Every finding on record at Pacific Palms Healthcare

Based on record review, and interview, the facility failed to ensure Registered Nurse (RN) 1 accurately documented one of three sampled resident's (Resident 1) blood glucose (the main sugar found in the bloodstream) results. This deficient practice resulted in an inaccurate portrayal of Resident 1's clinical status and the potential to result in unnecessary treatment and care. Findings:During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 1's cognition was moderately impaired. Resident 1 required partial/moderate assistance (helper does less than half the effort) with toilet hygiene, shower/bath, upper and lower body dressing.During a review of Resident 1's Progress Note dated 3/17/2026, the Progress Note indicated Resident 1's blood glucose level was 551 grams(g)/deciliter ([dl] a unit of measure, the normal range is 80 g/dl - 100 g/dl). During an interview on 4/7/2026 at 2:02 p.m., RN 1 stated she recorded Resident 1's blood glucose as 551 g/dl but that was not the correct number. Resident 1's actual blood glucose was 350 g/dl. RN 1 stated she forgot to document the correct blood glucose number, Resident 1 transferred to a General Acute Care Hospital (GACH) so it was not necessary to correct the blood glucose result. RN 1 stated she should have corrected Resident 1's blood glucose number because it was important to document the right information correctly for accuracy and safety. During an interview on 4/8/2026 the Director of Nursing (DON) stated she was made aware by RN 1 that Resident 1's correct blood glucose level was actually 350 g/dl not 551 g/dl. RN 1 should have corrected Resident's clinical record to reflect the right blood glucose results. During a review of the facility's Policy and Procedure (P&P) revised 7/2017, titled, Charting and Documentation the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psych social condition, shall be documented in the residents medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated not speculative) complete, and accurate.

Based on record review, and interview, the facility failed to monitor, document and record the intake and output ([I&O] the measurement and recording of all fluids entering and leaving the body over a specific period)for one of three sampled residents (Resident 1), who was readmitted to the facility on [DATE] with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).This deficient practice resulted in the inability to determine if Resident 1's was hydrated appropriately and had the potential for fluid overload and/or infection to go unrecognized. Findings:During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/27/2025, the MDS indicated Resident 1's cognition was moderately impaired. Resident 1 required partial/moderate assistance (helper does less than half the effort) with toilet hygiene, shower/bath, upper and lower body dressing.During a review of the Order Summary Report (Physician's Order), the Physician's Order indicated Resident 1 had a 16 French ([fr] size of the tubing) indwelling urinary catheter with a 10 cubic centimeter ([cc] unit of measurement) balloon. During an interview with Registered Nurse (RN) 1 and a concurrent review of Resident 1's clinical records on 3/7/2027 at 2:02 p.m., Resident 1's clinical record indicated there was no documentation of Resident 1's intake and output ([I&O] the measurement and recording of all fluids entering and leaving the body over a specific period). RN 1 stated Resident 1 was admitted to the facility on [DATE] with an indwelling catheter and the resident's I&O was not taken because there were no doctor's orders to do so. During an interview the Director of Nursing (DON) stated Resident's I&Os are monitored only if there is a problem identified.During a review of the facility's Policy and Procedures (P&P) the facility could not provide a policy on I&Os.

Based on observation, interview and record review, the facility failed to provide one of four sampled residents (Resident 1) medication as ordered by his physician when Resident 1 did not receive Refresh Liquigel Ophthalmic Gel 1 % (a thick, gel-like eye drop solution, often called artificial tears) in both eyes at bedtime for dry eyes.This deficient practice resulted in Resident 1 not receiving Refresh Liquigel Ophthalmic Gel 1 % as ordered and had the potential for Resident 1 to experience dry eyes.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 1's cognition (ability to think and reason) was intact required substantial/ maximal assistance (helper does less than half the effort) from staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report (Physician Order's) dated 12/18/2025, Resident 1 was to receive Refresh Liquigel Ophthalmic Gel 1 % one application in both eyes at bedtime for dry eyes, ordered on 12/18/2025. During an interview on 12/30/2025 at 10:56 a.m., Resident 1 stated he has not been receiving the eye drops at night that were ordered by his physician.During a concurrent observation and interview on 12/30/2025 at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, of the East 2 Station medication cart, LVN 1 stated there were no Refresh eye drops in the medication cart for Resident 1 and would need to follow up with the supervisor.During a concurrent observation and interview on 12/30/2025 at 12:21 p.m. and subsequent interview on 12/30/2025 at 2:36 p.m., with Registered Nurse (RN) 1, of the facility's House Supply closet (a locked storage area where a collection of over-the-counter medications [any non-prescription medicine] are kept in the facility) RN 1 stated there was no Refresh drops in the House Supply closet. RN 1 stated she could not find any pharmacy delivery receipts of the Refresh drops for Resident 1 indicating the Refresh drops were delivered to the facility. RN 1 stated there should have been a follow up regarding Resident 1's Refresh eye drops to see why it was not delivered to facility. RN 1 stated if Resident 1 does not receive the prescribed eye drops then Resident 1's eye dryness will remain untreated.During an interview on 12/30/2025 at 1:07 p.m., the Pharmacist confirmed Resident 1's order for the Refresh eye drops was processed today (12/30/2025). The Pharmacist stated if the medication is an over-the-counter medication, the Pharmacy will not provide it, unless it was specifically requested by the facility. The Pharmacist stated there was no documentation that the facility called regarding the Refresh eye drops.During a review of the facility's policy and procedure (P&P) titled Pharmacy Services, dated 4/2019, the P&P indicated residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. The P&P indicated nursing staff should communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.

Based on observation, interview, and record review, the facility failed to ensure one out of one sampled Certified Nursing Assistant (CNA) 3 was competent and knowledgeable with a pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) texture diet when passing the meal tray to Resident 13. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet not consistent with her physician's orders. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 was receiving a mechanically altered (change in texture of food) and therapeutic diet (a meal plan designed to treat a medical condition by controlling specific nutrients, textures, or calories). During a review of the facility's Diet Type Report dated 11/20/2025, Resident 13 had a current physician's order for a fortified (adding extra vitamins, minerals, protein, or calories to foods to increase their nutritional content) pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) diet. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her by Certified Nursing Assistant (CNA) 3. Resident 13's meal tray contained eggs that were scrambled but not pureed. During an interview on 11/20/2025 at 12:23 p.m., CNA 3 stated she set up the meal tray this morning for Resident 13 and described Resident 13's eggs on the meal tray as soft, looked like normal scrambled eggs but they were not pureed. CNA 3 stated Resident 13 was on a puree diet. CNA 3 stated the process for serving meal trays was for nursing staff (licensed nursing staff) to check the trays compared to the orders then when the trays are ready, the CNAs pass the trays verifying the tray against the meal ticket, set up the tray and open everything for the residents. During an interview on 11/20/2025 at 12:55 p.m., [NAME] (CK) 1 stated a puree diet had to be completely smooth and no chunks so the residents would not choke. CK 1 stated that morning they served scrambled eggs with cheese sprinkled on top and if it was a puree plate it would have been very smooshed and not look the same as regular scrambled eggs. CK 1 stated it was important to follow the physician's diet order for patient safety. CK 1 stated after the meal was plated and placed on the meal carts, the meal cart is sent to the nursing unit where nursing staff was supposed to verify the diet provided matched the physician's order for a second check because everyone makes mistakes. That second check was supposed to keep the improper diet from reaching the resident. During a concurrent interview and record review on 11/21/2025 at 8:37 a.m., Registered Nurse Supervisor (RNS) 4 stated he reviewed Resident 13's Nurses Progress Notes for 10/31/2025, the day the Dentist recommended Resident 13's previous diet be discontinued (minced and moist diet (a texture-modified diet where all foods are chopped or mashed into soft, moist, small pieces, typically no larger than 4mm wide for adults, and must be easy to swallow with little to no chewing)) and changed to the puree diet due to Resident 13's dental status. RNS 4 stated it was very risky to serve the improper diet to the residents because there was a risk for aspiration. During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was provided with the incorrect diet consistency, the resident may not be able to swallow the food correctly. The DON stated the CNA role while passing meal trays was to ensure the resident was getting the proper diet. The DON stated the CNA was supposed to make sure the meal ticket matched the diet the patient received. During a review of the facility's Certified Nursing Aide Job Description undated, the job description indicated it was part of the CNAs job duty to serve food and nourishments.

Based on observation, interview, and record review, the facility failed to ensure call light devices were within reach for three of 26 sampled residents (Residents 7, 100, and 121).This deficient practice had the potential for residents not being unable to summon health care workers for assistance as needed. a. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting left dominant side, stiffness of left shoulder, elbow, and hand, and history of falling. During a review of Resident 7's Minimum Data Set (MDS: a resident assessment tool) dated [DATE], the MDS indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 was dependent on chair/bed-to-chair transfer, lying to sitting, required maximal assistance (provide more than half the effort) for toileting hygiene, bathing, lower body (waist below) dressing, required moderate assistance (provide less than half the effort) for oral/personal hygiene, upper body (waist above) dressing, and required setup for eating. The MDS indicated Resident 7 had an impairment on one side of the upper (arms/shoulders) and lower extremity (legs/hips) and utilized a wheelchair. During a concurrent observation and interview on [DATE] at 11:13 a.m., with Resident 7, Resident 7 stated he did not have a call light and did not know where it was. Resident 7 stated he calls for help by raising his hand. The call light was observed behind the resident's bed. During a concurrent observation and interview on [DATE] at 11:15 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 7's call light was behind his bed and brought the call light to Resident 7's right side. LVN 2 stated call lights are important as when a resident requires assistance, it notifies the staff they need assistance. LVN 2 stated call lights should be placed in a reachable position. LVN 2 stated if a call light was behind the bed and not reachable, the residents may try to get up on their own to get help and increasing their risk for falls. During an interview on [DATE] at 12:42 p.m. with the Director of Nursing (DON), the DON stated call lights are important as if a resident needs assistance, the staff can respond right away, and the call light should be placed in a reachable position. The DON stated if the call light is not in a reachable position, the residents cannot use it. b. During a review of Resident 100's admission Record, the admission Record indicated Resident 100 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including history of falling, epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) . During a review of Resident 100's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 100 did not have the capacity (ability) to understand and make decisions. During a review of Resident 100's MDS, dated [DATE], the MDS indicated Resident 100 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, bathing/shower, toilet hygiene, moderate assistance (Helper does less than half the effort) from one staff for dressing, and set up assistance (Helper sets up or cleans up) from one staff for eating. During a concurrent observation and interview on [DATE], at 10:28 a.m., with Resident 100 in her room, Resident 100's call light was placed between left side foam padding and the left side siderails, and the call light button was dangling near the floor. Resident 100 stated, she knew how to use the call light, but she could not find it. Resident 100 stated, she would yell for help if she could not find the call light. During an interview on [DATE], at 10:31 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 100's room, CNA 2 stated, the call light should be placed within reach of the resident to accommodate the needs of the resident. CNA 2 stated, she did not know why the call light was placed between the foam padding and siderail where Resident 100 could not reach. CNA 2 stated, if the call light was not within reach, Resident 100 might be at risk for fall or accident. During an interview on [DATE], at 2:28 p.m., with the Director of Staff Development (DSD), the DSD stated, the call light was the resident's lifeline (a thing on which someone or something depends, or which provides a means of survival) for emergency situations. The DSD stated, it should be within reach at all times to prevent falls and injuries. During an interview on [DATE], at 3:52 p.m., with the Director of Nursing (DON), the DON stated, the call light should be within reach of the residents at all times to provide the assistance they needed. fall stated, Resident 100 was at risk for falls due to history of falling and the staff should have ensured that the call light was within reach to prevent injuries. During a review of Resident 100's Care Plan Report (CPR), initiated on [DATE] and next review date on [DATE], the CPR Focus indicated, Resident 100 was at risk for fall related to balance problem during transition, and assistance needed during walking and bed mobility. The CPR Interventions indicated, explain or educate the resident to use the call light to ask for assistance because she could injure herself if she transfers herself without calling for help. c) During a review of Resident 121s admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on [DATE] at 12:30 p.m., Resident 121's call light was not within Resident 121's reach and was on the left side of the bed. Certified Nurse Assistant (CNA) 1 stated the call light was not in reach and needed to be in reach. During an interview on [DATE] at 12:42p.m. with the Director of Nursing (DON), the DON stated call lights are important as if a resident needs assistance, the staff can respond right away, and the call light should be placed in a reachable position. The DON stated if the call light is not in a reachable position, the residents cannot use it. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2016, the P&P indicated communicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be treated with respect, kindness, and dignity. During a review of the facility's P&P titled, Answering the Call Light, revised 1/2010, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently.

