Every finding on record at Northern Pines Rehabilitation and Nursing

Based on interview and record review, the facility failed to include wound care on the 48-hour baseline care plan for a newly admitted resident with multiple wounds for 1 (#44) of 19 sampled residents. This deficient practice resulted in staff not knowing the specific care requirements for the resident. Findings include:During an interview on 1/13/26 at 9:58 a.m., NF4 stated resident #44 had a lot of sores when he was discharged from the hospital and admitted to the facility. NF4 stated the facility assessed his wounds when he arrived.During an interview on 1/14/26 at 9:14 a.m., staff member C stated wounds should be on the resident's baseline care plan. During an interview on 1/14/26 at 1:26 p.m., staff member B said a baseline care plan assessment is completed by the two admission nurses when conducting the admission. The baseline care plan should be filled out completely with all information for staff to provide care for the resident.During an interview on 1/15/26 at 10:15 a.m., staff member I said wounds should have been addressed on the baseline care plan, and they got missed for resident #44. Review of resident #44's baseline care plan, with an initiation date of 1/6/26, showed:. Physician's orders, see MAR.2. Is the resident at risk for skin integrity issues?-2a. If the resident is at risk for skin integrity issues, select the appropriate focus statement, goals, and interventions to address skin integrity: - Focus: Potential for altered skin integrity related to: - Intervention: Encourage good nutritional and oral fluid intake, - Intervention: Encourage/prompt resident to change positions., - Intervention: Nurses to perform weekly skin assessments., - Intervention: Staff will assist resident to turn/reposition., - Intervention: Staff will promote clean skin by encouraging/assisting resident to bathe regularly., - Intervention: Staff will provide prompt peri-care after incontinent episodes., - Intervention: The resident uses the following devices for pressure reduction: Heel protectors. The baseline care plan for resident #44 failed to show interventions for wound care and treatments. Review of a facility document titled Baseline Care Plan, with an implementation date of 4/23/25, showed: Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. [sic]Policy Explanation and Compliance Guidelines:1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: . ii. Physician orders.

Based on observation, interview, and record review, the facility failed to provide and maintain a safe environment for 1 (#16) of 19 sampled residents, as evidenced by unsecured medications stored in the resident's bedside nightstand. Findings include:During an interview on 1/12/26 at 2:45 p.m., resident #16 stated she took Tylenol every night for her right knee pain. Resident #16 pulled out a bottle of Tylenol from the top drawer of her nightstand. Resident #16 stated she told the nurses a couple of days ago that she has her own bottle of Tylenol.During an interview on 1/12/26 at 4:40 p.m., resident #16 stated she thought her daughter had brought in the bottle of Tylenol, but wasn't sure. During an interview on 1/13/26 at 1:29 p.m., staff member D stated she did not know resident #16 had Tylenol in her room. Staff member D stated, I always offer her Tylenol, but she never needs it, and tells me she is doing okay. Staff member D stated resident #16 probably got it at some point while out shopping on the facility's bus every Monday.During an interview on 1/14/26 at 11:43 a.m., staff member C stated she did not know resident #16 had Tylenol in her nightstand drawer. Staff member C stated if she found any medications in a resident's room she would tell staff member B right away.During an observation on 1/15/26 at 9:28 a.m., a bottom nightstand drawer in resident #16's room was noted to be completely full of various medication bottles including, but not limited to, Tylenol, Motrin, Aspirin, Premarin, eye drops, and topicals. During an interview on 1/15/26 at 9:30 a.m., staff member C stated she had no idea any of the medications in resident #16's drawer was there. Staff member C stated she would normally see an assessment in the chart for residents who give their own medications, and then stated, But no one that lives here has that.During an interview on 1/15/26 at 9:31 a.m., staff member B stated she was unaware that resident #16 had a full drawer of medications in her room, and did not have an assessment or order for resident #16 to be able to self-administer medications.Review of a facility policy, titled, Resident Self-Administration of Medication, Copyright 2025 The Compliance Store, LLC, reflected the following: . A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interview, and record review, the facility failed to maintain the privacy of personal health information, when a resident's height and weight were posted outside of the resident's door in a public location for 1 (#15) of 19 sampled residents. This deficient practice caused the resident to be disgusted by the posting. Findings include:During an observation on 1/12/26 at 2:18 p.m., resident #15's door had a piece of paper on the outside of her door which showed her height and weight.During an observation and interview on 1/14/26 at 8:12 a.m., resident #15's height and weight were posted on the outside of the resident's room door in public view. Resident #15 was asked if she gave permission for her height and weight to be posted on the outside of her room door in the public's view. Resident #15 replied, no, and stated she didn't think her height and weight were anyone's business. Resident #15 stated that posting her height and weight on the outside of her door was sick and questioned if the posting was ethical. Resident #15 reported no one had spoken to her about the posting and stated her height and weight should be kept private and out of the public's view. Resident #15 further stated the posting of her height and weight was disgusting.During an interview on 1/14/26 at 8:19 a.m., staff member H stated the height and weight posting on the outside of resident doors was posted when residents were admitted to the facility and used as a tool to remind CNAs to get the resident's weights.During an interview on 1/14/26 at 8:20 a.m., staff member G stated she did not ask resident's permission to post their height and weight outside of resident room doors. Staff member G stated there is potential for the resident to be negatively affected from height and weight being posted in view of the public.During an interview on 1/14/26 at 8:23 a.m., staff member B, said height and weight posting on the outside of the resident's door was a reminder for the CNAs to obtain weights upon admission to the facility and staff forget to take the postings down, especially when there was new staff. Staff member B said permission to post the weights on the outside of the door was obtained when a resident signed the consent to treat upon admission.Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, not dated, showed, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity a well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.12. Maintain resident privacy.

Based on interview and record review, the facility failed to maintain evidence of Ombudsman notification for a resident who was transferred to the hospital for 1 (#6) of 19 sampled residents. This deficient practice limited the Ombudsman's opportunity to review the facility's transfer protocols. Findings include:Review of resident #6's hospital discharge summary showed she was admitted to the hospital on [DATE] and discharged on 9/29/25.During an interview on 1/14/26 at 4:04 p.m., staff member I stated the Ombudsman was notified of transfers and discharges twice per month and the notification was done verbally.During an interview on 1/15/26 at 8:26 a.m., staff member G stated she notified the Ombudsman of transfers and discharges when the Ombudsman visited the facility. Staff member G stated the notification was verbal and informal. Staff member G stated she did not have documentation of the Ombudsman notification for resident #6's transfer on 9/26/25.A voicemail was left for the Ombudsman on 1/14/26 at 4:11 p.m., concerning the facility's process for Ombudsman notifications of facility transfers and discharges. There was no return call prior to the end of the survey.A request was made for Ombudsman notification for resident #6's hospital transfer on 9/26/25, on 1/14/26 at 3:45 p.m. Evidence of the notification was not provided prior to the end of the survey.Review of the facility's policy titled, Transfer and Discharge (including AMA), implemented on 4/11/25, showed, .Policy Explanation and Compliance Guidelines:.5. The facility will maintain evidence that the notice was sent to the Ombudsman.9. Non-Emergency Transfers or Discharges.d. The facility will provide transfer/discharge notice to the resident/representative and Ombudsman as indicated.10. Emergency Transfer to Acute Care.h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.

Based on observation, interview, and record review, the facility failed to comprehensively assess a resident's diagnosis of dementia for 1 (#2) of 19 sampled residents. This deficient practice had the potential to prevent the resident from achieving his highest practicable physical and mental well-being. Findings include: During an observation and interview on 1/12/26 at 2:14 p.m., resident #2 was sitting in his room attempting to turn off his radio. Resident #2 stated he was having trouble working both his television and his radio. Resident #2 was confused about the buttons and what they controlled on the television. During an interview on 1/15/26 at 9:45 a.m., staff member G stated, A diagnosis of dementia should be on the Minimum Data Set Assessment if the resident has a diagnosis of dementia. Staff member G said resident #2's diagnosis of dementia should have been on the Minimum Data Set Assessment since resident #2 had a diagnosis of dementia upon admission. Review of resident #2's medical record showed a diagnosis of unspecified dementia with a date of 4/16/24. Resident #2 was admitted to the facility on [DATE], so the diagnosis was not added on admission.Review of resident #2's Minimum Data Set Assessment, with an Assessment Reference Date of 10/2/25, showed the resident did not have Non-Alzheimer's Dementia, due to how the assessment was coded, which reflected: .Section I: Active Diagnoses: I4800. Non-Alzheimer's Dementia: No.The assessment showed the resident did not have dementia. The facility failed to identify and ensure that resident #2's diagnosis of dementia was accurately coded and reflected on the Minimum Data Set Assessment. The diagnosis was not documented on the MDS until the most recent Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 1/2/26, which was two years after the resident's admission. on 1/30/24.

