a target date of 5/17/17. The approaches directed staff to use a pressure alarm in bed and wheelchair dated 11/18/16, encourage gripper socks or shoes all times-as able dated 11/25/16, monitor resident frequently with rounds dated 3/8/17. The Care Plan identified the following recent falls: 3/8/17-self transfer, found on floor in room 3/7/17-found on floor at foot of bed 2/27/17-fall found in doorway 1/30/17-fall bathroom 1/25/17-fall out of recliner in room 1/15/17-fall activity room 1/4/17-fall self- transfer A timeline of falls for Resident #2 identified the following: a). On 10/18/16 a personal alarm was added after the resident had fallen in his/her room while attempting to use the bathroom unassisted. b). On 11/24/16, gripper/shoes after the resident had fallen in the bathroom. c). On 1/30/17, a pressure alarm added after resident had fallen on bathroom floor. Resident #2 had used the resident unassisted. A fall incident report dated 3/15/17 at 6:35 a.m. documented Staff A, licensed practical nurse, (LPN) observed Resident #2 laying on floor on back at the foot of bed. Noted socks were not gripper socks, alarm not sounding, and the residents head laid in a large amount of blood. The nurse assessed the resident and noted an approximately 2 cm laceration (tearing of skin) over a golf ball size hematoma (lump from collection of blood) on the left side of the residents head. Staff transferred the resident to the hospital emergency room for evaluation and treatment. The hospital provider note dated 3/17/17 at 1:10 p.m. documented Resident #2 arrived at hospital with an intracranial bleed after being found down at the nursing home. When the emergency medical staff arrived (at the nursing home), the resident already had blood coagulated in his/her laceration identifying he/she may have been down for some time. A laceration was noted to the back of the head, EMS transported to a local hospital and a CT scan of the resident's brain was positive for a subdural hematoma. The resident discharged back to the nursing home in stable condition on 3/17/17. During an interview on 4/12/17 at 11:11 a.m. Staff A, LPN, confirmed on 3/15/17 she heard Resident #2's roommate yell for help, she entered the room and observed Resident #2 on the floor at the foot of the bed, laid on back, with blood noted all around the resident's head. Staff A noticed the bed pressure alarm was not sounding and noted the socks the resident was wearing were not non-skid socks. Staff A reported she called for help, and requested Staff B, CNA (Certified Nurse Aide) check the alarm. Staff A reported she was informed by Staff B the alarm was not on. Staff A stated it is an expectation that all alarms are checked at the beginning of the shift during walking rounds, clarified that the day shift began at 6 a.m. Staff A revealed on 3/15/17 staff failed to complete walking rounds because of lack of staffing. Staff A further clarified that the resident was to have a pressure alarm on at all times when in bed and was to wear non-skid socks and but was found to be wearing socks that were not non-skid. In an interview on 4/12/17 at 12:20 p.m. Staff B, CNA confirmed on 3/15/17, Staff A, LPN requested she check the resident's bed pressure alarm after Resident #2 was discovered on the floor. Staff B confirmed the alarm was not sounding when she entered the room. Stated the alarm monitor was attached to the bed side rail and the monitor was connected to the pad pressure alarm. Stated she assumed the alarm was not on because it was not sounding. Staff B demonstrated on the actual alarm removed from the resident's room that the on/off button is not easily visible, and stated she did not have her glasses on so could not see. Clarified that she would normally test a pad pressure alarm by putting pressure on the pad, releasing and listening for audible alarm but confirmed she failed to test the resident's alarm after the fall. In a phone interview on 4/12/17 at 4:00 p.m. Staff C, CNA, confirmed she had assisted the resident to toilet at 5:30 a.m. on 3/15/17 and returned the resident to bed. Confirmed the alarm was in place attached to the side rail. Confirmed failed to complete walking rounds to check alarms during shift. Review of an Internal Investigation Witness Statement dated 3/15/17 documented staff D, CNA responded to questions from the Director of Nursing (DON). Staff D, CNA reported to work at 6:00 a.m. on 3/15/17. Staff D responded that she had not checked alarms when came in to work and failed to complete walking rounds to check alarms because she was answering call lights. In an interview on 4/12/17 at 2:45 p.m. the Administrator stated has always been an expectation that staff check alarms are in place and functioning at the beginning of every shift in addition need to check alarm every time alarm put in use. Confirmed staff failed to check alarms on 3/15/17. Clarified following the residents fall have implemented measures to monitor and hold staff accountable.