Based on interview and record review, the facility failed to ensure [NAME] (CK) 1 was competent in preparing pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) scrambled eggs and oatmeal.As a result of this deficient practice 27 residents who were on a puree diet were placed at risk for receiving eggs and oatmeal that were not completely smooth and without lumps which could lead to aspiration (when something other than air gets into your airways). Findings:During a review of the facility's Recipe titled, Pureed Eggs by Healthcare Menus Direct, LLC.2025, the recipe indicated to prepare eggs per recipe for eggs) and then puree the eggs on low speed (food processor or blender) to a paste consistency before adding any liquid then gradually add warm milk. The finished puree item should be smooth and free of lumps, hold its shape, while not being too firm or sticky. During a review of the facility's Recipe titled, Pureed Hot Cereal (Hot Cereal of Choice i.e. Oatmeal) by Healthcare Menus Direct, LLC. 2025, the recipe indicated to prepare the hot cereal as usual, puree the hot cereal and gradually add warm milk until the hot cereal was smooth and free of lumps. During an interview on 11/20/2025 at 12:55 p.m., CK 1 stated pureed foods needed to be smooshed and free of lumps. CK 1 stated when he prepared scrambled eggs with cheese that morning he did not put the eggs in the food processor or blender and just mashed them up by hand and for the oatmeal, he just prepared it as usual without any modification. CK1 stated to be honest they never puree the oatmeal, it is very liquidy and they have not had any problems up to this point. CK 1 stated while preparing food he was supposed to check the spreadsheet for the meal of the day versus the recipe to ensure it was the correct texture. CK1 stated it was important to follow the physician's order for food texture for the resident's safety. During an interview on 11/21/2025 at 10:33 a.m., the Dietary Supervisor (DS) stated she expected her cooks to prepare the proper food texture according to the recipe and pureed foods should be put in the blender or food processor to ensure the texture was smooth and free of lumps. The DS stated she spoke with CK 1 and he confirmed he was not pureeing the oatmeal and mashed the scrambled eggs by hand on 11/20/2025. The DS stated that was incorrect and a food processor or blender should have been utilized. The DS stated it was important to prepare the proper consistency because it placed the residents at risk for choking. During a review of the facility's Job Description: Dietary [NAME] dated 3/8/2025, the job description indicated the cook was to prepare meals and cook food according to standardized recipes and special diet orders.

Based on observation, interview, and record review, the facility failed to serve food that was at the correct temperature to one of three sampled residents (Resident 131).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 131's admission Record, the admission Record indicated Resident 131 was admitted to the facility on [DATE] with diagnoses including hypoglycemia (low blood sugar), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 131's Admit/Re-Admit Nursing Evaluation, dated 11/10/2025, the Evaluation indicated Resident 131 was alert and oriented. The Evaluation indicated Resident 131 needed assistance with all Activities of daily living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 131's Order Summary Report, dated 11/19/2025, the report indicated, starting on 11/10/2025, a diet order for Consistent Carbohydrate (diet used for managing blood sugar in diabetics) and No Added Salt (NAS) regular texture diet.During an interview on 11/18/2025 at 10:04 a.m., with Resident 131, Resident 131 stated the food was not always delivered warm. During a concurrent observation and interview on 11/19/2025 at 6:50 a.m., at the kitchen tray line, with [NAME] 1 (CK 1), CK 1 checked the pancake temperature and stated it was 130.8 degrees Fahrenheit.During a concurrent interview and record review on 11/19/2025 at 7:00 a.m., with the Dietary Supervisor (DS), the Daily Food temperature Log and Menus for 11/2025 were reviewed. The DS stated the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log. The DS stated that the temperature of waffles or pancakes were not checked as indicated in the log and today the temperature was below recommended temperature.During a concurrent interview and record review on 11/19/2025 at 2:00 p.m., with the Registered Dietician (RD), the Daily Food temperature Log and Menus for 11/2025 were reviewed. The RD stated the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log.During a review of the facility policy and procedure titled, Meal Service, 2023, the policy indicated pancakes service temperature should be 140 F or higher. The policy indicated the goal was to serve hot foods hot.

Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 13) was provided with a puree diet as ordered by the physician. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet consistent with her physician's orders. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 was receiving a mechanically altered (change in texture of food) and therapeutic diet (a meal plan designed to treat a medical condition by controlling specific nutrients, textures, or calories).During a review of the facility's Diet Type Report dated 11/20/2025, Resident 13 had a current physician's order for a fortified (adding extra vitamins, minerals, protein, or calories to foods to increase their nutritional content) pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) diet.During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her by Certified Nursing Assistant (CNA) 3. Resident 13's meal tray contained eggs that were scrambled but not pureed.During an interview on 11/20/2025 at 12:23 p.m., CNA 3 stated she set up the meal tray this morning for Resident 13 and described Resident 13's eggs on the meal tray as soft, looked like normal scrambled eggs but they were not pureed.During an interview on 11/20/2025 at 12:55 p.m., [NAME] (CK) 1 stated a puree diet had to be completely smooth and no chunks so the residents would not choke. CK 1 stated that morning they served scrambled eggs with cheese sprinkled on top and if it was a puree plate it would have been very smooshed and not look the same as regular scrambled eggs. CK 1 stated it was important to follow the physician's diet order for patient safety. CK 1 stated after the meal was plated and placed on the meal carts, the meal cart was sent to the nursing unit where nursing staff were supposed to verify the diet provided matched the physician's order, as second verification because everyone makes mistakes. That second check was supposed to keep the improper diet from reaching the resident.During a concurrent interview and record review on 11/21/2025 at 8:37 a.m., Registered Nurse Supervisor (RNS) 4 stated he reviewed Resident 13's Nurses Progress Notes for 10/31/2025, the day the Dentist recommended Resident 13's previous diet (minced and moist diet [a texture-modified diet where all foods are chopped or mashed into soft, moist, small pieces, typically no larger than 4mm wide for adults, and must be easy to swallow with little to no chewing]) be discontinued and changed to the puree diet due to Resident 13's dental status. RNS 4 stated it was very risky to serve the improper diet to the residents because there was a risk for aspiration.During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was provided with the incorrect diet consistency, the resident may not be able to swallow the food correctly leading to negative outcomes such as aspiration.During a review of the facility's policy and procedure (P&P) titled Therapeutic Diets revised a November 2015, the P&P indicated diets must be prescribed by the resident's attending physician and the food services manager would develop a tray identification system to ensure each resident received his or her diet as ordered.

Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions in one of one kitchen, by failing to:a) Ensure no staff personal belongings were in the kitchen preparation area.b) Ensure the sanitizer bucket was not in the food preparation sink while food was being prepared. c) Ensure the pancake, breakfast meat, and waffles holding temperature (temperature at which food is kept) on the steam table (specifically made for holding prepared foods at a consistent temperature) were checked prior to meal service.d) Ensure the ice machine was clean.e) Ensure two of three residents' (Resident 101 and 112) refrigerated personal food items were dated on when it was opened or procured.These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health.Findings: During a concurrent observation and interview on 11/18/2025 at 8:32 a.m., with the Dietary Supervisor (DS), in the kitchen, staff personal belongings were observed on a kitchen cart in the food preparation area. The DS stated staff's personal items do not belong in the kitchen.During an observation and interview with the Registered Dietician (RD) on 11/19/2025 at 6:45 a.m., the sink had a sign that indicated food preparation only. The food preparation sink had a red bucket labeled sanitizer. The RD stated the sanitizer should not be in the food preparation sink when food was being prepared.During an observation and interview on 11/19/2025 at 6:50 a.m., [NAME] 1 (CK 1) checked the pancake temperature and it was 130.8 degrees Fahrenheit.During an interview and record review on 11/19/2025 at 7:00 a.m., with the Dietary Supervisor (DS), the Daily Food temperature Log was reviewed, and the DS confirmed the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log.During a concurrent observation and interview on 11/19/2025 at 8:19 a.m., with the Maintenance Supervisor (MS) the facility ice machine was observed with black colored unidentified substance on the inside of the machine. The MS stated the inside of the ice machine was dirty.During a review of Resident 101's admission Record, the admission record indicated the facility admitted Resident 101 on 12/30/2022 with the diagnosis including gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest).During a review of Resident 101's Minimum Data Set ([MDS] resident assessment tool), dated 8/20/2025, the MDS indicated Resident 101 had intact cognition and needed set-up assistance when eating.During a review of Resident 112's admission Record, the admission record indicated the facility admitted Resident 112 on 9/2/2025 with the diagnosis including gastroesophageal reflux disease.During a review of Resident 112's MDS, dated [DATE], the MDS indicated Resident 112 had moderate cognitive impairment and needed set-up assistance when eating.During a concurrent observation and interview on 11/19/2025 at 11:40 a.m., with the RD, the Residents refrigerator was noted with Resident 101's personal food items including an opened and undated, 8-ounce pack of sliced cheese and 16-ounce pack of deli meat. During a concurrent interview and record review on 11/19/2025 at 11:40 a.m., with the RD, the food package instructions were reviewed, and the instructions indicated the cheese slices, and the deli meat was best if used within seven days of opening. During a concurrent observation and interview on 11/19/2025 at 11:45 a.m., with the Registered Dietician (RD), the Residents' refrigerator was noted with Resident 112's box of fried chicken with food that was undated. During a concurrent interview and record review on 11/19/2025 at 2 p.m., with the RD, the menus and Food temperature Logs for 11/2/2025 to 11/19/2025 were reviewed and the logs indicated there were days that the breakfast meat, pancakes, or waffles were not checked. The RD stated prior to serving, food temperatures for pancake/toast/ breakfast meat should be checked to ensure food was warm when resident gets the food and to prevent foodborne illness. Pancake temperature should be at least 140 degrees Fahrenheit.During an interview on 11/19/2025 at 2 p.m. with the RD, the RD stated the following: 1. Residents' food should be dated so residents will not acquire food borne illnesses. 2. The sanitizer bucket should not be in the sink designated only for food preparation during food prepping to prevent contamination of food items.3. The ice machine should be clean to prevent infection.4. Staff personal belongings should not be in the kitchen area to prevent contamination.During a review of the facility's policy and procedure (P&P) titled, Bringing in food for a Resident, 2023, the P&P indicated food should be labeled and dated with the date food was opened to monitor for food safety.During a review of the facility's P&P titled, Food for Residents from Outside Sources, undated, the P&P indicated if food is opened, the food will be dated with the date opened and disposed of in 2 days after opening.During a review of the facility's P&P titled, Storage of Food and Supplies, 2023, the P&P indicated items such as bleach, soap and other cleaning supplies should be stored in entirely separate and specific areas. During a review of the facility's P&P titled, Employee Personal Items, 2023, the P&P indicated personal items brought in by staff from the outside will not be kept in the kitchen area.During a review of the facility's P&P titled, Ice machine Cleaning Procedures, 2023, then P&P indicated the ice machine needs to be cleaned and sanitized.During a review of the facility's P&P titled, Meal Service, 2023, the P&P indicated the staff member will take the food temperatures prior to meal service.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for three of nine sampled residents (Resident 13, Resident 101, and Resident 113) when:a. Restorative Nursing Aide (RNA 1) documented he provided RNA feeding program (staff provide feeding assistance) assistance to Resident 13 for two meals, when he did not. b. RNA 1 documented Resident 101 wore both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for two hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 11/18/2025 when Resident 101 wore both knee splints for 40 minutes to one hour.c. RNA weekly documentation did not accurately reflect Resident 113's ambulation distance from 8/3/2025 - 10/4/2025. These deficient practices resulted in inaccurate medical documentation for Resident 13, Resident 113, and Resident 101 and had the potential for delayed assessment of both knee splints for Resident 101. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying assistance during the task). During a review of Resident 13's Order Summary Report dated 11/21/2025, the Order Summary Report indicated Resident 13 had an order placed 9/30/2024 for RNA feeding program with breakfast and lunch. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her, but staff (unknown) did not stay with her during the meal. Resident 13 fed herself. During an observation on 11/20/2025 at 12:22 p.m., Resident 13 was feeding herself lunch. Resident 13 ate the vegetables on the plate and did not consume the meat or potatoes. RNA 1 came into the room and picked up Resident 13's meal tray. During an interview on 11/20/2025 at 2:33 p.m., the Quality Assurance Nurse (QAN) stated Resident 13 had an order for the RNA feeding program and the RNA staff were supposed to assist the resident with feeding and sit with her while she ate. The QAN stated RNA staff were not supposed to leave Resident 13 unattended until she finished her meals. The RNA staff is supposed to supervise that she was eating safely and encourage her to eat. During an interview on 11/21/2025 at 10:56 a.m., RNA 1 stated he was assigned to Resident 13 the day prior (11/20/2025) for the RNA feeding program (breakfast and lunch). RNA 1 stated to be honest he only set up the meal tray for Resident 13 but then left the room because he had other residents to attend to. RNA 1 stated Resident 13 could feed herself, the staff must monitor her while she was eating. During a concurrent interview and record review on 11/21/2025 at 11:53 a.m., RNA 1 stated he reviewed Resident 13's Task Documentation for the RNA Feeding Program Task for 11/20/2025, question 1 was marked as the task was completed for breakfast and lunch and question 2 for the number of minutes spent with the resident was marked 20 minutes at both meals. RNA 1 confirmed he did not feed Resident 13 at breakfast or lunch on 11/20/2025 and he did not spend 20 minutes with the resident at mealtime. RNA 1 stated the documentation was not correct and he should not have documented something he did not do, During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was on the RNA feeding program the RNA should be in the room with the resident throughout the meal. The DON stated that even though the residents were on the RNA feeding program for encouragement and queuing, the staff should still be in the room throughout the meal. The staff need to motivate the resident to eat and be there if resident needed anything. The DON stated there was a possibility for weight loss if the resident was not encouraged to eat. The DON stated if a task was not completed, then it should not have been documented as done in the resident record. The DON stated setting up the tray and taking it away was not considered completing the RNA Feeding Program Task. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate. b. During a review of Resident 101's admission Record (AR), the AR indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including but not limited to primary osteoarthritis (OA, a progressive disorder of the knee joint, caused by a gradual loss of cartilage) of right hip and left shoulder, polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and morbid obesity due to excess calories (disorder involving excessive body fat that increases risk for health problems). During a review of Resident 101's Minimum Data Set (MDS, resident assessment tool) dated 8/20/2025, the MDS indicated Resident 101 had no cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 101 required setup assistance with eating, supervision for oral hygiene, and substantial assistance for toileting hygiene, showering, lower body dressing and sit to lying. The MDS indicated Resident 101 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 101 did not have any functional limitations in range of motion (ROM, full movement potential of a joint) in the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 101's Care Plan Report (CP), the CP initiated on 1/3/2023 and with a target date of 2/17/2026 indicated Resident 101 was at risk for decline in Activities of Daily Living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) functions, mobility and joint mobility related to OA, severe obesity, and right knee contracture (loss of motion of a joint. The CP goal indicated Resident 101 will minimize potential declines in joint mobility. The CP interventions indicated to observe for pain or joint stiffness while providing RNA/ROM, RNA to provide both knee extension splints (splints to help keep the knee in a straight position) two to four hours three times a week or as tolerated, RNA to provide both UE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) three times a week or as tolerated, RNA to provide both [NAME] passive range of motion (PROM, movement at a given joint with full assistance from another person) three times a week or as tolerated. During a review of Resident 101's Order Summary Report (OSR) dated 11/20/2025, the OSR indicated an order dated 9/23/2025 for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated. During a review of Resident 101's November 2025 Documentation Survey Report (DSR) for RNA tasks, the DSR indicated on 11/18/2025, both knee extension splints were applied and tolerated for two hours. During an observation and interview on 11/18/2025 at 10:35 a.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated she was supposed to have splints on her legs and staff put on the splints about 40 minutes at a time. There were no knee splints observed on Resident 101. During an observation and interview on 11/18/2025 at 2:54 p.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated RNA 1 came to put on the leg splints today and Resident 101 wore the leg splints for about 40 minutes. There were no knee splints observed on Resident 101. During an interview on 11/19/2025 at 9:28 a.m. with RNA 1, RNA 1 stated he completed RNA treatment with Resident 101 yesterday 11/18/2025 and RNA 1 put on the knee splints for only 45 minutes yesterday. During an interview and record review on 11/20/2025 at 10:00 a.m. with RNA 1, RNA 1 reviewed RNA daily documentation on 11/18/2025. RNA 1 stated he documented on 11/18/2025 that Resident 101 wore and tolerated both splints for two hours. RNA 1 stated Resident 101 put on the splint for one hour, because Resident 101 could not tolerate it anymore and told RNA 1 to take off the splint. RNA 1 stated he documented two hours because that was what the order indicated. RNA 1 stated he should have documented one hour. RNA 1 stated the 11/18/2025 RNA documentation was not accurate, because the documentation did not reflect what happened during RNA treatment on 11/18/2025. RNA 1 stated staff should document accurately because the documentation showed what happened with Resident 101 and told staff how Resident 101 was progressing with wearing the knee splints. RNA 1 stated Resident 101 has not tolerated two hours of wearing the knee splints except for possibly two previous times. During an interview on 11/20/2025 at 3:52 p.m. with the Director of Nursing (DON), the DON stated the purpose of documentation was to indicate what the resident did and what happened during treatment. DON stated all documentation needed to be accurate so that whatever happened to the resident, every shift and staff member would know what happened to the resident. DON stated RNA documentation should be accurate and indicate what happened during the RNA treatment session so that if the resident could not tolerate the splint for the time ordered, RNA should let nursing and therapy staff know and have therapy look into or recommend how much a resident could tolerate the splint. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate. c. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility 6/16/2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged pressure)of sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During an interview on 11/18/2025 at 10:01 a.m., with Resident 113, Resident 113 stated they used to walk with a walker with the staff, and but has gotten weaker and does not walk with the staff anymore. During a review of Resident 113's physician orders, the orders indicated: 6/26/2025 – 11/4/2025 Restorative Nursing Aide (RNA) to provide ambulation program with front wheel walker (FWW) 3x/week or as tolerated and document walking distance. During a concurrent interview and record review on 11/19/2025 at 2:21p.m., with RNA 1, Resident 113's daily and weekly RNA documentation from June 2025 to November 2025 was reviewed. RNA 1 stated the Daily RNA documentation is completed daily and indicated the distance a resident ambulates in feet (ft – a unit of measurement). RNA 1 stated the Weekly RNA documentation is a summary RNA services for a week including the total distance in feet ambulated in a week. RNA 1 stated the Weekly RNA documentation indicated the week of: 8/3/2025 – 8/9/2025 Resident 113 ambulated 150 ft, the Daily RNA documentation indicated Resident 113 ambulated 80 ft 8/10/2025 – 8/16/2025 Resident 113 ambulated 150 ft, the Daily RNA documentation indicated Resident 113 ambulated 40 ft 8/17/2025 to 8/23/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 70 ft 8/24/2025 – 8/30/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft 9/1/2025 – 9/6/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft 9/7/2025 – 9/13/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 70 ft 9/14/2025 – 9/20/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft 9/21/2025 – 9/27/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft 9/28/2025 – 10/4/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft RNA 1 stated the weekly RNA documentation should accurately reflect the daily RNA documentation, but they do not match. RNA 1 stated it was important for the Weekly RNA documentation to accurately reflect the resident's status to see if the resident is improving or declining. During an interview on 11/20/2025 at 3:52 p.m. with the DON, the DON stated the purpose of documentation was to indicate what the resident did and what happened during treatment. DON stated all documentation needed to be accurate so that whatever happened to the resident, every shift and staff member would know what happened to the resident. DON stated RNA documentation should be accurate and indicate what happened during the RNA treatment session. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate.