Based on observation, interview, and record review, the facility failed to comprehensively care plan and implement the use of a hand splint to prevent further left hand and wrist contractures for 1 (#6); and failed to include a diagnosis of dementia and interventions for 1 (#2) of 19 sampled residents. The deficient practice increased the risk of further contractures for the resident and had the potential to keep the residents from meeting their highest practicable well-being. Findings include:1. During an observation on 1/13/26 at 9:32 a.m., resident #6 was observed seated in her wheelchair with a support platform mounted on the left-hand side of her wheelchair to support her left hand and arm. Resident #6 was observed with her left hand in a flexed position. Review of resident #6's occupational therapy evaluation and plan of treatment for the certification period of 7/18/25 – 9/15/25, showed that resident #6 was being treated for Hemiplegia and hemiparesis following cerebral infarction affecting her left dominant side, Weakness, and Muscle weakness (generalized). The objective progress/short-term goals identified a new goal to evaluate for the appropriate left-hand splint to prevent further left-hand and wrist contracture with a target date of 9/15/25. The evaluation included, Had splint previously, but has not been wearing it. The evaluation further noted an increased generalized tightness with the resident's left upper extremity, and a near contracture at the wrist. Review of the resident #6's occupational therapy discharge summary, with dates of service ranging from 7/18/25 to 8/12/25, showed a new hand splint was to be ordered, and the comments included that the splint would be fitted upon arrival. During an interview on 1/15/26 at 8:40 a.m., staff member I stated resident #6's care plan needs to be more specific as it related to the care of the near contracture and use of the interventions in place to decrease the worsening of the near contracture. During an interview on 1/15/26 at 9:14 a.m., staff member O stated the condition of resident #6's hand and wrist near contracture were permanent, and a splint was ordered back in September of 2025. Staff member O said near contractures needed care planned interventions to prevent further contractures. During an interview on 1/15/26 at 7:57 a.m., staff member B said there was a lot of information on resident #6's care plan that didn't carry over from her prior admission. Staff member B stated there were new staff members completing the MDSs, and because they didn't know resident #6, the staff members took some of the care planned information out of the current care plan. During an interview on 1/15/26 at 8:32 a.m., staff member J stated she would expect contracture or near contractures to be on the care plan. During an interview on 1/15/26 at 10:57 a.m., staff member N said resident #6 does have a splint for her left hand, and it should be on her left hand, or it was in her room. Staff member N stated she had been trained on the placement of the splint for resident #6. Review of resident #6's comprehensive care plan, last reviewed on 10/29/25, lacked the intervention of a hand splint to prevent further contractures. 2. During an observation and interview on 1/12/26 at 2:14 p.m., resident #2 was observed trying to shut off his radio. It took some time before he found the right button and shut off the radio. Resident #2 stated he was also having trouble with his television. Resident #2 had some confusion when talking about his medical conditions and his time at the facility, stating that he . needs to go offsite to sell his paintings, or the facility will just take all of the money for themselves. During an interview on 1/14/26 at 7:49 a.m., staff member F stated, We have had dementia training and have been taught how to redirect residents with dementia. If a resident has dementia, it should be on the care plan with interventions. During an interview on 1/14/26 at 1:26 p.m., staff member B stated, The MDS coordinator used to do the care plans. Since that staff member left, the care plans are a mess. There is a lack of communication and too many people working on them. Staff member B stated, If a resident has a diagnosis of dementia, it should be on the care plan and include interventions. During an interview on 1/14/26 at 9:14 a.m., staff member C stated, If a resident has a diagnosis of dementia, it should be on the care plan and include interventions. During an interview on 1/14/26 at 2:40 p.m., staff member J stated she would expect to see a diagnosis of dementia care planned with interventions for anyone with a diagnosis of dementia. During an interview on 1/15/26 at 8:57 a.m., staff member G stated resident #2 had been admitted from another facility and had a diagnosis of dementia present since 4/2024. Review of resident #2's medical record showed: Diagnosis: Unspecified Dementia, mild, without behavioral disturbance, psychotic, mood disturbance, and anxiety, with a date of 4/16/24. Classification: Admission. Review of resident #2's comprehensive care plan, with a revision date of 1/8/26, failed to show a diagnosis of dementia and any related interventions. Review of a facility document titled Comprehensive Care Plans with an implementation date of 4/11/25, showed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. [sic]

Based on interview and record review, the facility failed to provide necessary treatments and services to a resident with wounds, to promote healing of the wounds, and the physician's orders for the wound treatments were not implemented in a timely manner, for 1 (#44) of 19 sampled residents. This deficient practice increased the risk of infection and worsening of the wounds. Findings include:During an interview on 1/13/26 at 9:58 a.m., NF4 stated resident #44 had multiple wounds when he got to the facility, and said, He even had sores on his feet. NF4 stated, The facility staff assessed all of the wounds and took notes on them as soon as he (#44) got to the facility. During an interview on 1/14/26 at 1:26 p.m., staff member B stated resident #44 was admitted to the facility on the 5th or 6th of January 2026. Staff member B stated that resident #44 had multiple wounds on admission, and the facility had assessed them. Staff member B stated, The sore on his bottom was dressed with a foam dressing and should be changed every three days, the sores on the toes should be painted with betadine and left open to air, the sores on his calves should be covered and changed every three days. Staff member B stated, I thought the orders were put in the computer when he was admitted . I didn't realize they (staff) weren't documenting the dressing changes, and the orders were put in late. The nurse who was supposed to enter the (physician) orders had forgotten to enter them.Review of resident #44's electronic medical record showed resident #44 was admitted to the facility on [DATE]. Review of resident #44's physician's orders showed all wound care orders were entered into the electronic medical record on 1/12/26. Review of resident #44's Treatment Administration Record, with a printed date of 1/14/26, showed:.L&R coccyx - cleanse with wound cleaner and apply foam dressing in the afternoon every 3 day(s) for wound care, order date: 1/12/26. The order was checked as completed on 1/12/26.-R great toe, R 2nd toe, L 2nd toe, L plantar foot - paint with betadine daily & leave OTA, socks off & no covers on toes while in bed in the afternoon for wound care, order date: 1/12/26. The orders were checked as completed 1/12/26 and 1/13/26.-R heel, L heel & lateral foot - cleanse with wound cleaner, apply foam dressings. Pressure reducing boot to R foot while up in the afternoon every 3 day(s) for wound care, order date 1/12/26. The orders were checked as completed 1/12/26.-L&R coccyx - cleanse with wound cleaner and apply foam dressing as needed, soiling or removal, order date: 1/12/26. There were no checks documented showing that the treatment order was completed. -R lower calf - cleanse with wound cleaner, cover with foam dressing as needed (for) soiling or removal, order date: 1/12/26. There were no documented checks showing the order was completed.Review of the Treatment Administration Record showed the facility failed to enter wound care orders promptly and failed to treat resident #44's wounds for six days after admission. Review of a facility document titled Wound Treatment Management with an implementation date of 4/11/25, showed: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.

Based on observation, interview, and record review, the facility failed to identify the need for and have processes in place to ensure resident personal refrigerators were maintained and monitored for 1 (#31) of 19 sampled residents. This deficient practice caused the residents' refrigerator to become dirty and to contain expired foods, which could have led to illness. Findings include:During an observation and interview on 1/12/26 at 1:12 p.m., resident #31 stated, A lady used to come in and check the fridge, but no one has in a while. You can look in it, but I wouldn't if I were you; it stinks. Observation of the refrigerator in resident #31's room showed it was at 46 Degrees Fahrenheit. It had a foul odor, and there was a mini pizza that was supposed to be frozen. The pizza in the box was pliable and not frozen. The refrigerator did not have a freezer portion in it.During an interview on 1/14/26 at 7:49 a.m., staff member F said she didn't think residents were supposed to have personal refrigerators in their rooms. Staff member F said maintaining the residents' personal refrigerators was the night nurse's responsibility. During an interview on 1/14/26 at 1:05 p.m., staff member H said she thought night staff were supposed to be monitoring resident fridge temperatures, and there should be a log on the side of the fridge. Staff member H stated, I don't think any residents have a personal fridge. I didn't think they were supposed to have them.During an interview on 1/14/26 at 1:26 p.m., staff member B said she thought the activity department was responsible for the oversight of the residents' personal refrigerators. Staff member B also said the night nurses were supposed to be monitoring the temperature of the fridge. During an interview on 1/14/26 at 2:58 p.m., staff member M said maintenance was supposed to oversee resident personal refrigerators, and the personal refrigerators should be cleaned per the residents' request. During an observation on 1/14/26 at 3:04 p.m., resident #31's personal refrigerator was observed to contain an open bag of Cheetos, three small containers of Folgers coffee, a bottle of salad dressing, chocolate candy bars, a mini DiGiorno pizza in the original packaging, which was observed earlier in the day, and other drinks and chips. The pizza had a best-by date of April 2025, and the box said to keep frozen. The fridge was still 46 degrees Fahrenheit. There was a foul odor upon opening the fridge door. During an interview on 1/15/26 at 8:30 a.m., staff member A said he was discussing this with the staff, and if the family was to bring in a fridge, it should be their responsibility to care for it. Staff member A stated, We will be working on the process moving forward. We knew the resident (#31) had a refrigerator, but did not have a process in place for its maintenance.During an interview on 1/15/26 at 8:37 a.m., staff member I said the resident came from the Assisted Living Facility, and the fridge was grandfathered in, so it was allowed. Staff member I said the fridge was not being maintained.Review of a facility document titled Resident Refrigerators with an implementation date of 4/11/25, showed: Policy: This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators.2. Designated facility (Nursing/Activities/Dietary) staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator.b. Temperatures will be at or below 41 degrees Fahrenheit, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulation).3. (Nursing/housekeeping) staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on observation and interview, the facility failed to employ a certified dietary manager or full-time dietician to oversee the dietary department duties. This deficient practice increased the risk of nutritional issues for all residents who received or will receive services from the dietary department. Findings include:During an interview on 1/12/26 at 12:49 p.m., staff member I stated the facility does not currently have anyone certified as the manager of the dietary department, and they do not have a full-time dietician. During an interview on 1/15/26 at 10:50 a.m., staff member K stated, I report to my manager, it is (staff member L), she is interim. I am not sure if she is certified. Our previous manager's last day was Christmas Eve. We have never had a formal training process. We are just thrown to the wolves when we start. That has always been a problem.During an interview on 1/15/26 at 10:51 a.m., staff member L stated, I have been filling in for dietary (oversight) since December 22nd. We are in the hiring process for a dietary manager. I had previous experience in printing the dietary tickets and some of the other duties. I am not certified, though.