Based on clinical record review, staff and resident interviews the facility failed to plan and implement appropriate fall preventions interventions to reduce the risk for falls. Concerns noted for one of four residents reviewed (Resident #2). The facility reported a census of 83 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated intact cognition. Resident #2 required extensive assistance of one person with bed mobility, walking, dressing and the extensive assistance of two persons with transfers and toilet use. Resident #2 required staff assistance to stabilize his/her balance while walking, turning around, moving on and off toilet and surface-to-surface transfers. The MDS documented no falls for Resident #2 since his/her 6/11/15 admission to the facility. [DIAGNOSES REDACTED]. According to the Face Sheet, Resident #2 initially admitted to the facility on [DATE]. Resident #2's medical [DIAGNOSES REDACTED]. A Palliative Medicine Consult Note dated 6/11/15 noted Resident #2 Active Problem List included osteoarthritis, spinal stenosis, generalized weakness, fracture of the left femoral neck (hip), sacral fracture, low back pain, dizziness and acute [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] assessed Resident #2 at a high risk for falls related to intermittent confusion, a history of three or more falls in the past three months, chair bound, medications and predisposing diseases. Resident #2 scored 20. The form noted a total score of 10 or above represents a high risk for falls. A fall risk assessment dated [DATE] noted Resident #2 scored 18 that indicated a high risk for falls. A hospital report dated 6/1/15 noted Resident #2's medical history included an open reduction and internal fixation of left hip fracture. Resident #2 admitted to the hospital for pain control and for urgent revascularization of the right lower extremity. A Care Plan dated 6/11/15 and revised 9/11/15, 9/25/15, 12/25/15 and 2/26/16 identified potential injury from fall related to a history of fall and [DIAGNOSES REDACTED] (abnormal brain function). The Care Plan goal: Will have no sustained injury related to a fall. The original approaches included keep the room free of clutter, fall assessment on admit, and in event of fall provide first aide. Handwritten additions to the Care Plan included: a. 8/21/15: I can be non-compliant with alarms/calling for assist with transfers. Blue clip alarm. b. 9/12/15: I transferred independently off the toilet and fell , Certified Nursing Assistant (CNA) just outside of bathroom door, continue with alarms. c. 9/14/15: Education for resident. d. 9/28/15: Fall 9/26 in room was going to take self to bathroom, reapply blue clip alarm. e. 11/15/15: Discontinue Blue clip alarm return from hospital. f. 1/25/16: resident reported he/she sat down hard on the toilet, make sure to educate resident to have staff assistance. g. 2/10/16: resident tipped over wheelchair on 2/9 went to hospital will apply anti-tip bars to wheelchair. h. Undated: Do not leave alone in room in wheelchair. The Do was crossed off and written attempt to. An Incident Report dated 9/12/15 at 11:15 p.m. noted during toileting while CNA was at the doorway, facing away from Resident #2, he/she stood up unattended and fell backwards onto the toilet and hit the back of his/her head. Noted small hematoma to back of head. When interviewed on 2/15/16 at 3:22 p.m. the Director of Nursing stated the facility Standard Of Practice mandated whenever a resident utilized an alarm the staff must stay with them while in the bathroom. An Incident Report dated 9/26/15 at 2:00 a.m. noted staff found Resident #2 on the floor between the bed and the window. Resident #2 attempted to toilet independently, removed the alarm and failed to press the call light. Resident #2 fell backwards and the walker fell on top of him/her. A Hospital Admission Report Sheet dated 11/12/15 noted Resident #2 was confused and restless and at risk for falls. An Activity Department Note dated 11/27/15 noted Resident #2 preferred to go to bed around 8 to 9:00 p.m. A Customary Routines/Preferences document dated 11/27/15 noted Resident #2's normal bedtime as 8:00 p.m. A Physical Therapy Evaluation dated 1/8/16 noted Resident #2 demonstrated poor gait pattern, was impacted by left upper extremity during gait and required constant verbal cues and moderate assistance with walker. A Nurse's Note dated 1/19/16 at 9:00 a.m. noted staff found Resident #2 sitting on the floor between the sink and the toilet. Alarm attached, not sounding, cord stretched. Resident #2 stated he/she had to go to the bathroom. Staff reattached the alarm and shortened the cord. An Incident Report dated 1/19/16 at 9:00 a.m. noted staff found Resident #2 on the floor between the sink and the toilet. Alarm attached and not sounding. The alarm cord stretched. Resident #2 reported he/she needed to use the bathroom. A Nurse's Note dated 1/26/16 at 12:30 p.m. noted Resident #2 refused to stand with staff for transfers. New order received at 7:10 p.m. to increase Resident #2's antidepressant medication Celexa to 40 milligrams (mg) daily. An Incident Report dated 2/9/16 at 7:22 p.m. noted staff found Resident #2 on the floor in his/her room, appeared to have tipped over in the wheelchair. Head against the wall, blood on lip. Resident #2 complained of severe back pain. Resident #2 rated his/her pain a ten out of ten, Resident #2 also complained of a headache. Directive to send Resident #2 to the hospital emergency room for an evaluation and treatment. The Emergency Department Notes dated 2/9/16 assessed Resident #2 with a thoracic spine fracture secondary to the fall. A provider communication form dated 2/9/16 at 7:28 p.m. noted staff found Resident #2 tipped over in wheelchair with head against the wall. Resident #2 was screaming in pain. Resident #2 was in severe pain from the fall. Fall with head injury and severe back pain. A Hospital History and Physical dated 2/10/16 noted while at the nursing home, Resident #2 was in his/her wheelchair and fell backwards and hit his/her head. Resident #2 complained of a headache, some backache and the fact he/she bit his/her tongue. Tests revealed an acute T 1 vertebral fracture. A hospital consultation report dated 2/10/16 noted the [AGE] year-old resident presented to the emergency room after a fall. Resident #2 was in his/her wheelchair and fell backwards and struck his/her head. Resident #2 was found to have a fracture of the T (thoracic) 1 vertebrae and was transferred to another hospital for further neurosurgeon evaluation. Cervical Aspen Collar when patient is out of bed. A Nurse's Note dated 2/10/16 at 1:30 a.m. noted Resident #2's family called at 11:30 p.m. and reported Resident #2 cracked a vertebrae and they wanted to send him/her to another hospital. The hospital recommended Resident #2 have surgery to cement the vertebrae. The family reported the physician stated the vertebrae would not heal and would hurt without the surgery. When interviewed on 2/10/16 at 4:50 p.m., Staff D CNA stated Resident #2 would rock in the wheelchair while propelling independently down the hall. On 2/9/16, after supper Resident #2 stated he/she wanted to go to bed. Staff D CNA assisted Resident #2 to put his/her feet up on the bed and told Resident #2 she would come back when she had time to help him/her into bed. Staff D CNA left Resident #2 in the wheelchair with his/her feet up on the foot of the bed and the over bed table on Resident #2's left side. Staff D CNA stated she failed to give Resident #2 the call light before she left the room. The call light remained wrapped around the half side rail and was not in reach of Resident #2. Staff D CNA stated after about 7 to 8 minutes, and no later than 10 minutes later she heard, Oh help me. Staff D CNA stated Resident #2 called out in a panic, not his/her normal call for assistance. Staff D CNA went to Resident #2's room and found Resident #2 had tipped his/her wheelchair over backwards. Resident #2 lay on the floor while still seated in the wheelchair. Resident #2 verbalized pain. Resident #2 stated his/her pain was terrible. Staff D CNA stated Resident #2 may have been reaching for the call light when he/she fell . Staff D CNA stated if she could do it over again, she would have given Resident #2 the call light and she would not have put Resident #2's feet up on the bed as it was not safe. When interviewed on 2/10/16 at 3:50 p.m. Staff E LPN (Licensed Practical Nurse) stated Resident #2 utilized alarms due to he/she liked to transfer independently. Staff E LPN stated Resident #2 did not spend a lot of time in the wheelchair due to when in his/her bedroom Resident #2 preferred to sit in the bed with the head of the bed up. Resident #2 spent a lot of time in his/her room. Resident #2 was known to transfer independently and was known to fall. Resident #2 fell about a week ago. Staff E LPN stated on 2/9/16 Resident #2 was very upset due to he/she reported the day shift staff failed to inform the nurse he/she needed a pain pill. Staff E LPN reported she was summoned to Resident #2's bedroom around 7:15 p.m. where she observed Resident #2 tipped backwards, on the floor, still in the wheelchair with his/her head against the wall. Resident #2 complained of real bad back pain. Resident #2 reported he/she bit his/her tongue and had blood on his/her lip. Resident #2 reported his/her pain was the worst pain he/she had ever felt. Resident #2 called out in pain as the staff assisted Resident #2 up off the floor. Staff called and received an order to send him/her to the emergency room . Staff E LPN later learned Resident #2 broke a vertebrae. When interviewed on 2/16/16 at 10:00 a.m. Resident #2 stated he/she remembered the day he/she fell backwards in his/her wheelchair. Resident #2 stated he/she was reaching for something when he/she suddenly went backwards in the wheelchair.