Based on observation, interview, and record review, the facility staff failed to: a. Perform hand hygiene when entering and exiting Resident 5's room.b. Replace Resident 96's tube feeding line when it was found on the floor without a cap. c. Implement and document control measures per water management policy and procedure.d. Monitor, document, and implement contact isolation precautions (infection control measures used to prevent the spread of germs by direct contact) for Resident 131. These deficient practices had the potential to transmit infectious microorganisms (living organisms that are too small to be seen with the naked eye) and increase the risk of infection for the residents. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and stiffness of right shoulder, elbow, and hand. During a review of Resident 5's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 5's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 5 was dependent on chair/bed-to-chair transfer, bathing, upper (above waist) and lower (below waist) body dressing, and required maximal assistance (provide more than half the effort) for oral and personal hygiene. The MDS indicated Resident 5 had impairments on one side of the upper (arms/shoulders) and lower (hips/legs) extremities and utilized a wheelchair. During a review of Resident 5's Order Summary (physicians order) dated 11/20/2025, the Order Summary indicated there was an order dated 8/31/2025: on Enhance Barrier Precaution (EBP: infection control measure requiring staff to wear a gown and gloves during high-contact activities with residents who have a g-tube and to prevent transmission of multidrug resistant organisms (MDROs infectious microorganisms that are resistant to multiple anti-infection medications): G-tube. During a concurrent observation and interview on 11/20/2025 at 10:23 a.m., Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed not performing hand hygiene prior to entering (before wearing personal protective equipment (PPE: equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) and exiting (post PPE removal) Resident 5's room. The LVN 1 stated hand hygiene is performed before and after exiting the resident room, prior to interacting with the resident, or prior to providing treatment. The LVN 1 stated he did not do hand hygiene prior to and exiting Resident 5's room and indicated he had contact with Resident 5 when observing her abdominal binder (belt used to support the abdomen after surgery, improve physical function). The LVN 1 stated hand hygiene prevents the spread of infection and cross contamination. b. During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, gastrostomy (g-tube), and Type 2 Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing) During a review of Resident 96's H&P, dated 8/22/2025, the H&P indicated Resident 96 could make needs known but could not make medical decisions. During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96's cognitive skills were moderately impaired. The MDS indicated Resident 96 is dependent on all aspects of activities of daily living (ADLs: routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 96 did not have any impairments on both sides of the upper and lower extremities and utilized a wheelchair and walker. During an observation on 11/19/2025 at 11:16 a.m., in Resident 96's room, the feeding tube that connected to the resident was on the floor with no cap covering the end that is connected to the resident. The tube feeding was dated 11/18/2025 at 9:20 p.m. and the fluids (water) bag was dated 11/18/2025 at 9:30 p.m. During a concurrent observation and interview on 11/19/2025 at 2:42 p.m. with the Licensed Vocational Nurse 3 (LVN 3), LVN 3 was shown what was observed on 11/19/2025 at 11:16 a.m. (feeding tube on the floor) and confirmed the current feeding observed running into Resident 96 and the feeding tube that was observed at 11:16 a.m. were the same. LVN 3 stated when she arrived at the room if she observed the tubing was on the floor, she would have to replace it to keep the resident safe as the tubing was on the floor exposed to dirt, which increases the risk of infections due to contamination. During an observation on 11/20/2025 at 9:51 a.m., Resident 96's feeding bag was dated 11/20/2025 at 12:30 a.m.(indicating the feeding was started 9 hours and 21 minutes ago). During an interview on 11/21/2025 at 12:42 p.m. with the Director of Nursing (DON), the DON stated hand hygiene should be done every time care is provided to the resident, and prior to entering and exiting the resident room to prevent infection. The DON stated if the tube feeding line is on the floor, they will replace the whole thing right away due to infection control. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated this facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; before and after entering isolation precaution settings. Hand hygiene is the final step after removing and disposing of personal protective equipment. c. During a concurrent interview and record review on 11/20/2025, at 9:56 a.m., with the Maintenance Supervisor (MS), the facility's Water Management Program Binder, dated 2025 was reviewed. The Water Management Program (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) Binder indicated, Residents' room water temperature was documented daily, and Boiler and water heater maintenance log was documented on 1/3/2025, 2/14/2025, 3 /20/2025,3/24/2025, 4/22/2025, 5/1/2025, 6/10/2025, 7/22/2025, 8/12/2025, 9/19/2025, 10/14/2025, and 11/12/25. The MS stated, the facility was monitoring and documenting water temperature for randomly selected residents' room daily and maintenance log for Boiler and water. The MS stated, there were no other monitoring logs for control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limit (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably). The MS stated, he should have monitored and documented all control measures and limits as the policy indicated to prevent Legionella (a type of bacteria that is naturally found in [NAME] environments) outbreak (two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number). During a concurrent interview and record review on 11/20/2025, at 10 a.m., with the Infection Preventionist Nurse (IPN), the facility's Policy and Procedure (P&P) titled, Legionella Policy: Water Management Program, undated was reviewed. The P&P indicated, Record Keeping: The following records shall be kept on file for a period of five years in a log book .Completed report sheets for: weekly flushing of infrequently used outlets, Monthly hot and cold water temperature checks including flow and return temperature, quarterly shower head cleaning, Annual domestic water tank visual inspection and cleaning, and annual calorifier visual sampling of drain valve water. The IPN stated, the water management program committee should have follow through monitoring and documenting control measures and limit to reduce and prevent the risk of getting Legionella infection. During an interview on 11/20/2025, at 3:52 p.m., with the Director of Nursing (DON), the DON stated, all control measures and limits should be monitored and documented per policy to prevent Legionella outbreak and to protect vulnerable residents. During a review of the facility's Policy and Procedure (P&P) titled, Legionella Water Management Program, revised 7/2017, the P&P indicated, Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 3. The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .5. The water management program includes the following elements .e. specific measures used to control the introduction and /or spread of legionella. f. the control limits or parameters that are acceptable and that are monitored .h. A system to monitor control limits and the effectiveness of control measures. d. During a review of Resident 131's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract ), pseudomonas infection (a group of bacteria commonly found in the environment, like in soil and water that can cause a range of infections, including lung infections) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 131's History and Physical (H&P), dated 11/11/2025, the H&P indicated, Resident 131 had the capacity (ability) to understand and make decisions. During a review of Resident 131's Minimum Data Set (MDS – a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 131 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, bathing/shower, toilet hygiene, toilet transfer, moderated assistance (Helper does less than half the effort) from one staff for bed mobility, dressing and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident competes activity) from one staff for eating. During a concurrent observation and interview on 11/18/2025, at 10:04 a.m. with Resident 131 in Resident 131's room, there was a signage indicated Enhanced Barrier Precaution [EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes] near the entrance of Resident 131's room. Resident 131 stated, she was recently diagnosed with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) and still having active diarrhea even this morning. Resident 131 stated, she had few episodes of diarrhea on 11/16/2025 and 11/17/2025 as well. Resident 131 stated, her nurse gave her the medication to stop diarrhea, but she still having diarrhea due to antibiotics (medicines that fight bacterial infections in people and animals) use for her UTI. During a concurrent observation and interview on 11/19/2025, at 9:20 a.m., with House Keeping Staff (HKS) 1, in a hallway near Resident 131's room, HKS 1 came out of Resident 131's room and did not perform hand hygiene. HKS 1 stated, she did not wash her hand because she just went in to check for trash can. HKS 1 stated, she should have washed her hands regardless she touched objects or not to prevent spreading infection. During an interview on 11/19/2025, at 9:27 a.m., with Certified Nurse Assistant (CNA) 5, CNA 5 stated, Resident 131 was on EBP that required to wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and hand hygiene with hand sanitizer. CNA 5 stated, hand washing with soap and water was not required for after caring Resident 131. CNA 5 stated, Resident 131 had diarrhea this morning and did not know if Resident 131 was having active C-diff infection. During a concurrent interview and record review on 11/19/2025, at 3:35 p.m., with the Infection Preventionist Nurse (IPN), Resident 131's Order Summary Report (CSR), dated 11/19/2025 was reviewed. The CSR indicated, contact isolation precaution (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the person or the person's environment) due to stool C-diff was ordered 11/14/2025. The IPN stated, Resident 131 was admitted to the facility on [DATE] and was not on contact isolation until 11/14/2025. The IPN stated, Resident 131 was having diarrhea upon admission and stool sample for C-diff was collected on 11/11/2025. The IPN stated, Resident 131 should have placed the contact isolation precaution while waiting for stool C-diff testing result to reduce the risk of spreading infection. During a concurrent interview and record review on 11/19/2025, at 3:45 p.m., with the IPN, Resident 131's Nurse Practitioner (NP-an advanced practice registered nurse who serve as primary and specialty care providers, delivering advanced nursing services to residents) Skilled Nursing Home Progress Note, dated 11/18/2025 was reviewed. The NP Skilled Nursing Home Progress Note indicated, Resident 131 had mild abdominal pain and diarrhea on 11/17/2025. The NP Skilled Nursing Home Progress Note indicated, continue with Vancomycin (antibiotics) and contact isolation. The IPN stated, she did not follow through with NP's progress note. The IPN stated, she was not aware of the episodes of diarrhea. The IPN stated, the staff should have confirmed with physician or NP before discontinuing contact isolation precaution on 11/18/2025 to ensure Resident 131 was free of C-diff infection. The IPN stated, the staff should have washed hands with soap and water after caring for the residents with C-diff because the friction from rubbing removes the C-diff spores (an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces). The IPN stated, there was no documentation regarding the reason why the contact isolation precaution was discontinued. During a review of Resident 131's General Acute Care Hospital (GACH) Laboratory Report, dated 11/12/2025, the GACH Laboratory Report indicated, Resident 131 tested positive (confirmation for infection) C-diff stool test on 11/12/2025. During a review of Resident 131's Bowel and Bladder (B&B) Elimination Task, dated from 11/11/2025 to 11/20/2025, the B&B Elimination Task indicated, Resident 131 had loose stool on 11/16/2025 and 11/17/2025. During a review of Resident 131's Medication Administration Record (MAR), dated 11/2025, the MAR indicated, Resident 131 received Imodium 2 milligram (mg) by mouth for control of diarrhea on 11/11/2025. During a review of Resident 131's McGeer's Criteria for Infection Control Surveillance (standardized surveillance definitions used to identify and monitor infections in long-term care facilities), dated on 11/10/2025 and 11/13/2025, the McGeer's Criteria for Infection Control Surveillance indicated, Resident 131 had C-diff infection on contact isolation and had three or more liquid or watery stools above what is normal for the resident within a 24 hours period. During a review of the facility's Policy and Procedure(P&P) titled, Infection Prevention and Control Manual Guidelines for Clostridium Difficile Infection (CDI), revised 2020, the P&P indicated, Isolation Precautions . A. Contact precautions should be used for CDI residents with diarrhea. B. Hands should frequently be washed with soap and water. An alcohol-based waterless hand cleanser is not effective against CDI spores . F. Precautions should continue until diarrhea ceases. (If no episodes of diarrhea are noted x 48 hours, DC Contact Isolation). During a review of the facility's Policy and Procedure(P&P) titled, Infection Control Guidelines for All Nursing Procedures, revised 8/2012, the P&P indicated, General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non­antimicrobial soap and water under the following conditions . When there is likely exposure to spores (i.e., C. difficile or Bacillus anthracis) (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30- 60 seconds with soap and water. During a review of the facility's Policy and Procedure(P&P) titled, Isolation - Notices of Transmission-Based Precautions, revised 8/2019, the P&P indicated, Policy Statement: Notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation . b. Contact Precautions: (1) A notice at the doorway instructing visitors to report to the nurses' station before entering the room. (2) A sign indicating contact precautions on the door to the resident's room.