Based on interview and record review, the facility failed to complete background checks on 6 (Staff IDs: O, L, R, N, M, and I) employees of 9 sampled employee files, prior to their start date in the facility. This deficient practice had the potential to put all residents at risk for abuse, neglect, exploitation, or misappropriation. Findings include:During an interview on 9/9/25 at 9:02 a.m., staff member H stated background checks on newly hired employees are completed upon hire and prior to the employee starting work. Staff member H reports it takes about 20 minutes for the background report to come back. Staff member H stated there was no exception to a background check being completed prior to employment.During an interview on 9/9/25 at 10:53 a.m., staff member H stated background checks were done after hire for staff members L and M. Staff member H stated both had worked shifts on the floor prior to the background check being completed. Staff member H stated that under previous Directors of Nursing there were times employees would start working before staff member H knew they had been hired. Staff member H stated this had been a problem in the past, but she believes they no longer have this issue. Staff member H stated staff member I was rehired 8/7/25 and a new background check was not on file since her (staff member I's) most recent hire date. During an interview on 9/10/25 at 12:16 p.m. staff member D stated background checks are completed upon hire and prior to the employee starting work on the floor. Staff member D stated this had been an issue identified previously at the facility. A review of a facility provided e-mail from staff member T, with a subject line, URGENT!!, dated 9/9/25 at 5:22 p.m., showed, We conduct background checks before they are hired. We evaluate them and compare the charges to the CMS regulations and make a decision based on that we do not do background checks after their date of higher unless something has occurred that would trigger us to do a background An example would be that someone is getting arrested or we got a report that something happened to an employee and so forth. [sic]A review of staff member O's employee file showed:-Date of hire 7/24/23.-Background check completed 11/20/24.A review of staff member L's employee file showed:-Date of hire 2/7/25.-Background check completed 3/6/25.A review of staff member R's employee file showed:-Date of hire 2/15/25.-Background check completed 9/9/25.A review of staff member N's employee file showed:-Date of hire 4/2/25.-Background check completed 4/8/25.A review of staff member M's employee file showed:-Date of hire 6/16/25.-Background check completed 9/8/25.A review of staff member I's employee file showed:-Date of re-hire 8/7/25.-Background check completed 2/6/25. A new background check was not completed upon rehire. A review of a facility policy titled, Background Screening Investigations, revised 3/19 showed: Policy StatementOur facility conducts employment background screening checks, reference checks and criminal investigation checks on all applicants for positions with direct access to residents ( direct access employees).Policy Interpretation and Implementation. 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. [sic]A review of a facility policy titled, Background Investigations, implemented 4/11/25 showed: Policy:Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company.Policy Explanation and Compliance Guidelines:1. The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied. [sic]

Based on interview and record review, the facility failed to report two allegations of abuse to the State Survey Agency within the required two-hour time frame for 1 (#1); and failed to report investigation findings to the State Survey Agency for 3 (#s 2, 5, and 10) of 12 sampled residents. Findings include: 1. Review of a facility reported incident, dated 4/15/25, showed an alleged incident of verbal abuse occurred between staff member N and resident #1 on 4/14/25. This incident was not reported to the State Survey Agency within the required two-hour time frame. Review of a facility reported incident, dated 7/13/25, showed an allegation of staff-to-resident abuse between staff member M and resident #1 on 7/12/25. This incident was not reported to the State Survey Agency within the required two-hour timeframe.During an interview on 9/10/25 at 10:05 a.m., staff member B stated she was notified of the incident on 7/13/25 at around 5:00 a.m. Staff member B stated she had notified staff member R, the building administrator at the time, but did not hear back from him until 9:00 a.m. Staff member B reported the incident after speaking with staff member R.During an interview on 9/10/25 at 10:25 a.m., staff member C stated that resident #1 will not always report an incident when it happened but would wait for a staff member she trusted to come on shift and then report the incident at that time. Staff member C stated that resident #1 had told staff member K about the incident, and staff member K reported it to staff member P. Staff member C stated she reported the incident as soon as she found out about it and started an investigation. Staff member C stated staff member P should have notified the administrative staff right away.2. Review of a facility reported incident, dated 1/20/25, showed, resident #2's wedding ring was allegedly missing. The findings were not submitted to the State Survey Agency.Review of a facility reported incident, dated 1/26/25, showed an incident involving an allegation of resident-to-resident abuse for resident #s 5 and 10. The findings were not submitted to the State Survey Agency until 2/12/25, 13 business days later.During an interview on 9/10/25 at 11:11 a.m., staff member D stated there had been multiple administrators in the building over the last couple months. Staff member D stated there have been issues with reporting and investigating incidents and those staff members are no longer there. Staff member D stated new policies were put into place in April 2025.Review of a facility document titled, Abuse Policy, undated, showed: . Abuse Identification and Reporting1.The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin. are reported immediately, but no later than 2 hours, after an allegation is made.Review of a facility document titled, Abuse, Neglect and Exploitation, dated 4/11/25, showed: . VII. Reporting/Response. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Not later than 24 hours if the events that cause the allegation do not involve abuse. [sic]

Based on interview and record review, the facility failed to fully investigate an abuse allegation for 5 (#s 4, 5, 7, 8, and 10) of 12 sampled residents. This deficient practice increased the risk of ongoing concerns of abuse due to the investigations being incomplete. Findings include:1. Review of a facility reported incident, dated 1/26/25, showed resident #5 and #10 were involved in an alleged resident-to-resident abuse incident. Resident #5 and #10 were in their room when a staff member heard resident #5 calling out, help, help, help. The staff member entered the room and the incident documentation showed, found [Resident #10] sitting in [Resident #5's wheelchair] pulling on [Resident #5's] arm. [Resident #5] stated he hit me. During an interview on 9/9/25 at 3:36 p.m., resident #10 could not recall the incident that occurred on 1/26/2025 with resident #5. Resident #5 was unable to be interviewed about the incidents he was involved in, as he had since passed away.Review of the facility reported abuse investigation documents, regarding resident #5 and resident #10, on 1/26/25, showed one staff interview, no resident interviews, or documentation of any ongoing monitoring after the alleged incident. The investigation was not thorough. 2. Review of a facility reported incident, dated 4/17/25, showed residents #7 and #8 were involved in an alleged incident involving resident-to-resident abuse. Resident #7 and #8 were in the dining room at the time of the incident. and the documentation showed, . [Resident #7] dropped a clothing protector on to the floor. [Resident #8] verbally instructed [Resident #7] to retrieve the item. When [Resident #7] did not comply, [Resident #8] picked up the protector and struck [Resident #7] in the face with it. Staff member I witnessed the event and immediately separated the two residents.During an interview on 9/9/25 at 1:22 p.m., resident #7 could not recall the incident with resident #8.During an interview on 9/9/25 at 2:03 p.m., resident #8 could not recall the incident with resident #7.Review of the facility reported abuse investigation documents, regarding resident #7 and resident #8, on 4/17/25, showed one staff interview, no resident interviews, or documentation of any ongoing monitoring after the alleged incident. The investigation was not thorough.3. Review of a facility reported incident, dated 5/23/25, showed resident #4 and #5 were involved in a verbal confrontation. Resident #4 was inside resident #5's room, and resident #4 told resident #5 to .Shut the F**K up, and was overheard by staff member U. Staff member U immediately instructed [Resident #4] to leave the room.On 9/9/25 at 9:40 a.m., resident #4 refused to speak with the surveyor. Review of the facility reported abuse investigation documents, regarding resident #4 and resident #5, on 5/23/25, showed one staff interview, no resident interviews, or documentation of any ongoing monitoring after the alleged incident. The investigation was not thorough.During an interview on 9/10/25 at 10:25 a.m., staff member C stated she had been involved with the investigation with all of the incidents involving resident #'s 4, 5, 7, 8, and 10. Staff member C stated she knew other resident and staff interviews had been conducted, but she could not locate the investigation information.During an interview on 9/10/25 at 4:12 p.m., staff member D stated she had looked though every file in staff member A's office and could not locate any of the complete investigations for the events identified as a concern. Staff member D stated she had provided what she could. Staff member D stated the investigations should have been done by staff member R or staff member S, both no longer work at the facility.Review of a facility document titled, Abuse Policy, undated, showed: . Abuse Investigations1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee shall conduct an investigation of the alleged incident.2. The Administrator or designee shall interview any staff members, residents, family members or any other who may have knowledge of the incident and document a summary of interviews completed. [sic]Review of a facility policy titled, Abuse, Neglect, Exploitation, dated 4/11/25 showed: . V. Investigation of Alleged Abuse, Neglect, and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.B. Written procedures for investigations include:. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations;. 6. Providing complete and thorough documentation of the investigation. [sic]