Based on record review, observations and staff and family interviews the facility failed to adequately supervise Resident #1 to ensure against hazards from self and failed to protect the resident from injury due to a fall. The sample consisted of 4 residents and the facility reported a census of 83 residents. Findings Include: 1. The MDS (Minimum Data Set) assessment with a reference date of 1/9/2014 reported Resident #1 transferred from one surface to another with extensive assistance of two staff, unsteady balance when transferring with assist, frequent incontinence of bowel and bladder. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident had falls since admit or the prior assessment. The Care Plan reflected Resident #1 had potential for injury from falls related to dementia, agitation, a fall on 1/9/14 at the nurse ' s station with abrasions to the forehead and nose. The Care Plan also identified the resident had noncompliance with calling for assist with transfers related to dementia. The Care Plan directed staff to apply alarms to the bed and wheelchair, keep the resident by the nurse's station as needed for safety, notify family as needed for assistance with resident, and administer antianxiety medication as needed. On 1/13/2014, the facility added a soft tray to the resident's wheelchair when up in the chair. The plan revealed the resident had an admission to hospice on 1/14/2014 per the family ' s request. The Nurse's Notes dated 1/3/2014 at 11:15 a.m. identified staff admitted the resident to the facility. The note at 9:00 p.m. on 1/3/14 revealed the resident continuously tried to stand up out of the wheelchair. The resident voiced no complaints of pain/discomfort. The Nurse's notes dated 1/4/14, 1/5/14, 1/6/14, 1/7/14, 1/8/14, included documentation the resident had restlessness, tried to staff up from the chair, confusion and required close monitoring. Staff documented they kept the resident at the nurse's station for supervision, and called the family in at times to supervise. The Nurse's Notes dated 1/9/2014 at 8:50 p.m. revealed staff found Resident #1 face down on the floor after a fall from the wheel chair. Staff A, LPN (Licensed Practical Nurse) documented the resident had open areas on the nose and right forehead. Staff A assessed the resident and notified the family and physician. At 10:45 p.m. the staff telephoned the family to come and sit with the restless resident. At 1:15 a.m. Staff noted the resident's eye appeared black and blue and noted swelling to the forehead. At 8:15 a.m. Staff noted the resident ' s bilateral (both) eyes appeared black. At 9:10 a.m. the resident's family requested the resident be seen by the physician to rule out a fracture. The CT (computed tomography) of the head or brain report dated 1/10/2014 revealed no acute intracranial abnormalities. The resident returned to the facility with and order for pain and antianxiety medication and an order to hold the resident's blood thinner (medication) for two days and recheck labs (laboratory tests). The physician signed the Major Injury Determination Form and believed the resident had a major injury. On 1/13/2014 the resident received a hospice referral, and on 1/15/2014 the resident discharged to a hospice house facility. The Incident/Accident. Unusual Occurrence Form dated 1/9/2014 reported Resident #1 fell at 8:50 p.m., alarms sounded and staff found the resident flat on the floor at the nurse's station. Resident #1's Fall Risk Evaluation dated 1/3/2014 revealed a score of 13 which identified the resident had a high risk for falls. The facility Falls Protocol Quick Reference included: 1). Identifying residents at risk a. Complete a fall risk assessment for each resident at time of admission and quarterly. b. For those residents identified at risk of falls, initiate/implement preventative interventions via care plan. Observation on 1/15/2014 at 10:30 a.m. revealed the resident lying in a low bed with eyes shut and calm. The resident had a large amount of purple and yellow bruising present on the forehead, cheeks and eyes. During an interview on 1/15/2014 at 9:30 a.m., the DON (Director of Nursing) reported Resident #1 had a fall from the wheelchair while seated at the nurse's station on 1/9/2014 after supper. The resident sustained [REDACTED]. On 1/10/2014, the resident