Based on interview and record review, the facility failed to:a. 1.Administer the coronavirus vaccination for one of five sampled residents (Resident 5). b. 2. Offer and educate coronavirus vaccinations for staff per facility's policy for three of five sampled employees. These failures had the potential to place all residents at risk for exposure to infection of coronavirus.Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain). During a review of Resident 5's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 5 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required maximal assistance (helper does more than half the effort) when for oral hygiene and dependent (helper does all the effort) for toileting hygiene, upper and lower body dressing, and bathing. During a concurrent interview and record review on 11/20/2025 at 3:10 p.m., with the Infection Preventionist Nurse (IPN), Resident 5's medical record was reviewed. The IPN stated Resident 5's responsible party (RP) gave consent for Resident 5 to receive the coronavirus vaccine on 9/17/2025. The IPN stated there is no documentation that Resident 5 received the coronavirus vaccine. During an interview on 11/20/2025 at 3:52 p.m., with the Director of Nursing (DON), the DON stated if it is not documented, it was not done. During a review of the facility's policy and procedure (P/P), titled Coronavirus Disease (Covid-19) - Vaccination of Residents, revised December 2021, the P/P indicated Covid-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee. The individual who coordinates these responsibilities in the facility is: Infection preventionist. 2. During a concurrent interview and record review on 11/20/2025 at 3:16 p.m., with the IPN the Employee Tracking Record for Vaccination for 2025 was reviewed. The IPN stated the coronavirus vaccine booster and vaccines are encouraged to all employees. The IPN stated all employees should have the vaccine consent form. The IPN stated the vaccine consent form is proof that the facility educated the employee about the vaccination risks and benefits. The IPN stated Registered Nurse Supervisor (RNS) 3, Licensed Vocational Nurse (LVN) 8, and Certified Nurse Assistant (CNA) 4 do not have a vaccine consent form for the 2025 coronavirus vaccine. The IPN stated it is important that all employees are educated about the risks and benefits of the coronavirus vaccines so the employees do not acquire coronavirus which could be transferred to the residents. During an interview on 11/21/2025 at 2:56 p.m. with the DON, the DON stated it was important to educate and document staff coronavirus vaccinations in order to protect residents and staff from a coronavirus outbreak. The DON stated respiratory season is from November 1st to March 31st. The DON stated 100% of employees should have been educated and offered the coronavirus vaccine before during the respiratory season. The DON stated a declined vaccine consent form is proof that the employee was educated. During a review of the facility's policy and procedure (P/P), titled Coronavirus Disease (Covid-19) - Vaccination of Staff, revised January 2022, the P/P indicated all staff are required to be fully vaccinated for COVID-19 in accordance with 483.80(i).The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following (as applicable): a. That staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; b. That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; c. A copy of the informed consent; and d. Verification of vaccination or documentation of exemption/delay.

Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula was provided and documented as physician ordered for two of three sampled residents (Resident 28 and Resident 2).This failure had the potential to result in Resident 28 and Resident 2 receiving inaccurate amounts of GT feeding formula that could lead to unintended weight loss. Findings:a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain) affecting left side of body. During a review of Resident 28's History and Physical (H&P), dated 9/6/2025, the H&P indicated, Resident 28 was alert and cooperative.During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 28 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, shower, maximal assistance (Helper does more than half the effort) from one staff for dressing, and moderate assistance (Helper does less than half the effort) from one staff for bed mobility.During an observation on 11/18/2025, at 11:37 a.m., in Resident 28's room, Resident 28's GT formula was dated as 11/18/2025, at 1:30 a.m. and the feeding pump was turned off.During an observation on 11/19/2025, at 2:52 p.m., in Resident 28's room, Resident 28's GT formula was dated as 11/19/2025, at 6:45 a.m. and the feeding pump was turned on.During a concurrent interview and record review on 11/19/2025, at 3:02 p.m., with Licensed Vocational Nurse (LVN) 7, Resident 28's Order Summary Report (OSR), dated 11/19/2025 was reviewed. The OSR indicated, give GT feeding with Jevity (GT feeding formula with high protein and high fibers) 1.5 at 60 cubic centimeter (cc) per hour for 20 hours to provide 1200 cc or 1800 kilocalorie (Kcal) per day. The OSR indicated, start the GT feeding at 2 p.m. till dose is completed via enteral (feeding) pump was ordered on 9/29/2025. LVN 7 stated, the label Resident 28's feeding that indicated the starting date and time of feeding formula should reflect 2 p.m. as the physician ordered. LVN 7 stated, it was important to start the feeding at 2 p.m., as ordered to ensure Resident 28 received the 1200 cc of formula per day. LVN 7 stated, the staff should have changed all tubing of the GT feeding and started a new container of GT feeding formula at 2 p.m. LVN 7 stated facility staff should document the amount of GT feeding delivered every shift to ensure 1200 cc was delivered as ordered without delays due to interruptions in administering the GT feeding due to providing hygiene care and re positioning Resident 28.During a concurrent interview and record review on 11/20/2025, at 3:52 p.m., with the Director of Nursing (DON), Resident 28's Medication Administration Record (MAR), dated 11/2025 was reviewed. The MAR indicated, there was no documentation of the amount of nutrition delivered per shift or per day. The DON stated, the nursing staff should have provided, and documented prescribed amount of GT feeding formula. The DON stated, there was no documentation regarding the amount of the GT feeding delivered. The DON stated, there could be delays due to hygiene care and therapy sessions, but this should have been communicated between the staff to ensure delivery of 1200 cc as prescribed.b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain). During a review of Resident 2's History and Physical (H&P), dated 7/11/2025, the H&P indicated, Resident 2 did not have the capacity (ability) to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, shower, dressing, and bed mobility.During an observation on 11/18/2025, at 2:20 p.m., in Resident 2's room, Resident 2's GT formula was dated as 11/17/2025, and started at 7:30 a.m., the feeding pump was turned on.During an observation on 11/19/2025, at 2:57 p.m., in Resident 2's room, Resident 2's GT formula was dated as 11/19/2025, and started at 6 p.m., and the feeding pump was turned on.During a concurrent interview and record review on 11/19/2025, at 3:08 p.m., with LVN 7, Resident 2's OSR, dated 11/19/2025 was reviewed. The OSR indicated, give GT feeding with Diabetisource (GT feeding formula for controlling blood sugar) 1.2 at 60 cc per hour for 20 hours to provide 1200 cc or 1440 kilocalorie (Kcal) per day. The OSR indicated, starting the GT feeding at 2 p.m. to 10 a.m. or until dose is completed via enteral pump (feeding pump) was ordered on 9/27/2025. LVN 7 stated, new GT feeding formula should be hung at 2 p.m. and the label should be reflected at 2 p.m. as ordered. LVN 7 stated, all tubing should be changed when the formula was newly hung at 2 p.m.During an interview on 11/20/2025, at 3:14 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated, Resident 28 and Resident 2's GT feeding should be changed and dated 2 p.m. daily per physician's order. The MDSC stated, the nursing staff should have followed the physician's order to start new formula at 2 p.m. daily to ensure accurate amount of GT feeding formula being delivered as ordered. The MDSC stated, the amount delivered should be documented to ensure delivery of the prescribed amount of the feeding formula to prevent weight loss.During a concurrent interview and record review on 11/20/2025, at 3:55 p.m., with the Director of Nursing (DON), Resident 2's MAR, dated 11/2025 was reviewed. The MAR indicated, there was no documentation of the amount delivered per shift or per day. The DON stated, if the nursing staff did not provide GT feeding as ordered, the residents might not get the amount as prescribed and might be at risk for weight loss. During a review of the facility's Policy and Procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, revised 3/2015, the P&P indicated, Initiate Feeding .5. On the formula label document initials, date and time the formula was hung/ administered, and initial that the label was checked against the order . Documentation: The person performing this procedure should record the following information in the resident's medical record.1. The date and time the procedure was performed .4. Amount and type of enteral feeding .7. All assessment data obtained during the procedure.During a review of the facility's Policy and Procedure (P&P) titled, Enteral Nutrition, revised 1/2014, the P&P indicated, Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered.