Based on interview and record review, the facility failed to ensure nursing staff followed professional standards for medication administration before administering a controlled substance for 1 (#3) of 12 sampled residents. This deficient practice resulted in the administration of a controlled substance without a current physician's order on three separate days. Findings include:During an interview on 9/9/25 at 12:40 p.m., staff member E stated that each resident had their own supply of resident-specific narcotic medications in the medication cart. When there was a change to the order or the medication was discontinued, the card should be pulled from the medication cart and destroyed. Staff member E stated this ensured the resident no longer received the medication once the medication was discontinued. During an interview on 9/9/25 at 12:51 p.m., staff member F stated that when a narcotic was discontinued, the medication card should be pulled from the locked narcotic box and destroyed by two nurses. Staff member F stated this was to help ensure the medication was not given after it was discontinued. During an interview on 9/9/25 at 2:00 p.m., staff member B stated she did not know why the medication card for resident #3 was not removed from the medication cart when it was discontinued or why the nurse involved gave the medication after it was discontinued. Staff member B stated the medication should not have been given after the discontinuation date. During an interview on 9/10/25 at 2:11 p.m., NF1 stated that a controlled substance should not be administered without a current physician's order, and when a narcotic was discontinued, the medication should have been removed from the medication cart and all of the pills destroyed with two nurses present. Record review of resident #3's physician orders, dated 2/18/25, showed, . LORazepam Oral Tablet 0.5 mg by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED (F41.9) until 02/24/2025 23:59 (11:59 p.m.) administer 0.5mg po Q HS x 1 week then D/C. [sic] Review of resident #3's Medication Administration Record, dated 2/1/25 to 2/28/25, showed:- . LORazepam Oral Tablet 0.5 mg by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED (F41.9) until 02/24/2025 23:59 (11:59 p.m.) administer 0.5mg po Q HS x 1 week then D/C. [sic]- The Medication Administration Record dated 2/1/25 to 2/28/25, showed the LORazepam was discontinued on 2/24/25.- The Medication Administration Record dated 2/1/25 to 2/28/25, showed there was no active physician's order for LORazepam after 2/24/25. Review of a facility provided Controlled Substance Log, dated 1/29/25, for resident #3 showed: - Lorazepam 0.5 mg was tracked on the Controlled Substance Log.- The medication was removed for administration on 2/25/25, 3/2/25, and 3/3/25, although the medication was discontinued on 2/24/25. Review of a facility provided document titled, Misappropriation Report, dated 4/12/25 showed:- The medication errors occurred on three separate days and were not identified by the facility until 4/12/25. This was over a month after the medication errors occurred. the Controlled Substance Log reveals that three additional doses were documented as administered after the discontinuation date:February 25, 2025 @ 1900 (7:00 p.m.)March 2, 2025 @ 1900 (7:00 p.m.)March 3, 2025 @ 2000 (8:00 p.m.) [sic]Review of a facility provided training document titled Controlled Substance Expectations updated 4/15/25, showed:- . When narcotics are discontinued/there is no longer an active order the DON/ADON needs to be alerted and the medication will be destroyed by 2 nurses.-- . It is unacceptable and a violation of the standard of practice to administer medications without an order.- . Rights of Medication Administration: .- . Right Documentation - .- . It is not acceptable to administer medications without a current order. [sic]Review of the facility policy titled, Medication Administration, adopted 12/19/16 showed:- . Medications must be administered in accordance with the orders. - . The individual administering the medication must verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. [sic]

Based on observation, interview, and record review, the facility failed to prevent Immediate Jeopardy level accidents and hazards by failing to effectively use a fall prevention program, root cause analysis, identify and implement appropriate interventions, and ensure staff used the interventions appropriately, for 3 (#s 7, 25, and 27) of 17 sampled residents. The on-going failure led to resident #25 sustaining a head laceration, requiring staples and an overnight stay in the hospital; resident #7 sustaining a head laceration requiring staples, a hip hematoma, and bruising on the left temple; and resident #27 sustaining a hematoma above the left eye and bloody nose. On 11/20/24 at 4:30 p.m., the facility Administrator and administrative staff were notified of an Immediate Jeopardy involving resident #25, pertaining to F689 - Free of Accident Hazards/supervision/devices. The facility provided an acceptable plan to remove the immediacy for the resident involved, and the time the immediacy was removed was at 12:00 p.m. on 11/21/24. The surveyors were onsite and verified the removal of immediacy by observations, interviews, and record reviews. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to H. Findings include: 1. During an observation and interview on 11/19/24 at 7:54 a.m., resident #25 stated he . had a fall and busted my head open, and had to get five staples. Resident #25 stated he fell in the bathroom. Resident #25 had black slip resistant tape on the floor in the bathroom, next to his bed, and in front of his lift recliner. Resident #25 stated his lift recliner was broken and had not worked over the past month. Resident #25 stated his reacher tool was on the other side of the room somewhere, but he did not know where. During an interview on 11/20/24 at 9:54 a.m., staff member M stated the interventions for resident #25 were grip tape on the floors, grip socks, and to provide call light education. Staff member M stated resident #25's recliner chair had been broken for at least two weeks. Staff member M stated she had reported the broken lift recliner to staff member C at least two weeks prior. Staff member M stated there were no other fall interventions for resident #25, and she was not aware of a toileting program for resident #25. During an interview on 11/20/24 at 10:11 a.m., staff member K stated she had been saying the lift recliner had only been working off and on for the past month. Staff member K reported the broken chair to staff member C. Staff member K stated she did not know resident #25 was on a toileting program. Staff member K stated resident #25 toileted himself. Review of resident #25's EHR reflected resident #25 was admitted to the facility on [DATE]. Review of resident #25's Fall documentation, dated 5/15/24 - 10/24/24, reflected: - Resident #25 fell on [DATE]. The nurse reported resident #25 stated he fell off the chair while attempting to change his clothes. No IDT notes were available per staff member C. - Resident #25 fell on [DATE], after walking from the bathroom to his chair. Resident #25 slid off the chair while attempting to sit. No nurses' notes or IDT notes were available per staff member C. - Resident #25 fell on [DATE] while walking from the bathroom to his chair. No IDT notes were available per staff member C. - Resident #25 fell on [DATE] while in the bathroom, toileting himself. No IDT notes were available per staff member C. - Resident #25 fell on [DATE] while attempting to get out of bed and urinated prior to reaching the bathroom or having assistance. Non-skid socks were the intervention listed after the fall. No IDT notes were available per staff member C. - Resident #25 fell on [DATE] while in the bathroom. Resident #25 stated the toilet riser was not bolted down and it slid off the toilet. IDT interventions listed included a lift recliner and toilet riser that would bolt down. - Resident #25 fell on [DATE] while in the shower room with the CNA. Resident #25 attempted to sit when no chair was behind him and fell to the floor. The IDT re-educated the CNA on placing a chair behind the resident before the resident sat down. - Resident #25 fell on [DATE] while in the bathroom. Resident #25 stated he was changing his underwear when he became dizzy and fell . Resident #25 stated he was trying to stand up and could not grip the floor. This fall resulted in a head laceration, requiring five staples in the emergency room , and an overnight stay in the hospital for observation and tests. IDT interventions listed included a room move closer to the nurse's station, a toileting program which would prompt him to attempt to toilet at least every few hours, and he agreed to push the call light when he needed to use the restroom. - Resident #25 fell twice on 9/27/24, once at 3:25 a.m. and again at 12:54 p.m. while in the bathroom. The nurse reported the resident #25 stated the floor was too slick. The nurse reported the non-skid strips had not yet been placed in the resident's new room. Resident #25 changed rooms on 9/24/24 for closer observation. IDT interventions listed included replacing the non-skid strips to floor in the bathroom, and the resident's room was rearranged to move his lift recliner closer to the bathroom. The IDT note of investigation was dated 10/24/24 for the second fall on 9/27/24. - Resident #25 fell on [DATE] while attempting to get from his lift chair to his bed. Resident #25 stated his legs gave out. IDT interventions listed included preventative measures that were in his previous room were put in place in new room, re-educated on call light use, wearing non-skid socks, and use his hemi-walker. - Resident #25 fell on [DATE] while getting his clothes from the closet resulting in an abrasion to his left shoulder, and a small laceration to his left elbow. IDT interventions listed included re-educating the resident on call light use, wearing non-skid socks, and to use his hemi-walker. Review of resident #25's Fall risk assessment, dated 5/4/24 - 10/18/24, reflected resident #25 was at high risk for falls. Review of resident #25's care plan, dated 5/4/24 - 11/20/24, reflected the following interventions: - Resident #25 was at risk for falls related to left-sided weakness, - Call light needed to be within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance with a date initiated of 5/14/24, - Resident #25 required an unknown amount of assistance with bed mobility and bathing/showering, toileting use, transfers, and eating. The ADL care plan, initiated on 10/25/24, had a standardized template and was not completed with resident-specific information, - Resident #25 required a sit-to-stand recliner for rising assistance with a date initiated of 9/18/24, - Resident #25 was to have set interval toileting and/or continence programs; providing easy access to urinals and bedpans with a date initiated of 10/25/24, and - Resident #25 was to have a reacher tool for assistance with picking items up from the floor with a date initiated of 7/8/24. Review of a hand-written facility document, dated 9/24/24, in the CNA communication log, was a note that reflected: - . We are also implementing a toileting program for him. Every 2 hours ask him to use the bathroom and standby if he needs assistance. We are attempting to prevent further falls. He agreed to the above plan. During an interview on 11/20/24 at 5:31 p.m., staff member F stated resident #25 was stubborn, and he should be on a toileting program since he didn't use his call light and could not use the urinal successfully. Staff member F stated, He's (resident #25) a bit of a sticky-wicket, but we should be trying everything we can to prevent the falls. 2. During an observation on 11/19/24 at 8:27 a.m., resident #7 was in her room, in a wheelchair. The call light was on the floor, but under her bed. There were two large black trash bags on floor in her room. Resident #7 was getting up from her wheelchair and using furniture to attempt to walk in her room. The space was very tight, between the end of the bed and the wall, and the wheelchair would not fit to reach her belongings on the far side of her bed. Resident #7 attempted to maneuver her wheelchair around the walker, a chair, and black bags on the floor, but she became stuck between the end of the bed and the wall. Resident #7 was sitting in the wheelchair with blankets piled on her lap, and unable to move her wheelchair. Resident #7 was calling out for help. Facility staff did not hear resident #7 calling out. This surveyor notified staff member N that the resident was calling for help and unable to reach a call light. Staff member N assisted resident #7 to free her wheelchair. Review of resident #7's EHR reflected resident #7 was admitted to the facility on [DATE]. Review of resident #7's fall investigations, dated 11/22/23 - 8/14/24, reflected: - Resident #7 fell on [DATE]. The nurse reported resident #7 stated she slid off the bed while putting on her pants. No IDT notes were available, per staff member C. - Resident #7 fell on [DATE] while getting her clothing, resulting in a head laceration requiring five staples in the emergency room , a hip hematoma, and bruising on the left temple. No IDT notes were available, per staff member C. Review of resident #7's BIMS assessment(s), dated 2/22/24 - 8/27/24, reflected resident #7 had severe cognitive impairment. Review of resident #7's Fall Risk Assessment(s), dated 8/30/23 - 10/18/24, reflected resident #7 was at moderate to high risk of falls. Review of resident #7's care plan, dated 3/13/23 - 11/20/24, reflected: - Resident #7 was at high risk for falls related to incontinence, gait balance, and weakness, - Call light needed to be within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, - Resident #7 required limited to extensive assistance of one person with bed mobility, transfers, and ambulation, - Resident #7's care plan did not include a comprehensive fall care plan until after resident #7's second fall on 12/17/23, - Resident #7's care plan did not include any interventions related to dressing assistance. 3. During an observation and interview on 11/19/24 at 10:04 a.m., resident #27 stated he had a fall where he slid off the mattress resulting in a knot above his eye and a bloody nose. Resident #27 stated he slid out of wheelchair on another occasion. Resident #27's call light was clipped to the wall above his bed, out of reach. Resident #27 was sitting in his wheelchair in his room. Resident #27 stated he did not know where his reacher tool was located. Review of resident #27's EHR reflected resident #27 was admitted to the facility on [DATE]. Review of resident #27's fall investigations, dated 2/1/24 - 5/13/24, reflected: - Resident #27 fell on [DATE] while attempting to pick up papers he dropped on the floor. No IDT notes were available per staff member C. - Resident #27 fell on [DATE] having slid out of his wheelchair. No IDT notes were available per staff member C. - Resident #27 fell on [DATE] with resident #27 found on the floor. The floor and bed both soaked in urine and the bed mattress sliding off the frame. This fall resulted in a hematoma above the left eye and a bloody nose. No IDT notes were available per staff member C. - Resident #27 fell on [DATE] having fallen asleep and slid out of his wheelchair. No IDT notes were available per staff member C. - Resident #27 fell on [DATE] when he attempted to pick up the remote from the floor and tipped over his wheelchair. No IDT notes were available per staff member C. - Resident #27 fell on [DATE] when he attempted to pull up his pants in the bathroom. The IDT team interventions listed resident education to use the call light, resident to be placed in bed when in his room. Review of resident #27's care plan, dated 2/2/24 - 11/20/24, reflected the following interventions: - Resident #27 required an unknown amount of assistance with bed mobility, bathing/showering, dressing, personal hygiene, toileting use, transfers, and eating. The ADL care plan, initiated on 2/26/24, had a standardized template which was not completed with resident-specific information, - Resident #27 was to be oriented to the call light, the call light was to be kept within reach, and staff were to encourage him to use it for assistance as needed, and this was initiated on 2/26/24, - Resident #27 was to have a reacher tool available to pick up items off the floor with a date initiated of 3/4/24. During an interview on 11/20/24 at 10:16 a.m., with staff members B and C, staff member C stated she did not know why toileting and getting his clothing out were not considered earlier with resident #25's falls, and the IDT was trying to figure out their (fall investigation) processes. Staff member C stated resident #25 did not use his call light, and the IDT was waiting for the regional support team to train the IDT related to fall investigations and interventions. Staff member B stated the facility was supposed to have training in April 2024, but the regional support person was pulled to another facility, so the training occurred in October 2024. Staff member B and C both reported they could not speak to falls prior to May 2024, because they were not in the facility at that time. Staff member B stated they recognized the facility had an issue with care plans and falls and started a PIP but were waiting for the regional support training to start the PIP. Staff member C stated she was aware the lift chair was having problems but thought the chair had been fixed. Staff member C stated she was not aware the CNAs or nurses were not aware of the toileting program or offering resident #25 toileting assistance every two hours. Review of the facility document titled, Incidents by Type Fall Report, dated 11/18/23 - 11/18/24, reflected a total of 188 falls. Of the 188 total falls, 21 residents accounted for 150 falls or 79% of the total falls. Review of the facility's policy, Fall-Clinical Protocol, dated September 2012, reflected: - . 3. For an individual who has fallen, the interdisciplinary team will complete an evaluation to identify the root cause and recommend appropriate new interventions to address risk factors of falling. - . 8. If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.