went to the physician and had a CT scan that showed no injury. The physician determined the resident had a major injury because the resident's lab report showed an INR (International Normalized Ratio), a blood test that identifies how fast the blood clots, of 4.9. The resident received Coumadin, an oral blood thinner. On 1/13/2014 the resident had a 1.7 INR. When the resident admitted on [DATE], the physician ordered an INR lab draw on 1/16/2014. The resident had no indication to draw it earlier. During an interview on 1/21/2014 at 10:09 a.m., Staff B, RN (Registered Nurse) reported working on second shift on 1/9/2014. Around 9:00 p.m. she walked up the 300 hall along with a CNA (Certified Nurse's Aide) and heard Resident #1's chair alarm sounding at the nurse's station. Staff B stated she had no knowledge of the resident being at the nurse's station that evening. The resident frequently attempted to stand, setting off the chair alarm. Staff B stated when she arrived at the nurse's station, Resident #1 lay face down, and she summoned the resident's nurse, Staff A. During an interview on 1/16/2014 at 9:10 a.m., Staff A, LPN reported working on 1/9/2014 on second shift on the 200 hall where Resident #1 resided. The resident had a tendency to get up, that's why they (the facility) applied the alarms. The resident usually waited until third shift to go to bed. They (the staff) placed the resident where family or staff could observe him/her and called in family when needed. That night the resident had restless behaviors and staff placed him/her at the nurse's station. Staff A stated she administered resident treatments on the 200 hall, and failed to observe the resident for approximately one half hour. The resident sat at the nurse's station out of her view. Staff A stated she received a page while in another resident's room, and unable to hear the resident's alarms sounding until stepping into the hall. Staff A stated she assessed the resident along with Staff B, RN, phoned the physician and family. She informed the on call physician of the resident ' s fall and the bump on the resident ' s head and abrasion on the nose, but failed to inform the physician the resident received Coumadin. During an interview on 1/21/2014 at 9:30 a.m., Staff C, CNA reported working second shift on 1/9/2014. At approximately 6:30 - 7:00 p.m. Staff C brought Resident #1 to the nurse's station and told the nurses to watch him/her. Staff C continued to assist other residents to bed. The resident attempted to stand often and set off the chair alarms. At approximately 9 o'clock p.m. Resident #1 fell . Staff C failed to hear the chair alarm because he/she administered a treatment in another resident's room. Staff C reported the resident required one on one attention when up, even when in bed until he/she fell asleep. During an interview on 1/21/2014 at 3:35 p.m. Staff D, CNA reported working second shift on 1/9/2014 on the 200 hall. Staff D stated she did not hear Resident #1's alarm when he/she fell . Staff D stated she received a page asking for help. That night she saw the resident around 6:00 p.m. during dinner. Staff D reported not assisting the resident at dinner or placing the resident at the nurse's station after dinner. Staff D recalled assisting Staff C to toilet the resident before dinner. During an interview on 1/21/2014 at 2:20 p.m., Staff E, LPN reported working the night shift on 1/9/2014. When Staff D arrived to work, Resident #1 sat at the nurse's station in the wheelchair. The resident's family member came in to sit with the restless resident until 2:00 a.m. Typically the resident stayed up at the nurse's station when up or staff needed to stay with the resident while in bed. The resident continuously set off the alarms. The resident started bruising and swelling during the night. During an interview on 1/15/2014 at 3:50 p.m., the family members voiced concerns regarding the resident's fall from the wheel chair. The family felt staff failed to appropriately supervise the resident. The facility called them to the facility to supervise the resident after the fall. Following the resident's fall the facility placed the resident in a different wheelchair, one that reclined and had a high back and lap tray. The resident's neurologist suggested the resident receive hospice services.