Based on observation, interview, and record review, the facility failed to monitor the urine (liquid waste product made by the kidneys, stored in the bladder, and expelled from the body through the urethra) output for two out of two sampled Residents (Resident 15 and Resident 121) who had indwelling urinary catheters (a thin tube inserted into the bladder to drain urine continuously into a collection bag).This deficient practice had the potential to cause a delay in addressing Resident 15 and Resident 121's overall hydration status (the process of replenishing water in the body), kidney function (how well the kidneys are working), and fluid balance (the body's regulation of fluid intake versus output to maintain stable hydration and electrolyte levels for essential bodily functions) issues.Findings: A. During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility 9/22/2025 with diagnoses of history of malignant neoplasm (cancerous tumor) of the large intestine, type 2 diabetes (your body does not use insulin properly, leading to high blood sugar) and presence of urogenital implants (injections of material into the wall of the urethra to help control urine leakage [urinary incontinence] caused by a weak urinary sphincter). During a review of Resident 15's Order Summary Report, the Order Summary Report indicated a physician's order was placed 9/23/2025 for an indwelling catheter to gravity drainage (a method that uses natural gravity to move fluids (urine)). During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/2025, the MDS indicated Resident 15 had moderate cognitive impairment (a stage of decline in cognitive abilities like memory and thinking that is more significant than normal aging). During an observation on 11/20/2025 at 8:16 a.m., Resident 15 was noted to have an indwelling urinary catheter draining pale yellow liquid. B. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including chronic kidney disease (involves a gradual loss of kidney function [kidneys filter wastes and excess]), benign prostatic hyperplasia (a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination), and presence of urogenital implants (injections of material into the wall of the urethra to help control urine leakage [urinary incontinence] caused by a weak urinary sphincter). During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 121's Admit/RE-Admit Nursing Evaluation, dated 11/12/2025 at 10:30 p.m., the evaluation indicated Resident 121 had a foley catheter (medical device that helps drain urine from your bladder) in place. During a concurrent interview and record review on 11/20/2025 at 3:45 p.m., with Registered Nurse Supervisor (RNS) 2, Resident 15 and 121's medical records were reviewed and there was no record of foley output being recorded. RNS 2 stated the facility does not measure or record foley catheter urinary output but it was a good idea to record the output to make sure the residents did not have any complications. During an interview on 11/21/2025 at 3:37 p.m. with the Director of Nursing (DON), the DON stated foley catheter output was not measured unless there was a physician order. The DON stated measuring the output was important to prevent dehydration. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary revised 9/2014, the P&P indicated: 1) The purpose of this procedure was to prevent catheter-associated urinary tract infections. 2) Maintain an accurate record of the residents' daily output, per facility policy and procedure.

Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 101, 55, and 113) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to:1a. Provide Resident 101 with a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) evaluation and assessment prior to increasing the wear time for both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 30 minutes to two to four hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment.1b. Objectively measure Resident 101's ROM in both legs during the PT Evaluation dated 7/13/2025.2a. Objectively measure Resident 55's ROM in the right leg during the PT Evaluation dated 9/26/2025.2b. Objectively measure Resident 55's ROM in the left hand during the Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 9/26/2025.3. Ensure Resident 113 received appropriate interventions to prevent mobility decline.These deficient practices had the potential to cause injury and pain due to ill-fitting splints for Resident 101, prevent accurate monitoring of declines in range of motion for Residents 101 and 55, and cause decline in mobility in Resident 113.Findings:1.During a review of Resident 101's admission Record (AR), the AR indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including but not limited to primary osteoarthritis (OA, a progressive disorder of the knee joint, caused by a gradual loss of cartilage) of right hip and left shoulder, polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and morbid obesity due to excess calories (disorder involving excessive body fat that increases risk for health problems). During a review of Resident 101's Minimum Data Set (MDS, resident assessment tool) dated 8/20/2025, the MDS indicated Resident 101 had no cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 101 required setup assistance with eating, supervision for oral hygiene, and substantial assistance for toileting hygiene, showering, lower body dressing and sit to lying. The MDS indicated Resident 101 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 101 did not have any functional limitations in range of motion (ROM, full movement potential of a joint) in the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 101's Care Plan Report (CP), the CP initiated 1/3/2023 and target date of 2/17/2026 indicated Resident 101 was at risk for decline in Activities of Daily Living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) functions, mobility and joint mobility related to OA, severe obesity, right knee contracture (loss of motion of a joint. The CP goal indicated Resident 101 will minimize potential declines in joint mobility. The CP interventions indicated to observe for pain or joint stiffness while providing RNA/ROM, RNA to provide both knee extension splints (splints to help keep the knee in a straight position) two to four hours three times a week or as tolerated, RNA to provide both UE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) three times a week or as tolerated, RNA to provide both [NAME] passive range of motion (PROM, movement at a given joint with full assistance from another person) three times a week or as tolerated. 1a. During a review of Resident 101's Order Listing Report (OLR) dated 11/20/2025, the OLR indicated an order dated 7/30/2025 and discontinued on 9/23/20225 for RNA to provide both knee extension splints for 30 minutes three times a week or as tolerated. During a review of Resident 101's Restorative Assessment/Referral (RAR) dated 9/23/2025, the RAR indicated to discontinue the RNA order to provide both knee extension splints for 30 minutes three times a week or as tolerated.During a review of Resident 101's Order Summary Report (OSR) dated 11/20/2025, the OSR indicated an order dated 9/23/2025 for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated. During a review of Resident 101's RAR dated 9/23/2025, the RAR indicated for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated. During an observation and interview on 11/18/2025 at 10:35 a.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated she was supposed to have splints on her legs and staff put on the splints about 40 minutes at a time. During an observation and interview on 11/20/2025 at 9:47 a.m., RNA 1 performed Resident 101's RNA treatment in Resident 101's room. Resident 101 was lying in bed and was able to move both arms up and down. Resident 101 knees were bent all the way and rotated to the left side. RNA 1 attempted to lift Resident 101's right leg up but Resident 101 refused and stated it was painful. Resident 101 was able to move the left knee from the bent position and straighten the knee a little. RNA 1 put on both knee splints that were black and had dials on the side of the knee brace. The right knee brace dial was not next to the right knee and was lower next to the calf for the right leg. RNA 1 stated it was tricky to put on both knee splints. RNA 1 stated Resident 101 wore the knee brace for usually about an hour. During an interview and record review on 11/20/2025 at 10:56 a.m., the Occupational Therapist (OT 1) stated therapy staff was the profession that had the training and education to evaluate and assess whether a splint or brace was appropriate, including establishing a safe and tolerable splint wear time for each resident. OT 1 stated during therapy treatment sessions, the therapist will trial a splint and slowly increase the wear time to assess how long a resident was able to tolerate the splint. OT 1 stated it was important for a therapist to assess and slowly increase splint wear time, because the splint can be painful or cause changes in skin integrity if the splint was not fitted correctly. During the same interview and record review, OT 1 reviewed Resident 101's medical records and stated Resident 101 had an order dated 9/23/2025 for RNA to put on both knee extension splints for two to four hours three times a week. OT 1 reviewed Resident 101's PT records and indicated Resident 101's PT evaluation dated 7/13/2025 did not indicate any goals related to knee splints. OT 1 reviewed PT treatment records from 7/13/2025 to 7/23/2025 and PT Discharge summary dated [DATE] and indicated there were no PT treatment notes indicating PT addressed the knee splint or worked on increasing wear time for both knee splints. OT 1 reviewed Resident 101's PT records and stated Resident 101 did not receive any further PT treatment after Resident 101 was discharged from PT on 7/23/2025. During an interview and record review on 11/20/2025 at 2:34 p.m., OT 1 reviewed Resident 101's Restorative Assessment/Referral (RAR) forms dated 7/23/2025 and 9/23/2025 signed by OT 1 and PT 2 (who was no longer working at the facility). OT 1 stated Resident 101's RAR dated 9/23/2025 indicated to change Resident 101's RNA order for wearing both knee splints from 30 minutes to two to four hours three times a week. OT 1 stated there was no PT intervention or assessment on or around 9/23/2025 to safely assess Resident 101's tolerance from 30 minutes to two to four hours. OT 1 stated to increase wear time for any splint from 30 minutes to two to four hours was a lot of time and PT would need to assess and wear the knee splint first for two to four hours before an RNA order for splint wear time should be changed. OT 1 stated a therapy assessment was required first, because if a resident wore a splint for longer than a resident could safely tolerate, it could put pressure on bony prominences (where a bone is close to the surface of the skin), cause pain and a decline in skin integrity. During a phone interview on 11/20/2025 at 4:12 p.m., Physical Therapist (PT 1) stated a splint helped to prevent worsening of contractures and a lot of decision making from a therapist went into whether a splint was appropriate for each individual resident or not. PT 1 stated a therapist assessed and established a program for a splint or brace. PT 1 stated a therapist had to first establish a protocol in which the therapist assessed the type of splint was appropriate for a resident and how long to wear the splint for. PT 1 stated a therapist set up the parameters for splint wear time, because the tolerance for the splint needed to be assessed such as if a resident had pain, then the splint wear time needed to be decreased. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 1b. During a review of Resident 101's PT Evaluation and Plan of Treatment dated 7/13/2025, the PT Evaluation indicated Resident 101's right hip, ankle, and foot were within normal limits (WNL) and the left hip, ankle, and foot were WNL. The PT Evaluation indicated Resident 101's right knee and left knee were impaired. The PT Evaluation did not include measurements of Resident 101's knees. During a concurrent interview and record review on 11/20/2025 at 10:56 a.m. with OT 1, PT Evaluation dated 7/13/2025 was reviewed. OT 1 stated the PT Evaluation dated 7/13/2025 indicated Resident 101's both knees were impaired, but the PT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the PT Evaluation, OT 1 could not tell how impaired Resident 101's knees were. OT 1 stated it was standard of practice for therapy evaluations to include ROM assessments. OT 1 stated therapy staff needed to include objective measurements for ROM to monitor changes in the joints. During a phone interview on 11/20/2025 at 4:12 p.m., Physical Therapist (PT 1) stated a PT would assess ROM during a PT evaluation. PT 1 stated if a joint had impaired ROM, the expectation would be to document the measurements and degrees of ROM the joint had. PT 1 stated PT and OT were the only disciplines that had the education and training to provide ROM measurements at a certain joint. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments will include care-specific details including assessment data. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 2. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including but not limited to parkinsonism (a group of conditions that cause movement problems), anxiety disorder, muscle wasting and atrophy (gradual decline). During a review of Resident 55's Physician Progress Notes dated 6/27/2025, the Physician Progress Notes indicated Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's Minimum Data Set (MDS, resident assessment tool) dated 8/12/2025, the MDS indicated Resident 55 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 55 required substantial assistance for eating, oral hygiene, toileting hygiene, showering, upper body dressing. The MDS indicated Resident 55 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 55 had functional limitations in range of motion (ROM, full movement potential of a joint) on one side of the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 55's Care Plan Report (CP), the CP initiated 9/25/2025 and target date of 2/9/2026 indicated Resident 55 was noted with decrease in ROM to both UE and both [NAME]. The CP goal indicated Resident 55 will not have further decrease in ROM to BUE and BLE by next review date, will show improvement. The CP interventions indicated for PT/OT as ordered. During a review of Resident 55's Occupational Therapy Evaluation and Plan of Treatment dated 9/26/2025, the OT Evaluation indicated Resident 55 had impaired ROM in the left index finger, middle finger, ring finger, and little finger. The OT Evaluation did not include measurements of Resident 55's left finger joints. During a review of Resident 55's Physical Therapy Evaluation and Plan of Treatment dated 9/26/2025, the PT Evaluation indicated Resident 55 had impaired ROM in the right ankle. The PT Evaluation did not include measurements of Resident 55's right ankle. During an observation and interview on 11/18/2025 at 9:26 a.m., Resident 55 was lying in bed with head of bed up about halfway. Resident 55 stated he received exercises for his arms and legs five days a week. Resident 55 was able to lift both arms to about shoulder level and open both fingers a little. Resident 55's left and right ring and little fingers were slightly bent at two joints closer to fingertips and could not fully straighten his fingers. Resident 55 was able to move both legs a little and both ankles were pointed away from the body. Resident 55 was able to move both ankles a little. During a concurrent interview and record review on 11/20/2025 at 10:56 a.m. with Occupational Therapist (OT 1), Resident 55's OT Evaluation dated 9/26/2025 and PT Evaluation dated 9/26/2025 were reviewed. OT 1 stated Resident 55's OT Evaluation dated 9/26/2025 indicated Resident 55's left fingers were impaired, but the OT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the OT Evaluation, OT 1 could not tell how impaired Resident 55's left fingers were. OT 1 stated Resident 55's PT Evaluation dated 9/26/2025 indicated Resident 55's right ankle was impaired, but the PT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the PT Evaluation, OT 1 could not tell how impaired Resident 55's right ankle was. OT 1 stated it was standard of practice for therapy evaluations to include ROM assessments. OT 1 stated therapy staff needed include objective measurements for ROM to monitor changes in the joints. During a phone interview on 11/20/2025 at 4:12 p.m. Physical Therapist (PT 1) stated a PT would assess ROM during a PT evaluation. PT 1 stated if a joint had impaired ROM, the expectation would be to document the measurements and degrees of ROM the joint had. PT 1 stated PT and OT were the only disciplines that had the education and training to provide ROM measurements at a certain joint. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments will include care-specific details including assessment data. 3. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility 6/16/2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged pressure)of sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During an interview on 11/18/2025 at 10:01 a.m. with Resident 113, Resident 113 stated they used to walk with a walker with the staff, and but has gotten weaker and does not walk with the staff anymore. During a review of Resident 113's physician orders, the orders indicated: 6/26/2025 - 11/4/2025 Restorative Nursing Aide (RNA) to provide ambulation program with front wheel walker (FWW) 3x/week or as tolerated and document walking distance 11/4/2025 RNA to provide bilateral (both) upper extremity (BUE)/Bilateral lower extremity (BLE) active range of motion (AROM- resident can move independently with instruction) 3x/week or as tolerated. During a concurrent interview and record review on 11/19/2025 at 2:21p.m. with Restorative Nursing Aide (RNA a specialized Certified Nursing Assistant who supports residents in regaining or maintaining physical function) RNA 1 , Resident 113's daily and weekly RNA documentation from June 2025 to November 2025 was reviewed. RNA 1 stated the daily documentation indicated: In July 2025, Resident 113 ambulated 150 feet (ft- a unit of measurement of distance) with the RNA every week The week of 8/3/2025 - 8/9/2025, Resident 113 ambulated 80 ft with the RNA The week of 8/10/2025 - 8/16/2025, Resident 113 ambulated 40 ft with the RNARNA 1 stated if a resident refuses or there are changes such as a decline, the RNA reports the change to the Licensed Vocational Nurse (LVN) or the Director of Nursing (DON) who would report it to the physician. RNA 1 stated During a concurrent interview and record review on 11/21/2025 at 10:07 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 113's medical record was reviewed. The MDSC stated the physician was notified on 10/202/2025 that Resident 113 had lower back pain and right leg weakness and was notified on 10/24/2025 that Resident 113 refused to ambulate. The MDSC stated The MDSC stated if a resident's ambulation declines from 150 ft to less than 100 ft, it should be communicated to the physician. During a concurrent interview and record review on 11/21/2025 at 11:27 a.m. with LVN 1, Resident 113's medical record was reviewed. LVN 1 stated if there is a decrease in distance ambulated, they would expect the RNA to report the change to the LVN who would initiate a Change of Condition (COC) and notify the physician. LVN 1 stated they would have expected the physician to be notified by 8/11/2025 when the distance ambulated was trending down. During an interview on 11/21/2025 at 1:44 p.m. with the Director of Rehabilitation (DOR), the DOR stated any concerns or decline in resident ambulation should be discussed in the weekly RNA meetings which include the RNA's, the DON, and the DOR. During an interview on 11/21/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated it is important to notify the physician when there is a change of condition such as a decline in ambulation so the provider is aware of the resident's condition, and so that the resident gets proper evaluation and treatment. During an interview on 11/21/2025 at 4:17 p.m. with the Medical Director (MD), the MD stated, in general, if there is a decline in ambulation the facility should notify the provider, and the provider would usually recommend a physical therapy evaluation. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised December 2016, the P&P indicated The nurse will notify the residents attending physician or physician on call when there has been a: .d. significant change in the residence physical/emotional/mental condition.f. Refusal of treatment or medication two or more consecutive times. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.

Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Resident 11 and Resident 125) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and impaired blood sugar control. Findings:a. During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cataract (clouding of the eye's natural lens)During a review of Resident 11's History and Physical (H&P), dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 11 Minimum Data Set (MDS - a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 11 had intact cognition (ability to think and understand). The MDS indicated Resident 11 needed set up or clean up assistance from staff for eating and oral hygiene. The MDS indicated Resident 11 needed moderate assistance from staff for toileting hygiene and bathing.During a review of Resident 11's Physician Order dated 9/14/2025, the Physician Order indicated an order of insulin lispro (fast-acting insulin that works fast to lower blood sugar) injection solution 100 unit per milliliters (unit/ml, units of insulin contained within each milliliter of liquid), inject 3 unit subcutaneously three times a day for DM, hold if blood sugar is less than 100. During a review of Resident 11's Physician Order dated 9/15/2025, the Physician Order indicated an order of insulin glargine (long-acting insulin that works slowly and steadily to keep blood sugar stable) subcutaneous solution 100 unit/ml, inject 10 unit subcutaneously at bedtime for DM.During a review of Resident 11's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin glargine subcutaneous solution 100 units/ml was administered on:11/5/2025 at 8:53 p.m. on the arm-right11/6/2025 at 10:11 p.m. on the arm-right11/13/2025 at 10:26 p.m. on the arm-right11/14/2025 at 8:24 p.m. on the arm-right11/15/2025 at 10:12 p.m. on the arm-right11/17/2025 at 9:05 p.m. on the arm-right11/18/2025 at 8:47 p.m. on the arm-rightDuring a review of Resident 11's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin lispro injection solution 100 unit/ml was administered on:11/2/2025 at 5:26 p.m. on the arm-right11/3/2025 at 5:54 a.m. on the arm-right11/3/2025 at 5:48 p.m. on the arm-right11/4/2025 at 6:32 a.m. on the arm-right11/4/2025 at 5:30 p.m. on the arm-right11/5/2025 at 6:03 a.m. on the arm-right11/8/2025 at 11:51 a.m. on the arm-right11/9/2025 at 5:33 a.m. on the arm-right11/10/2025 at 6:53 a.m. on the arm-right11/13/2025 at 7:35 a.m. on the arm-right11/13/2025 at 10:26 p.m. on the arm-right11/14/2025 at 6:08 a.m. on the arm-right11/14/2025 at 8:24 p.m. on the arm-right11/15/2025 at 5:50 a.m. on the arm-right11/16/2025 at 5:40 a.m. on the arm-right11/17/2025 at 6:14 a.m. on the arm-right11/17/2025 at 6:24 p.m. on the arm-rightDuring an interview on 11/20/2025 at 9:31 a.m., with Resident 11, Resident 11 stated she preferred to receive insulin injections in her right arm, did not like injections in her abdomen and her left arm had a dialysis access site. Resident 11 stated she was not aware of the risks associated with repeated use of same site for insulin injections.During a concurrent interview and record review on 11/21/2025 at 9:53 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 11's Physician Order, Medication Administration Report (MAR), and Location of Administration Report for 11/1/2025 to 11/20/2025 were reviewed. LVN 3 stated Resident 11 received injections to same site on multiple occasions. LVN 3 stated insulin injections should be injected to different sites because repeated injections at the same site can lead to altered subcutaneous tissue integrity, resulting in inconsistent medication absorption. b. During a review of Resident 125's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 1/2/2024 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 125 Minimum Data Set (MDS - a resident assessment tool), dated 11/16/2025, the MDS indicated Resident 125 had moderate impaired cognition (ability to think and understand). The MDS indicated Resident 125 needed set up or clean up assistance from staff for eating and dependent on staff for toileting hygiene and bathing.During a review of Resident 125's Physician Order dated 11/11/2025, the Physician Order indicated an order of insulin lispro injection solution 100 unit/ml, inject as per sliding scale: If 151-200=2 units; 201-250=4units; 251-300=6 units; 301-350=8 units; 351-400=10 units; If blood sugar less than 400 give 12 units and call MD, subcutaneously before meals and at bedtime for DM.During a review of Resident 125's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin glargine subcutaneous solution 100 units/ml was administered on:11/13/2025 at 12:36 p.m. on the abdomen-Left Upper Quadrant (LUQ)11/13/2025 at 5:31 p.m. on the abdomen-LUQ11/13/2025 at 8:08 p.m. on the abdomen-Right Lower Quadrant (RLQ)11/15/2025 at 5:33 p.m. on the abdomen-RLQ11/16/2025 at 5:42 p.m. on the abdomen-LUQ11/16/2025 at 11:02 p.m. on the abdomen-LUQDuring a concurrent interview and record review on 11/20/2025 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 125's Physician Order, Medication Administration Report (MAR), and Location of Administration Report for 11/1/2025 to 11/20/2025 were reviewed. LVN 1 stated Resident 125 received injections to same site on multiple occasions. LVN 1 stated failure to rotate injection sites can affect the subcutaneous tissue, resulting in decreased insulin absorption and reduced effectiveness of the medication and repeated use of same site may cause tissue damage.During an interview on 11/21/2025 at 12:43 p.m., with Director of Nursing (DON), the DON stated insulin injections should follow professional standards of practice by rotating injection sites. The DON stated failure to rotate injection sites can cause bruising to the skin.During a review of facility's Policy and Procedure (P&P) titled, Insulin Administration revised 9/2014, the P&P indicated Insulin may be injected into the subcutaneous tissue of the upper arm, the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. Injection sites should be rotated, preferably within same general area (abdomen, thigh, upper arm).

Based on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two out of seven sampled residents (Resident 9 and Resident 13). This deficient practice had the potential for Resident 9 and Resident 13 to not receive person-centered care. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). During a review of Resident 13's Occupational Therapy Treatment Encounter Note(s) dated 11/16/2025, the Occupational Therapy Treatment Encounter Note indicated Resident 13 was non-compliant in regard to wearing the left Wrist-Hand-Finger Orthosis (WHFO, a type of brace or support that extends from the forearm to the tips of the fingers and thumb, providing support and positioning for the entire hand and wrist structure). During an observation on 11/19/2025 at 9:34 a.m., Resident 13 was noted to have a left hand and wrist contracture. During an interview on 11/21/2025 at 1:02 p.m., Occupational Therapist (OT) 1 stated she reviewed Resident 13's Occupational Therapy Treatment Notes for the month of November 2025 and stated Resident 13 was being seen by occupational therapy twice a week and they were working on Resident 13's tolerance to the left WHFO splint to the left wrist. OT 1 stated Resident 13 had limitations to left upper arm, and she had a contracture on the shoulder, elbow, and hand of left upper arm. OT 1 stated Resident 13 was supposed to wear the splint for one hour total for the week but based on the Occupational Therapy Treatment notes, Resident 13 often refused to wear the left WHFO. During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated she reviewed Resident 13's care plans and there was no care plan created regarding refusing the left WHFO splint. The DON stated care plans for refusals were important to communicate between the different departments and for continuity of care. The DON stated care plans were important to ensure the resident was receiving proper care. A review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised December 2016, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. A review of Resident 9's admission Record, dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic strong enough to interfere in everyday activities) and seizure disorder (a medical condition caused by uncontrolled electrical activity in the brain.) A review of Resident 9's History and Physical (a record of a physician's comprehensive medical examination), dated 6/9/25, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 9's Order Summary Report (a summary of all active physician's orders), dated 11/20/25, indicated she was prescribed the following medications: 1. Buspar 10 milligrams (mg – a unit of measure for mass) by mouth twice daily for anxiety manifested by uncontrollable screaming/yelling. 2. Depakote DR 500 mg by mouth twice daily for seizure disorder. A review of Resident 9's care plan for anxiety, initiated 11/12/23, did not indicate the use of Buspar as a targeted intervention related to Resident 9's anxiety disorder. A review of all available care plans indicated there were no other care plans to address Resident 9's use of Buspar for behavioral management. A review of Resident 9's care plan for seizure disorder, initiated 11/1/23, did not indicate the use of Depakote as a targeted intervention related to Resident 9's seizure disorder. A review of all available care plans indicated there were no other care plans to address Resident 9's use of Depakote for the management of seizure disorder. During an interview on 11/20/25 at 10:46 AM with the Director of Nursing (DON), the DON stated the facility failed to create a comprehensive care plan related to the use of Resident 9's Buspar and Depakote. The DON stated the seizure care plan does not list Depakote as a targeted intervention and the anxiety care plan does not list Buspar as a targeted intervention. The DON stated the care plans for psychotropic medications or medications with FDA black box warnings are necessary so that the nursing staff are educated in their specific risks and required monitoring for a resident's medication therapy. The DON stated if care plans are not made to address the use of high-risk medications, it is possible that the resident may experience adverse effects of those medications possibly leading to a decline in their quality of life. A review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the facility's policy Behavioral Assessment, Intervention and Monitoring, revised December 2016, indicated The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The care plans will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure one of two resident's (Resident 20) Bilevel positive airway pressure ([BIPAP] type of noninvasive ventilation that helps you breathe) machine was maintained as indicated in facility policy and indicated in the BIPAP User Guide. The deficient practices had the potential to result in serious health risks such as bacterial growth and infection and potential damage to the device.Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD]a chronic lung disease causing difficulty in breathing) and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).During a review of Resident 20's Minimum data Set ([MDS] a resident assessment tool), dated 9/26/2025, the MDS indicated Resident 20 had intact cognition (ability to make decisions of daily living). The MDS indicated Resident 20 needed set up assistance when eating, supervision with oral hygiene, partial assistance (helper does less than half the effort) with personal hygiene, and substantial assist (helper does more than half the effort) with toileting hygiene. During a review of Resident 20's Order Summary Report, the report indicated, starting on 4/18/2025, BIPAP machine use starting at 8 p.m. and off at 7 a.m. every evening and night shift. During a concurrent observation and interview on 11/18/2025 at 12:37 p.m., at Resident 20's bedside, Resident 20's BIPAP machine was observed with water still in the humidifier canister. Licensed Vocational Nurse (LVN) 4 stated the water the staff used for the machine was purified water (water which may contain trace amounts of minerals or dissolved gases, unlike distilled water which removes nearly all impurities through evaporation and condensation).During a concurrent interview and record review on 11/20/2025 at 10:10 a.m., with Registered Nurse Supervisor (RNS) 2 Resident 20's physician orders and Medication and Treatment Administration records, dated 4/2025 to 11/2025, were reviewed. RNS 2 stated BIPAP machine, masks, tubing care and maintenance were not completed. During an interview on 11/20/2025 at 3:53 p.m. with the Director of Nursing (DON), the DON stated if BIPAP machine, masks, tubing care and maintenance was not documented it was not done. During a review of the facility's policy and procedure (P&P) titled, CPAP/BIPAP Support, revised 3/2015, the P&P indicated the policy was to promote resident safety. The P&P indicated specific cleaning instructions are obtained from the manufacturer/supplier of the device. The P&P general guidelines for cleaning, include:1. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed.2. Humidifier (if used):a. Use clean, distilled water only in the humidifier chamber.b. Clean humidifier weekly and air dry.c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly.3. Replace disposable filters monthly.4. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between use.5. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to airdry. During a review of Resident 20's BIPAP User manual, undated, the User guide indicated the following:1. Regularly clean and check for damages the tubing assembly, humidifier and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health.2. Clean the humidifier and tubing device weekly.3. Empty the humidifier daily and wipe it thoroughly with clean, disposable cloth and air dry. 4. Replace the air filter at least every 6 months or as needed.During a review of the guide titled, Looking after your CPAP gear, A guide to cleaning, maintenance and ongoing care, 2023, the guide indicated keeping the CPAP mask clean was key to ensuring that it fits and seals well. The guide indicated cleaning the mask cushion and tubing daily and the mask frame and headgear weekly. The guide indicated replacing the foam mask cushions a monthly.