Based on interview and record review, the facility failed to ensure the director of food and nutrition services met the education qualifications required by CMS for a food service director, which increased the risk of residents being affected negatively since the director provided oversight for the entire dietary department. Findings include: During an interview on 11/19/24 at 12:13 p.m., staff member I stated staff member B told him to complete the first eight hour course of training and not to worry about the 16 hour training course until later. During an interview on 11/20/24 at 8:39 a.m., staff member D stated no policies specific to the dietary manager training requirements were available, and the facility used the CMS guidelines. During an interview on 11/20/24 at 9:41 a.m., staff member B stated staff member I did not have any further training in the Food Service Manager program. Staff member B stated staff member I had completed the first eight hours of the training course and did not realize he had the second part to complete. Staff member B stated no other staff in the building had completed the dietary manager certification requirements. Review of staff member I's employee file reflected staff member I was hired on 8/28/24 and had not completed the dietary manager certification training.

Based on interview and record review, the facility administrator failed to provide adequate oversight and training for the Administrator in Training (AIT), and the DON, with regard to the responsibilities of the interdiscipliary team reviews and processes to be used, and how to conduct a performance improvement project related to the fall prevention protocol, for 3 (#s 7, 25, and 27) for 18 sampled residents; and the administrator failed to ensure the facility employed a certified Infection Preventionist, and failed to ensure the facility employed a qualified Dietary Manager which may affect any resident at the facility. Findings include: 1. Review of resident #25's EHR showed the resident sustained 12 falls between his admission on 5/2/24, and the start of the survey, on 11/18/24. The IDT did not address the first five falls sustained by the resident between 5/15/24 and 9/16/24. Resident #25 sustained a fall on 9/17/24 which necessitated an overnight hospital stay for monitoring and staples to a head laceration. The only care plan revision, other than the fall prevention interventions initiated at the time of his admission, showed the only revision to the care plan was the addition of a reacher tool on 7/8/24 and non-skid socks after a fall on 8/23/24. IDT notes between 9/17/24 and 11/18/24 failed to show an effective evaluation of the root causes of the resident's repeated falls. Review of resident #7's EHR showed the resident sustained two falls between 11/22/23 and 12/17/23, resulting in a head laceration, requiring staples and bruising to her left hip. The resident had severe cognitive impairment and was at a high risk for falls. The resident's care plan, managed by the IDT, failed to show a fall prevention plan until after the resident's third fall on 1/13/24. IDT documentation failed to show an effective evaluation of the root causes for the resident's repeated falls. Review of resident #27's EHR showed the resident was admitted to the facility on [DATE] and sustained six falls between 2/1/24 and 5/13/24. There were no IDT notes until 5/13/24. IDT documentation failed to show an effective evaluation of the root causes for the resident's repeated falls. See F689 Free OfAccidents and Hazards/supervision/devices for additional details regarding resident #s 7, 25, and 27's falls. During an interview on 11/20/24 at 10:16 a.m., with staff members B and C, staff member C stated the IDT was trying to figure out their processes, and they were waiting for regional support to provide fall prevention training. Staff member B stated the training was supposed to occur in April (2024), but did not happen until September of 2024. Staff member B stated the facility recognized they had issues with fall prevention and care plan management. During an interview on 11/21/24 at 8:22 a.m., staff member A stated the process of fall management started with a resident falling. The staff member who witnessed the fall or found the resident was responsible for reporting the incident to the nurse. The nurse did an assessment and notified the administrator and the DON. Staff member A stated the IDT was responsible for doing a root cause analysis and determining what interventions would be implemented. Staff member A stated staff member P (regional support) did education in September (2024) regarding fall management. 2. During an interview on 11/21/24 at 3:25 p.m., staff member C stated she was just beginning to learn about infection control and prevention and was not familiar with any specific antibiotic management algorithms for monitoring appropriate antibiotic use. Staff member C stated staff member F was, not following McGreer Criteria (antibiotic use protocol). Staff member C also stated the facility had difficulty obtaining urine culture results and had to call the hospital several times to obtain most laboratory test results. See F882 Infection Preventionist Qualifications/role for additional details regarding the qualifications of the Infection Preventionist. 3. During an interview on 11/20/24 at 9:41 a.m., staff member B stated staff member I did not have any further training in the Food Service Manager program. Staff member B stated staff member I had completed the first eight hours of the course and did not realize he had the second part to complete. Staff member B stated no other staff in the building had completed the dietary manager certification requirements. See F801 Qualified Dietary Staff for additional details regarding the qualifications of the Dietary Manager.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist was qualified through an approved certification program prior to assuming the role of Infection Preventionist. The deficient practice had the potential to affect all residents receiving care in the facility. Findings include: During an interview on 11/18/24 at 3:48 p.m., staff member A stated the facility's Infection Preventionist resigned approximately one week earlier, and staff member C was in the process of taking the class. Staff member A stated the facility did not have a certified infection preventionist currently. During an interview on 11/21/24 at 3:25 p.m., staff member C stated she had only been in the Infection Preventionist role for about one week. Staff member C stated she was still learning and had not yet completed the infection preventionist training. A request for the Infection Preventionist certificate of training was requested on 11/18/24. No documentation was received by the end of the survey.

Based on observation, interview, and record review, the facility staff failed to serve food in accordance with professional standards for food service safety, by not wearing hairnets, while in food service areas. Failure to uphold food safety may affect any resident at the facility. Findings include: During an observation on 11/18/24 at 2:51 p.m., staff member O had no hairnet on while walking through the kitchen while the cook was making meatballs. Staff member J was not wearing a hairnet while walking through the kitchen and working on stocking directly next to the prep table, where the cook was preparing meatballs. During an observation on 11/18/24 at 5:12 p.m., staff member J was prepping meal trays (for another location), and was not wearing a hairnet. She had braids hanging down past her shoulders in front. The ends of the braids hung over the food when she leaned forward. During an observation on 11/19/24 at 8:15 a.m., staff member J had braids hanging down past her shoulders, in the front, while prepping trays in the kitchen. Hair from the end of the braids was nearly touching the trays while she was bent over reaching for the other trays. During an interview on 11/19/24 at 12:13 p.m., staff member I stated all staff entering the kitchen were required to wear a hairnet covering all hair. Staff member I stated the hairnets and beard nets were kept in the top drawer of his desk, by the back door. Staff member I stated he was working to get hairnet dispensers on the other doors to the kitchen since staff from other departments enter from those doors. Review of a facility policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated October 2017, reflected: - . 12. Hairnets or caps/hats and beard restraints (as indicated) must be worn to keep body hair from contacting exposed food, clean equipment, utensils, and linens.

Based on observation, interview, and record review, the facility failed to develop and implement a facility policy which contained the name and contact information for the grievance official; failed to provide forms within reach of residents who were unable to stand to reach the grievance forms; and failed to provide residents with the option to file grievances anonymously, for 4 (#s 15, 22, 25, and 32) of 18 sampled residents. Findings include: During an interview on 11/19/24 at 7:57 a.m., resident #25 stated he was upset the facility management had not ordered his electric wheelchair. Resident #25 stated he was concerned the staff would be mad if he filed a complaint about them. Resident #25 stated he did not know how to file a grievance anonymously. During an interview on 11/19/24 at 3:24 p.m., resident #22 stated the resident council met monthly, and he would complete the grievance forms on behalf of the resident council, for any concerns brought forward at the meeting. Resident #22 stated the facility provided grievance forms near the nurse's station, but there was not a way to file a grievance anonymously. During an interview on 11/19/24 at 3:25 p.m., resident #15 stated the facility did not provide a way for residents to file grievances anonymously. Resident #15 stated she would like to file anonymously but did not know where to get a form. During an interview on 11/19/24 at 3:26 p.m., resident #32 stated the facility did not provide a way for residents to file grievances anonymously. During an observation and interview on 11/20/24 at 3:03 p.m., staff member C stated the facility did not have a way for residents to file a grievance anonymously or have a box for residents to place grievances in anonymously. Staff member C stated residents would need to give grievances to the staff to be turned into a supervisor or social services. Staff member C stated the only two places to obtain a grievance form were the beginning of each hall near the nurse's station. The yellow grievance forms were in a wall-mounted letter hanger, at standing shoulder level height. The forms were not reachable by a resident in a wheelchair. During the walkthrough with staff member C, grievance return boxes were not found on any facility unit. Review of a facility policy titled, Filing Grievances/Complaints, dated April 2008, showed, . 3.Residents or the resident representative also has the right to file a grievance anonymously. The policy failed to include the name and contact information for the grievance official.

Based on observation, interview, and record review, the facility failed to ensure residents were offered hand hygiene before meals in the dining room for 1 (#22) of 18 sampled residents; and failed to follow appropriate infection control practices for proper hand hygiene between resident contact for 4 (#s 2, 19, 25, and 32) of 5 sampled residents for medication administration. Findings include: 1. During an observation in the dining room on 11/19/24 at 8:06 a.m., the residents were being brought down to the dining room and set-up at tables. Residents were offered a clothing protector and offered a drink of their choice. The meal trays were then being served by staff at the kitchen window. Residents were not offered the option to clean their hands before they received their meals. During an interview on 11/19/24 at 8:16 a.m., resident #22 stated the staff did not offer hand hygiene to the residents. During an interview on 11/19/24 at 9:35 a.m., staff member K stated hand hygiene was, offered sometimes, but we forget most of the time to be honest. And it's hard to get patients up to the sink, especially if they are wheelchair bound. They don't offer another way to wash their hands in the dining room. During an interview on 11/19/24 at 12:13 p.m., staff member I stated there was nowhere except the sink for residents to perform hand hygiene before meals. During an interview on 11/20/24 at 8:39 a.m., staff member D stated the facility's policy on hand hygiene for residents was the same as the hand hygiene for staff. 48268 2. During an observation on 11/19/24, between 7:56 a.m. and 9:25 a.m., staff member H was observed for medication preparation and administration. A total of five resident medication administrations were observed. Hand hygiene was not performed between residents for four of the five medication administration observations, which were #s 2, 19, 25, and 32. During an interview on 11/21/24 at 11:12 a.m., staff member C stated hand hygiene was required by all staff before and after resident contact to prevent infection. Review of facility document titled, Handwashing/Hand Hygiene, dated August 2014, showed the following: - . 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. - 4. Residents, family members and/or visitors will be encouraged to practice hand hygiene .

Based on observation, interview, and record review, the facility failed to ensure a resident was weighed after an illness and hospitalization , for the identification of weight changes. This deficient practice delayed the identification of the resident's severe weight loss, for 1 (#5) of 17 sampled residents. Findings include: Review of resident #5's nursing progress notes, dated October 2023 - November 2023, showed the resident had been very ill for several weeks with Covid-19. Review of resident #5's hospital summary, dated 11/9/23-11/13/23, showed resident #5 had been admitted for UTI, Atypical Pneumonia, Failure to Thrive, and Anemia. Her weight on her 11/9/23 hospital admission was 123 lbs. Review of resident #5's Weight Summary showed her last documented weight in the facility was on 10/5/23. She weighed 148.5 lbs. She had no documented weight for the month of November. During an interview on 11/20/23 at 10:38 a.m., staff member A stated a Significant Change MDS had been started after resident #5 had been very ill the past month, and there had been concern she would not recover. She was not aware the resident had not been weighed since returning to the facility on [DATE]. During an interview on 11/20/23 at 11:38 a.m., staff member D stated she had asked for resident #5's weight a week ago. During an observation on 11/20/23 at 12:08 p.m., resident #5 was weighed by two CNAs. She weighed 125.5 lbs. This represented a 15.5% severe loss in under two months.

Based on interview and record review, the facility failed ensure adequate monitoring, glucose administration, and insulin parameters were in place for diabetic residents for 1 (#27) of 1 sampled resident. This deficient practice had the potential to affect any resident receiving insulin. During observations on 11/18/23 - 11/19/23, resident #27 was not observed to get out of bed or join any of the meals. Trays left at her bedside went untouched. During an observation and interview on 11/19/23 at 4:42 p.m., resident #27 was lying in bed and stated she hadn't had much to eat and was very sleepy. Review of resident #27's MAR, dated November 2023, showed she had an order for Blood Glucose AC and HS before meals and at bedtime related to .Diabetes mellitus with hyperosmolarity with coma. There were no high or low physician notification parameters. Review of resident #27's MAR showed her blood glucose on 11/19/23 was: - 57 at the 8 a.m. check - 63 at the noon check. There was no documentation of interventions for the low values. There was no documented food or fluid intake for the time period. Review of resident #27's MAR, dated November 2023, showed she was receiving for Lantus SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ML .Inject 22 unit subcutaneously at bedtime. There were no parameters for the insulin administration. During an interview on 11/19/23 at 4:59 p.m., staff member E stated she did not know what the specific hypoglycemia protocol was, and physician notification was different depending on the specific resident. During an observation and interview 11/19/23 at 5:02 p.m., staff member B showed the hypoglycemia management policy taped to cupboard in the medication room. Staff member B stated according to the policy, for resident #27's morning blood sugars, the resident should have been given some juice, her physician notified, and these steps documented. Staff member B stated they should also call the physician and get parameters for the resident's nighttime insulin. Review of the Management of Hypoglycemia policy, revision date November 2020, showed: For Level 1 hypoglycemia (<70 mg/dl): a. Give the resident an oral form of rapidly absorbed glucose (15-20 grams); b. Notify the provider immediately . d. Recheck blood glucose in 15 minutes .