Based on observation, interview, and record review, the facility failed to obtain a consent form for the use of an abdominal binder (belt used to support the abdomen after surgery, improve physical function), complete the restraint assessment, and monitor the use of abdominal binder for one of 26 sample residents (Resident 121). These deficient practices resulted in unnecessary restraint and placed the residents at risk of physical harm, skin injuries, or entrapment.During a review of Resident 121s admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities).During a review of Resident 121's Minimum Data Set ([MDS] a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 121's Admit/RE-Admit Nursing Evaluation, dated 11/12/2025 at 10:30 p.m., the evaluation indicated Resident 121 had a gastrostomy tube ([G- tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a concurrent observation and interview, on 11/19/2025 at 3:45 p.m., at Resident 121's bedside, with Registered Nurse Supervisor (RNS) 1, Resident 121 was noted with an abdominal binder (wide compression belt that encircles the abdomen) in place covering the G-tube site. RNS 1 1 stated that Resident 121 had the abdominal binder in place to prevent Resident 121 from pulling out the G-tube. RNS 1 stated Resident 121 cannot remove the abdominal binder easily and the abdominal binder prevents Resident 121 from pulling the G-tube.During a concurrent interview and record review on 11/19/2025 at 3:45 p.m., with RNS 1, Resident 121's medical records were reviewed. RNS 1 stated there was no assessment for abdominal binder use and there was no informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) obtained from the resident or responsible party. During an interview on 11/21/2025 at 2:56 p.m. with the Director of Nursing (DON), the DON stated a restraint was a device that restricts residents' movements. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, revised 12/2007, the P&P indicated:1) Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.2) Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etcetera) that may improve the symptoms.3) Residents and/or responsible parties shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.

Based on interview and record review, the facility failed to inform one of two sampled residents (Resident 11) of the risks associated with repeated subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections administered in the same anatomical site.This deficient practice had the potential to limit Resident 11's ability to make informed decisions regarding treatment.Findings:During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cataract (clouding of the eye's natural lens).During a review of Resident 11's History and Physical (H&P), dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 11 had intact cognition (ability to think and understand). The MDS indicated Resident 11 needed set up or clean up assistance from staff for eating and oral hygiene. The MDS indicated Resident 11 needed moderate assistance from staff for toileting hygiene and bathing.During a review of Resident 11's Physician Order dated 9/14/2025, the Physician Order indicated an order of insulin lispro (fast-acting insulin that works fast to lower blood sugar level) injection solution 100 unit per milliliters (unit/ml, units of insulin are contained within each milliliter of liquid), inject 3 unit subcutaneously three times a day for DM, hold if blood sugar is less than 100. During a review of Resident 11's Physician Order dated 9/15/2025, the Physician Order indicated an order of insulin glargine (long-acting insulin that works slowly and steadily to keep blood sugar stable) subcutaneous solution 100 unit/ml, inject 10 unit subcutaneously at bedtime for DM.During an interview on 11/20/2025 at 9:31 a.m., with Resident 11, Resident 11 stated she preferred to receive insulin injections in her right arm, did not like injections in her abdomen and her left arm had a dialysis access site. Resident 11 stated she was not aware of the risks associated with repeated use of same site for insulin injections.During a concurrent interview and record review on 11/21/2025 at 9:53 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 11's Physician Order for 11/2025, Medication Administration Report (MAR) for 11/2025, Location of Administration Report for 11/1/2025 to 11/20/2025 and Progress Notes for 11/13/2025 to 11/17/2025 were reviewed. LVN 3 stated Resident 11 received injections to same site on multiple occasions. LVN 3 stated when a resident preferred a specific insulin injection site, nursing staff should educate the residents on the risks of repeated injections and benefits of rotating sites to make residents aware and able to make informed decisions regarding care. LVN 3 stated there was no documentation in Resident 11 Progress Notes and MAR indicating that Resident 11 had been educated regarding insulin site rotation. During an interview on 11/21/2025 at 12:43 p.m., with Director of Nursing (DON), the DON stated residents had rights to refuse care and treatment, but nursing staff must educate residents that repeated injections in the same site can cause bruising or harm.During a review of facility's policy and procedures (P&P) titled, Resident Rights revised 12/2016, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to.be informed of, and participate in, his or her care planning and treatment.participate in decision making regarding his or her care.

Based on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room. 3. Ensure Resident 89's room was changed closer to the nursing station for a closer observation/visibility as care planned. These deficient practices resulted in Resident 89 attempting to remove his soiled incontinence brief (diaper) himself and fall out of bed sustaining a left hip fracture and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. At the GACH Resident 89 was diagnosed with closed left basicervical (area located at the junction between the femoral [the bone of the thigh] neck [part of the bone that connects the head of the bone with the middle part of the bone] and intertrochanteric region [area where the femur changes from a vertical bone to a bone angling at a 45 angle]) femur fracture requiring left hip open reduction internal fixation ([ORIF]-a type of surgery used to hold the broken bone together) with cephalomedullary nail (a surgical devise to stabilize the fracture). Resident 89 returned to the facility on [DATE] with 11 staples on the incision (surgical cut) measured 5.0 centimeters [(cm) a unit of measure] by 0.1 cm to superior (top) surgical site of left hip, seven staples on the incision measured 4.0 cm by 0.1cm to inferior (bottom) surgical site of a left hip. Findings: During a review of Resident 's 89 Admission Record (Face Sheet), the Face Sheet indicated Resident 89 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty in walking, unspecified dementia (impaired ability to remember, think, or make decisions), spinal stenosis (space inside the backbone is too small) of lumbar region (lower part of the back) type 2 diabetes (a disease that occurs when a person's blood glucose, also called blood sugar, is too high) and transient ischemic attack [(TIA) a condition when blood supply to part of the brain was briefly interrupted). During a review of Resident 89's History and Physical (H/P), dated 8/12/2023, the H/P indicated, Resident 89 had the capacity to understand and make decisions. During a review of Resident 89's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 6/07/2023, the MDS indicated Resident 89's cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making were mildly impaired. The MDS indicated, Resident 89 required extensive physical assistance from staff for bed mobility, transfer, walk in room, toilet use, and personal hygiene. The MDS indicated Resident 89 was frequently (seven or more episodes) incontinent with urinary continence and frequently (two or more episodes) incontinent of bowel. During a record review of Resident 89's Fall Risk Evaluation dated 6/07/2023 and timed at 5:00 p.m., the Fall Risk Evaluation indicated Resident 89 was scored seven (0-5 low risk, 6-20 medium risk, 21-45 high risk) which indicated moderate risk for falls. The Fall Risk Evaluation indicated to provide Resident 89 with safe environment, clutter free, necessary belonging within reach, and attend needs in a timely manner. During a review of Resident 89's GACH Emergency Department (ED) notes, dated 8/08/2023, and timed at 10:51 a.m., the ED notes indicated Resident 89 presented to the ED after rolling out of bed and landing on his left hip. The ED notes indicated Resident 89 was diagnosed with a nondisplaced intertrochanteric left hip fracture. The ED notes indicated Resident 89 undergo ORIF of the left hip. During a review of Resident 89's GACH Computerized tomography [(CT) computerized x-ray {a photographic or digital image of the internal composition of something}] scan dated 8/08/2023, CT scan indicated the resident had an acute nondisplaced intertrochanteric fracture of the proximal left femur neck fracture. During a review of the facility's Licensed Nurses Progress Note (LNPN), dated 8/07/2023, and timed at 9:56 p.m., the LNPN indicated Resident 89 was found lying on the floor in the resident's room. The LNPN indicated Resident 89 was complaining of pain of the left hip and the resident had a purple discoloration on the forehead. The LNPN indicated 911 (emergency number) was called and Resident 89 was transferred to GACH. During a review of Situation Background Assessment and Recommendation [(SBAR) communication framework that can help teams share information about the conditions of the resident] form and LNPN dated 8/07/2023, and timed at 9:51 p.m., the SBAR indicated, at around 8:30 p.m., clinical nurse (CN) summoned the registered nurse supervisor (RNS) to Resident 89's room. The CN observed Resident 89 lying on the floor. SBAR indicated Resident 89 complained of pain level five out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is worse possible pain) of the left hip. SBAR indicated Resident 89 was transferred to the GACH for further evaluation at 8:45 p.m. During a review of Resident 89's Care Plan (CP) titled, Risk for fall related to balance problem during transition (sit to stand) initiated on 6/1/2023, the CP indicated the resident required assistance with walking and bed mobility. The CP indicated the goal for Resident 89 was to decrease significant injury as a result from falls and to minimize the risk for potential for fall related to resident's getting out of bed without waiting for staff assistance. The CP interventions included to provide Resident 89 with the adequate support from staff during activities of daily living (ADL) and transfers. The CP also indicated to move Resident 89 to a room close to the nursing station for a better visibility. During an interview on 10/05/2023 at 11:42 a.m. with Resident 89, the resident stated he called for assistance by using the call light and waited for a long time and no one came to help. Resident 89 stated he needed his soiled diaper changed. Resident 89 stated it felt like he was waiting for more than an hour. Resident 89 stated he just kept on pressing the call light and no one was responding to his call for help. Resident 89 stated, when CNA 6 came in response to his (Resident 89's) call light, CNA 6 saw his soiled diaper needed to be changed. Resident 89 stated CNA 6 did not change his diaper and told him (Resident 89) to wait until he (CNA 6) comes back and left the room. Resident 89 stated, he had been waiting for a long time, so he decided to remove his diaper by himself. Resident 89 stated, when he attempted to sit up in bed, he felt dizzy and rolled out of his bed to the floor. Resident 89 stated, he had severe pain to his left side and screamed in pain. During a phone interview on 10/05/2023, at 3:01 p.m., with CNA 6, CNA 6 stated on 8/07/2023 around 8:20 p.m., he answered Resident 89's call light and found Resident 89 trying to remove his diaper while in bed. CNA 6 stated to Resident 89 to leave the diaper on and left the room. CNA 6 stated he explained to Resident 89 that he would grab some towels and water to clean him. When CNA 6 came back, Resident 89 was on the floor adjacent to his bed laying on his back complaining of left-side pain. During an interview on 10/5/2023 at 3:24 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 89 can make his needs known to staff. LVN 3 stated Resident 89 was assessed as moderate risk for fall and should not be left alone and provided the care needed. LVN 3 stated the Director of Rehabilitation (DOR) assess the residents upon admission and staff should provide the residents with assistance based on the DOR assessment. During a concurrent interview and record review on 10/06/2023, at 8:41 a.m., with the DOR, the DOR reviewed Physical Therapy (PT) Discharge Summary, and stated, Resident 89 was able to safely ambulate using front-wheeled walker (assistive device) with supervision or touching assistance for proper sequencing (correct way of walking with assistive device) Physical Therapy discharge Summary dated from 6/20/2023 to 8/7/2023 indicated, Resident 89 required supervision or touching assistance with bed mobility, transfer, and ambulation. The DOR stated, there was a great possibility that Resident 89 could fall if Resident 89 gets out of bed by himself and/or walks by himself. The DOR stated, he did not recommend at all for Resident 89 to walk or get out of bed by himself. During a review of Resident 89's PT Discharge Summary dated from 6/20/2023 to 8/7/2023, the PT Discharge Summary indicated, Resident 89 required supervision or touching assistance with bed mobility (roll left and right), transfer from bed to chair, ambulation, and picking up object. During a phone interview on 10/6/2023 at 8:54 a.m. with LVN 4, LVN 4 stated he remembered that on 8/7/2023 during 3 p.m. to11 p.m. shift at around 8 p.m. he heard a loud scream coming from Resident's 89's room when he (LVN 4) was attending to another resident. LVN 4 stated he walked to Resident 89's room and saw Resident 89 was lying on the floor, on his left side. LVN 4 stated, he remembers that Resident 89 needed moderate to maximum physical assistance from one staff. Resident 89's room was located about 40 feet away from the nursing station. LVN 4 stated, CNA 6 told him that CNA 6 walked out of Resident 89's room to get water and towel and when CNA 6 came back to Resident 89's room, Resident 89 was found on the floor. LVN 4 stated, Resident 89 was not supposed to be left alone when the resident needed help because Resident 89 has been trying to stand up by himself and tried to be independent. During an interview on 10/06/2023, at 12:11 p.m., with the Director of Nursing (DON), the DON stated, if a resident was at moderate risks for falls, she educated a resident to use a call light for assistance. The DON stated after Resident 89's fall on 8/8/2023 we moved the resident in a room closer to the nursing station. The DON stated the facility staff should answer a call light promptly especially when a resident is at the risk for fall. The DON sated the facility staff discuss and communicate with each other to identify the residents who were at a moderate to high risk for fall. The DON stated the facility staff should not left Resident 89 alone since CNA 6 noticed Resident 89 felt uncomfortable with having on a soiled diaper. The DON stated if staff noticed that the resident would try to clean himself or herself up, staff should stay with the resident and ask other staff (CNA/LVN) to get the needed supply. The DON stated CNA 6 should have used the call light to ask for staff assistance and not leave resident 89's room. During a review of the facility's undated P&P titled, Fall Prevention Program, revised 12/2007, the P&P indicated to assist resident with toileting needs upon rising before and after meals, before and after bed and as needed. During a review of the facility's P&P titled, Safety and Supervision of Residents revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's undated P&P titled, Answering the Call Light. (undated) the P&P indicated staff to answer the resident's call as soon as possible. The P&P indicated, if assistance is needed when staff enter the room, summon help by using the call signal. During a review of the facility's P&P, titled Care Plans-Comprehensive, revised 09/2010, the P&P indicated, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representatives (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