Based on observation, record review and interview, the facility failed to recognize and anticipate when a resident experienced pain; failed to evaluate the root cause(s) of pain; and failed to utilize available medications ordered by the physician to treat the resident's pain, for a resident who had cognitive deficits, and could not always voice pain or explain his needs effectively for one (#10); and failed to properly document the monitoring, status, and interventions for treatment of [REDACTED].#1); and failed to monitor and document the status of a drained furuncle, failed to complete a physician ordered wound culture, or that a wound to the scrotum was monitored, the status was documented, or that the physician was notified for one (#2) out of 10 sampled residents. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged the facility on 10/6/14. Review of the resident's Significant Change assessment, with an ARD of 9/16/14, showed the resident had unclear speech, and scored a three on the Brief Interview for Mental Status, showing the resident had severe cognitive impairment. The resident was coded as extensive assistance of two or more people. Section J0300 was coded as a No (0), when asked if he had pain or hurting at any time in the last five days. Section J0800, Staff Assessment for Pain, was incomplete. The resident had not participated in physical or occupational therapy programs. A review of the resident's nursing progress notes, and medication administration notes showed the resident had 11 falls between 6/3/14 and 10/1/14. The resident received injuries during eight of the falls which included two head injuries. The first fall occurred on 6/13/14 when the resident was found on the floor after attempting to transfer to the bathroom. After the fall, the resident was assessed by the nurse and had redness to the right buttock. The nursing notes showed the resident complained of back pain intermittently after this date. The nurse documented the resident first voiced pain to the right hip on 6/20/14. The 2nd fall occurred on 8/15/14. The resident was found on the floor with reddened areas on the temple, the left outer hip and the left outer knee. The resident had a third fall on 8/16/14 which resulted in a reddened right knee. After these falls, the resident's behaviors began to increase, as well as his confusion. -8/18/14 The resident complained of right hip pain at 4:35 a.m. The nurse documented that the resident was medicated with "Tylenol x 1 without much sustained release." -8/19/14 At 4:59 a.m., the resident complained of right hip pain. The nurse repositioned the resident and offered a warm blanket for his hip. Up to this point, the medical record lacked evidence for any follow up action taken to identify a potential injury to the hip. The resident was restless stating he did not want to die, and praying he would not die that day. The nurse documented the resident had difficulty sleeping. -8/20/14 The resident was unable to be redirected, reassured, or consoled. He continued to yell out while staff attempted to talk to him to determine his needs. -8/22/14 The resident had three falls this day. He landed on the fall pad and the floor without a fall pad. Bruising from prior falls was noted during the physical assessment. -8/29/14 The nurse documented the resident was restless and called out frequently, but unable to state his needs. The resident voiced he had pain in the right hip and the nurse applied ointment and a warm blanket with "some relief." -8/31/14 The resident complained of chronic right hip pain. The resident continued to call out for help, but was unable to tell staff what his needs were due to cognitive deficits. The nurse applied pain relief cream and a hot pack to the area. -9/2/14 The nurse documented the CNA reported the resident would not bear weight when transferring with assistance. The documentation lacked evidence for any action taken or interventions provided for the change in weight bearing status and the resident had continued right hip pain. -9/3/14 A new physician's orders [REDACTED]. -9/8/14 The nurse documented, "(Resident) seems to not get any sleep at all during the noc (night) shift. He is having behavior problems possibly due to his pain and the resulting lack of sleep. Perhaps with medication assisted sleep, his behavior will get better if he gets a prescription for more therapeutic pain med's," and the resident cried out constantly through the shift. He did not seem to get relief from the medications, [MEDICATION NAME] or Tylenol. The nurse went on to document that the resident was not able to function daily without pain. -9/12/14 The nurse documented on the continued right hip pain and the resident was given [MEDICATION NAME] to alter his comfort. The nurse wrote, "It is not believed this is a new pain for the resident." Later in the day, the resident was calling out for help most of the shift, stating he did not want to die, and the nurse wrote, "PRN [MEDICATION NAME] seem (sic) only to help pain a little bit." -9/15/14 the resident continued to be "unable to bear much weight if any." For the days following, the resident began to exhibit a decline in health until discharge. A review of the resident's physician progress notes [REDACTED]. When assessed, the resident had fair range of motion, but tenderness in the right hip area. The physician documented the initiation of two medications, one for pain and one for sleep. A review of the Resident's Medication Administration Records for June-September 2014 showed a lack of evidence that the resident was offered and given the physician ordered medication to treat his pain, and that medications to treat the resident's behaviors were initiated prior to an increase in dosage or the utilization of all doses available for the treatment of [REDACTED]. June 2014 Tylenol- 51 of 65 opportunities available were not given for the treatment of [REDACTED]. July 2014 Tylenol- 80 of the 93 opportunities for available medication were not given. [MEDICATION NAME] Sodium, 220 mg, one tablet in the morning, and two tablets at bedtime was ordered on [DATE] for arthritic pain. The medication did not change the frequency of pain complaints. August 2014 Tylenol- 76 of the 93 opportunities for available medication were not given. September 2014 Tylenol- 86 of 90 opportunities were not given to treat pain. [MEDICATION NAME] was not given for 119 of the 126 opportunities available to treat the resident's pain symptoms or complaints. The [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, was initiated on 9/10/14 and was to be taken every four hours as needed for pain. Alternate medications to treat the resident's symptoms included: [MEDICATION NAME] 15 mg, at bedtime, was ordered for [MEDICAL CONDITION] on 7/30/14. [MEDICATION NAME] 125 mg, twice a day, was ordered on [DATE] related to dementia with behavioral disturbances. [MEDICATION NAME] 0.5 mg, one tablet every eight hours as needed for anxiety, was ordered on [DATE]. A review of the resident's care plan showed a problem for Comfort/Pain was initiated on 6/16/14. The problem showed, "When I am in pain and cannot tell you, I exhibit the following cues: ywelling (sic) out, agitated, unable to console." Staff interventions included, "Evaluate pain when (Resident) starts to exhibit agitation or restlessness, and initiates (sic) pain management per MD order. Staff acknowledge (Resident's) inability to adequately recognize pain as cause of behavior." A review of handwritten notes to the physician was provided on 5/7/15. The listing included entries for the resident which were: 7/29/14-Resident still very depressed, having a difficult time sleeping and frequently anxious. 8/4/14-The resident complained of right hip pain at night. Stated he could not get comfortable and Tylenol was not effective. The nurse requested a stronger pain medication. No changes were made. 8/10/14-Resident was crying throughout the day. Does not know what he wants. Sleeping medication was not effective. No changes were made. 8/20/14-The resident was continuing to call out and have restlessness. He continued to complain of right hip pain, despite the medications taken. The nurse wrote the resident was, "crying often." The physician's response was "Need psych." No changes were made. 9/7/14-The nurse documented the resident needed a higher level of pain control medication, antianxiety medication, and documented, "He has remained the same since admission, please help him with his pain." 9/24/14-The resident had a fall and complaint of right hip pain, but moves the right leg well. A review of the facility's Pain Management Protocol and policies, showed the use of non medicinal interventions, Pain Assessment Guidelines, Pain Assessment for Advanced Dementia patients, pain rating scales, and a Behavioral Observation Scale for a resident who was unable to communicate. The Pain Management Guideline form showed the medication concepts the facility utilized, to include identifying pain equability, use of scheduled dosing over PRN dosages and use, and how PRN medications were given as "rescue" doses for breakthrough pain situations and are ordered with long-acting opioids. During an interview on 5/7/15 at 10:30 a.m., staff member D, care manager, stated she would observe the resident for grimacing, favoring a body part, decline in eating or activity attendance, and observe if the resident was calm or agitated to determine if the resident was in pain. Staff member D stated all narcotics provided required the nurse to assess the resident's pain level at the time the medication was given. During an interview on 5/7/15 at 11:00 a.m., staff member B, director of nursing, stated the facility was in the process of changing the medical director for the facility, and discussed past difficulties with obtaining pain management interventions for the residents. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a wound notification form on 11/3/14 showed the resident was discovered to have a corn or a stage II ulcer on his left second toe. A review of the resident's care plan lacked any evidence of [MEDICAL CONDITION] on the left toe on 11/3/14. Review of the e-z graph wound assessment tools for 3/18/15 reflected skin wounds on the right and left foot. The wounds on the left foot were on the great toe and the third toe. There were no previous descriptions of the wounds on the left foot in the nurse's notes or the e-z graph wound assessment tools. There was no evidence the facility had assessed, monitored, had any interventions in place, or had any physician orders [REDACTED]. During an observation on 5/6/15 at 2:50 p.m., resident #1 was taken to his room by staff member C, RN, to view his left toes. The resident was observed to have a scabbed area on the tip of his left great toe. In an interview on 5/6/15 at 2:56 p.m., regarding the lack of wound assessment for the left foot, staff member C stated it was a process problem they were having. 3. Resident #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing progress note, dated 9/12/14, reflected the resident had a raised, white area on the right inner thigh by the scrotal area. The resident complained of pain when the area was touched and when the area was touched, some white, thick discharge drained from the area. The discharge was foul smelling. There was no documentation in the resident's chart that the MD was notified and if the area was monitored or observed for worsening infection or required treatment. During an interview on 5/6/15 at 5:15 p.m., staff member E, regional director of clinical operations, stated there was no documentation on the scrotal wound discovered on 9/12/14. Review of the nursing progress note, dated 9/23/14, reflected the resident had a raised pus filled area to the right buttock and was warm to the touch with a reddened area. Warm compression was applied and the area began draining with slight pressure. The drainage amount was approximately 10 cc. A note was left for the MD. Review of the physician progress notes [REDACTED]. The physician plan was for the nurse to observe for worsening infection. The medical record lacked evidence for the monitoring and status of the drained furuncle and/or potential identification of worsening infection. Review of the physician's orders [REDACTED]. There was no documentation in the resident's chart that this was completed and results of a wound culture were not found.

Based on interview and record review, the facility failed to use a systematic-resident directed approach to adequately evaluate and anticipate a resident's needs, for a resident who had repeated falls, who voiced recurrent pain to the hip and had a decline in weight bearing status. Specifically, the resident's fall history was not utilized to identify fall patterns, implement interventions based on the resident's needs and preferences, and identify potential causal factors for the repeated falls to ensure future safety; and failed to document the interventions attempted in the clinical record for one (#10) of 10 sampled residents. Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. A review of the resident's nursing progress notes showed the resident had 11 falls between [DATE] and [DATE]. The resident received injuries during eight of the falls including two head injuries, bruises, abrasions, skin tears and several injuries resulted in pain after the fall. All of the falls were unwitnessed. -The first fall occurred on [DATE] at 6:35 a.m. The resident was found on the floor. He was trying to go to the bathroom, and was looking for his wife. Review of the incident report reflected "Full body assessment done, no apparent injuries, no bumps, bruises, or skin tears. Denies pain." The resident was oriented to person only, anxious and restless. The documentation stated that "PT (physical therapist) worked with the resident and he seemed fine." -The second fall occurred on [DATE] at 3:40 a.m. The resident was found on the floor after he attempted to roll over in bed. The fall resulted in a reddened area on the temple, as well as the left outer hip and the left outer knee. The nurse documented the resident had no increase in pain with the exam or with position change. The intervention for future prevention of falls included the placement of bumper pads on the bed, but the resident refused these, so they were removed. -The resident had a third fall on [DATE] at 4:20 a.m., which resulted in a reddened right knee. The resident stated he slid off the bed. This was the third fall that occurred between the hours of 3:40 a.m. and 6:35 a.m. The resident was assessed and put back into bed with the bumper pads returned to the bed. The resident was angry about the use of the bolster pads and the nurse discussed the need for safety. The resident then agreed to the use of the pads. The investigation did not include why the resident slid off the bed. -On [DATE], the nursing progress notes showed the resident complained of right hip pain at 4:35 a.m. The nurse documented, "Resident has not rested well tonight." She stated he was calling out "Please help me." The nurse administered "Tylenol x1" without much sustained release. The documentation does not show action taken on the hip pain or if the nurse notified the physician of the concern. -On [DATE] at 4:59 a.m., the resident complained of right hip pain. The nurse repositioned the resident and offered a warm blanket for pain. The medical record lacked evidence of action taken to identify the cause of the pain. The resident was restless, stating "he doesn't want to die today." On [DATE], the resident had three falls which included: At 00:54 a.m., the resident was found on the floor calling out for help. He landed on his left shoulder and hit his head, which caused redness. He also had an abrasion to the left knee. The resident attempted to crawl over the bolster pads and fell to the floor. The bolster pads were replaced, and the resident was returned to bed. A fall mat was placed next to the bed. At 2:42 a.m. the resident was calling out for help and found on the floor. He was on the opposite side of the bed from where the fall mat was placed earlier in the evening. The resident had attempted to climb over the bolster pads and fell from the bed. The nurse removed the bolster pads from the bed. The nurse noted after the fall, the resident had light purple/red area to the front of his forehead. At 11:52 p.m., the resident fell from the bed. He was on the fall mat next to the bed. The nurse identified the staff had replaced the bolster pads to the bed and the resident attempted to climb over them again. The nurse removed the bolsters from the room and educated the staff. The bed was pushed up against the wall and a fall pad was placed on the open side of the bed. The nurse documented the resident had been more restless at night, but had no complaints of pain from the fall. -On [DATE], the resident fell at 9:45 p.m. The resident slid from the bed to the floor. The fall mat had slid away from the bed and was not in place. The nurse did not document what the resident was doing to cause the slide from bed. No injuries were identified from the fall. -On [DATE] at 2:31 a.m., the resident remained restless. He complained of chronic right hip pain. The resident was calling out for help, but unable to tell staff what his needs were due to his cognition. Complaints of hip pain continued throughout the day. The documentation does not reflect follow up action taken for the continued pain to the hip. -On [DATE], the nurse documented the CNA reported the resident would not bear weight when transferring, but documentation showed there was no evidence of injury from the recent fall. The documentation lacked evidence of any action taken or interventions provided for the change in weight bearing status. -On [DATE], a new order for Depakote was received to assist with the resident's escalating behaviors. -On [DATE] at 4:28 a.m., the nurse documented, "(Resident) seems to not get any sleep at all during the noc (night) shift. He is having behavior problems possibly due to his pain and the resulting lack of sleep. Perhaps with medication assisted sleep, his behavior will get better if he gets a prescription for more therapeutic pain med's." The documentation lacked evidence of any interventions provided for the lack of sleep, pain, or if the physician was contacted on the concerns. -On [DATE] at 4:59 a.m., the resident was calling out for help. The nurse told the resident she needed to get assistance to take him to the bathroom and exited the room. Upon return, the resident was found lying on his right side on the floor mat next to the bed. The resident denied pain at the time of the fall. The nurse explained to the resident that he needed to wait for assistance before trying to get out of bed. -On [DATE], the nurse documented on the continued right hip pain and the resident was given Norco to alter his comfort. The nurse wrote, "It is not believed this is a new pain for the resident." Later in the day, the resident was calling out for help most of the shift, stating he did not want to die, and the nurse wrote, "PRN Norco seem (sic) only to help pain a little bit." -On [DATE], the resident continued to be "unable to bear much weight if any." For the days following, the resident began to exhibit a decline in health and continued pain in the hip. The documentation lacked evidence for action taken on the inability to bear much weight. -On [DATE] at 7:55 p.m., the resident was found on the floor in his room on his back. He stated he was reaching for something when he fell from the wheelchair. The resident did not have pain with position changes. The documentation in the nursing notes lacked evidence for any interventions implemented to prevent future falls. -On [DATE] at 5:34 a.m., the resident was found on the floor on his right side. The resident was unable to state what happened to cause the fall. The resident complained of right hip pain. The nurse documented he had no pain with movement or range of motion. The resident had bruises identified from a prior fall on his extremities. The documentation does not show what interventions were implemented to prevent future falls. -On [DATE] at 2:10 a.m., the resident was found on the fall mat next to the bed. The documentation does not reflect why the resident fell from bed. He did not complain of pain with movement. The back page of the incident report showed the resident had five falls in the last 30 days and 6 falls in ,[DATE] days. The intervention implemented was documented as, "Move bed against wall." b. A physician communication book was provided on [DATE]. It contained several entries for the resident. The documentation was not included in the resident's clinical record, but showed the nurse informed the physician of the following: -[DATE]-Resident still very depressed, having a difficult time sleeping and frequently anxious. -[DATE]-The resident complained of right hip pain at night. Stated he could not get comfortable and Tylenol was not effective. The nurse requested a stronger pain medication. No changes were made. -[DATE]-Resident was crying throughout the day. Does not know what he wants. Sleeping medication was not effective. No changes were made. -[DATE]-The resident was continuing to call out and have restlessness. He continued to complain of right hip pain, despite the medications taken. The nurse wrote the resident was, "crying often." The physicians response was "Need psych." No changes were made. -[DATE]-The nurse documented the resident needed a higher level of pain control medication, antianxiety medication and, "He has remained the same since admission, please help him with his pain." -[DATE]-The resident had a fall and complaint of right hip pain, but moves the right leg well. A review of the resident's physician progress notes [REDACTED]. When assessed, the resident had fair range of motion, but tenderness in the right hip area. The physician documented the initiation of two medications, one for pain and one for sleep. c. A review of the Resident's Medication Administration Records for June-[DATE], showed a lack of evidence that the resident was offered and given the physician ordered medication to treat his pain, and that medications to treat the resident's behaviors were initiated prior to an increase in dosage or the utilization of all doses available of the pain medication. The documentation lacked evidence for if the new medications may have increased the resident's fall risk. [DATE] Tylenol- 51 of 65 opportunities available were not given for the treatment of [REDACTED]. [DATE] Tylenol- 80 of the 93 opportunities for available medication were not given. Naproxen Sodium, 220 mg, one tablet in the morning, and two tablets at bedtime was ordered on [DATE] for arthritic pain. The medication did not change the frequency of pain complaints. [DATE] Tylenol- 76 of the 93 opportunities for available medication were not given. [DATE] Tylenol- 86 of 90 opportunities were not given to treat pain. Hydrocodone was not given for 119 of the 126 opportunities available to treat the resident's pain symptoms or complaints. The Hydrocodone-Acetaminophen ,[DATE] mg, was initiated on [DATE] and was to be taken every four hours as needed for pain. Alternate medications to treat the resident's symptoms included: Remeron 15 mg, at bedtime, was ordered for insomnia on [DATE]. Depakote 125 mg, twice a day, was ordered on [DATE] related to dementia with behavioral disturbances. Lorazepam 0.5 mg, one tablet every eight hours as needed for anxiety was ordered on [DATE]. A review of the interdisciplinary progress notes, physician progress notes [REDACTED]. On [DATE], the nurse documented the resident repeatedly yelled out for "water." Later that day, the resident was ordered normal saline 1000 cc bolus, then 125 cc administered intravenously. The resident continued to decline in health after this date, and comfort care was provided until his death on [DATE]. d. A review of the Incident Reporting-Resident policy showed under Procedures, number 16, "An immediate intervention needs to be implemented after an incident to attempt to prevent a recurrence." A review of the Fall Prevention Policy and Procedure, under the Procedure category, number nine, showed "Once a week, the interdisciplinary Team Fall Committee will meet and complete a Fall Review on each resident who has fallen during the preceding week. Under the Risk Factors category for multiple falls, the policy provided examples of what nursing staff could look for as underlying health problems or conditions that predisposed a resident to falls. Some of the items listed were identified during the resident's clinical record review, and included: arthritis, joint pain, potential injury to the hip, decline in cognition, mood, medications, devices such as wheelchair, lack of sleep, unsteady gait, decline in functional status and history of falls. During an interview on [DATE] 9:00 a.m., staff member B, director of nursing, stated the facility addressed the resident's behavior as it was challenging, as well as the resident's cognitive status. She was unable to recall specific information relating to the resident's hip or potential injury to the hip. During an interview on [DATE] at 9:08 a.m., staff member D, care manager, stated when a resident fell , the resident was assessed for injury before moving the resident. The incident was then documented in a progress note and SBAR (incident progress note). She stated new forms for falls had been implemented and were being used when a resident fell . During an interview on [DATE] at 10:30 a.m., staff member F, RN, stated if a resident was unable to state pain, the nurse would observe for grimacing, favoring a body part, comfort level or agitation. If the resident displayed behaviors of this nature, she would attempt to identify the cause of the problem and provide a potential intervention.