Based on observation, interview, and record review, the facility failed to ensure four of ten sampled residents (Resident 83, 20, 19, and 81) received appropriate services to prevent a decline in range of motion [(ROM) a full movement potential of a joint] and mobility. The facility failed to: 1. Ensure a Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) service was provided to Resident 83's right hand per Occupational Therapist [(OT), professional who provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations upon discharge from therapy on 10/7/2021 and 2/2/2022. 2. Ensure Resident 83 was provided with ROM services based on the Joint Mobility Assessments, which indicated Resident 83's had a decline in right hand ROM. The Joint Mobility Assessments indicated Resident 83's right hand ROM was at a minimal loss on 1/21/2022, and 3/31/2022, and at severe loss on 7/1/2022, and on 10/5/2022. 3. Ensure Resident 20 was assisted out of bed in accordance with the resident's wishes to maintain and improve the resident's mobility. 4. Ensure Resident 19's physician's order for RNA contained information on the distance for the resident's ambulation with RNA to maintain the resident's mobility. 5. Ensure Resident 81's physician's order for RNA contained information on the distance for the resident's ambulation with RNA to maintain the resident's mobility. These failures resulted in Resident 83's loss of ROM in right hand and developing contracture (chronic loss of joint motion associated with deformity and joint stiffness) and pain. As a result of these failures, Residents 19, 20, and 81 were placed at risk to experience physical, emotional, and functional mobility decline. Findings: A. During a review of Resident 83's Admission Record (AR), the AR indicated Resident 83 was admitted to the facility on [DATE] with diagnoses including right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following an intracerebral hemorrhage (bleeding in the brain), functional quadriplegia (inability to move due to severe physical disability or medical condition), and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 83's Minimum Data Set (MDS), a standardized assessment and a care-screening tool, dated 9/30/2021, the MDS indicated Resident 83 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was non-verbal. The MDS indicated Resident 83 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), dressing, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for transfers (moving from one surface to another such as a bed or chair), eating, and bathing. The MDS indicated Resident 83 had functional limitations in ROM on one arm (shoulder, elbow, wrist, hand), and both legs (hip, knee, ankle, foot). During a review of a document titled, Occupational Therapy HMO Evaluation and Plan of Treatment (OT Evaluation), dated 9/26/2021, the OT Evaluation indicated Resident 83 had the right-hand ROM within normal limits [(WNL), no joint mobility limitations] but did not have the strength to move the right hand independently. A review of Resident 83's OT Discharge Summary, dated 10/7/2021, indicated OT recommended Resident 83 to have an RNA program upon discharge from OT therapy, to maintain current function and joint mobility. During a review of Resident 83's physician's orders, there were no physician's order for Resident 83 to have RNA services as recommended by OT on 10/7/2021. A review of Resident 83's quarterly Joint Mobility Evaluation conducted by the Director of Rehabilitation (DOR), dated 12/20/2021, indicated Resident 83's right hand/fingers ROM were within functional limits [(WFL), sufficient joint movement to functionally complete daily routines] with 1-25% ROM impairment. The Joint Mobility Limitation Key on the Joint Mobility Evaluation form indicated WFL limitation represented variance (decline) due to normal aging process allowed up to 25%. A review of Resident 83's Joint Mobility Evaluation (JME), dated 1/21/2022, indicated Resident 83's right hand/fingers had minimal ROM limitations (26-50% ROM impairment). The JME additional comments specified the resident's right hand had a contracture, which was indicative of a decline since prior ROM evaluation on 12/20/2021. A review of Resident 83's physician's orders, dated 1/27/2022, indicated OT evaluation was ordered. A review of the 'Occupational Therapy HMO Evaluation and Plan of Treatment,' dated 1/28/2022, indicated Resident 83's right hand ROM was impaired with minimal swelling. A review of Resident 83's OT Discharge Summary (DS), dated 2/2/2022, indicated OT recommended Resident 83 to have an RNA program upon discharge from OT therapy. During a review of Resident 83's physician's orders (PO), the PO indicated there were no physician's order for Resident 83 to receive RNA services as OT recommended on 2/2/2022. A review of Resident 83's quarterly JME, dated 3/31/2022, indicated Resident 83's right hand/fingers had minimal ROM limitations (26-50% ROM impairment). Additional comments indicated, (Baseline) passive Range of Motion (PROM- movement at a given joint with full assistance from another person). A review of Resident 83's quarterly JME, dated 7/1/2022, indicated Resident 83's right hand/fingers had severe ROM limitations (76-100% ROM impairment). During a review of Resident 83's physician's orders (PO), dated 7/7/2022, the PO indicated the order for RNA to perform PROM to both arms and both legs three times per week indefinitely as recommended by the Rehabilitation department. During a review of Resident 83's RNA documentation, from 7/2022 to 10/2022, the RNA documentation indicated an RNA provided PROM to Resident 83's both arms and both legs three times per week with start date on 7/8/2022. A review of Resident 83's quarterly JME, dated 10/5/2022, indicated Resident 83's right hand/fingers had severe ROM limitations (76-100% ROM limitations). During a review of Resident 83's physician's orders (PO), dated 10/26/22, the PO indicated the order for OT evaluation and treatment. During a review of a document titled Occupational Therapy HMO Evaluation and Plan of Treatment (OT Evaluation), dated 10/27/2022, the OT Evaluation indicated Resident 83 was referred to OT due to .decrease in strength and decrease in ROM especially right-hand, causing change in ADL participation related to risk of contracture. The evaluation listed measures to implement (to prevent) right hand contracture. The OT evaluation indicated the ROM of all fingers of Resident 83's right hand was impaired and included the following assessments: 1. Right thumb interphalangeal (IP, joint below the fingernail of the thumb) extension (straightening the joint): 0-30 degrees (30-degree range, normal range is 0-80 degrees). 2. Right index finger proximal interphalangeal (PIP, joint of the finger in between the fingertip joint and the large knuckle joint) PIP extension: 80-90 degrees (10-degree range, normal range is 0-100 degrees). 3. Right middle finger PIP extension: 80-90 degrees (10-degree range, normal range is 100 degrees). 4. Right ring finger PIP extension: 80-100 degrees (20-degree range, normal range is 100 degrees). 5. Right little finger PIP extension: 70-80 degrees (10-degree range, normal range is 100 degrees). OT evaluation further indicated the treatment plan indicated need for skilled therapeutic intervention, including ROM and splints to the right hand to address ROM loss and developing right hand contracture. During an interview with the DOR, an Occupational Therapist (OT), on 10/26/2022, at 1:29 PM, the DOR stated Resident 83 was evaluated by OT earlier that day. The DOR stated OT recommended a skilled therapy program and right-hand splints due to right hand ROM loss and high risk for contracture development. During a concurrent interview and record review of Resident 83's OT evaluations and Joint Mobility Screens with the DOR on 10/28/2022, at 9:30 AM, the DOR confirmed Resident 83 was admitted to the facility with normal right-hand ROM. The DOR confirmed OT Discharge Summaries on 10/7/2021 and 2/2/2022 recommended an RNA program at the time of discharge from the OT therapy to maintain Resident 83's current level of function. The DOR stated an RNA program should have been ordered on 10/7/2021 and 2/2/2022 based on OT discharge recommendations. The DOR confirmed there was the only RNA order in Resident 83's medical record dated 7/7/2022. The DOR confirmed Resident 83's Joint Mobility Assessments showed a progressive increase in right hand ROM limitations on 1/21/2022 (minimal limitations), 3/31/2022 (minimal limitations), 7/1/2022 (severe limitations), and 10/5/2022 (severe limitations). The DOR confirmed an OT evaluation should have been but was not ordered again until 10/26/2022. During a concurrent observation, in the presence of DOR, and interview on 10/28/2022, at 1:14 PM, in Resident 83's room, Resident 83 was lying in bed with the right arm resting on a pillow. Resident 83's right hand observed to have minimal swelling and was positioned in a tight fist with the thumb tucked inside the palm. Resident 83 was awake, non-verbal, and had difficulty following simple instructions. The DOR was observed unable to unclench Resident 83's right hand and had difficulty measuring the finger lengths due to Resident 83 experiencing pain. Resident 83 observed grimacing, moaning, grunting, and reaching across the body with the left arm several times to try to stop the DOR from continuing right-hand ROM. The DOR stated Resident 83 appeared to be in pain and annoyed with ROM attempts. The DOR stated Resident 83's right hand felt very stiff, the fingers could not be straightened, and the PIP joints of all the fingers had a hard end feel (felt hard/stiff at the end of the joint range). During a concurrent interview and record review with the Director of Nursing (DON) on 10/28/2022, at 2:23 PM, the DON stated there were no RNA orders and no RNA flowsheets for Resident 83 prior to 7/7/2022. The DON stated Resident 83 did not receive RNA services until after 7/7/2022 (9 months after the first OT's recommendation for RNA dated 10/7/21) as RNA was not allowed to provide services without a physician's order. During an interview with Restorative Nursing Aide 2 (RNA 2) and Restorative Nursing Aide 3 (RNA 3) on 10/28/22, at 2:33 PM, RNA 2 and RNA 3 stated they began right hand ROM exercises with Resident 83 in 7/2022. RNA 2 and RNA 3 stated Resident 83's right hand was held in a fist and felt very stiff. RNA 2 and RNA 3 stated Resident 83 did not tolerate right hand ROM exercises well due to pain and they had not been able to straighten Resident 83's fingers since RNA services began in 7/2022. During an interview with the DOR on 10/28/2022, at 2:45 PM, the DOR stated there was no Restorative Referral/Assessment form for Resident 83 in their records. The DOR stated Resident 83 was not transitioned to RNA upon discharge from OT if a Restorative Referral/Assessment form was not completed. The DOR stated monthly meetings with RNA were recently implemented so that no one gets missed like this. During a concurrent interview and record review with the DON on 10/28/2022, at 5:15 PM, the DON stated the decline in Resident 83's right hand ROM could have been avoided if the appropriate ROM services were provided. The DON confirmed Resident 83 was admitted to the facility with no right-hand ROM limitations. The DON confirmed Resident 83 developed significant right hand ROM loss since admission due to lack of ROM services. The DON confirmed Resident 83 did not receive RNA services in accordance with OT discharge recommendations for RNA program on 10/7/2021 and 2/2/2022. The DON stated OT should have evaluated Resident 83 once the Joint Mobility Assessments identified a decline in right hand ROM from minimal to severe. During a review of the facility's policy and procedure (P/P) titled, Resident Mobility and Range of Motion, revised on 7/2017, the P/P indicated the residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The P/P indicated the interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. B. During a review of Resident 20's Admission Record (AR), the AR indicated Resident 20 was readmitted to the facility on [DATE] with diagnoses including but not limited Type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), psychomotor deficit (slowing down of thoughts and physical movements) following cerebral infarction (stroke, blockage of the flow of blood to the brain, causing or resulting in brain tissue death), and muscle weakness. A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/21/2021, indicated Resident 20 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 20 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), dressing, eating, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for transfers (moving from one surface to another such as a bed or chair) and bathing. The MDS indicated Resident 20 had functional range of motion [(ROM), full movement potential of a joint)] impairments on both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). A review of Resident 20's care plan, dated 10/21/2021 and revised on 4/29/2022, indicated Resident 20 had a self-care deficit and was at risk for skin injury related to bowel and bladder incontinence (having no or insufficient voluntary control over urination or defecation) and needed assistance for bed mobility and transfers. The care plan indicated a goal for Resident 20 was to maximize functional mobility in the next three months. The care plan did not have documented interventions for staff to implement to maintain or improve Resident 20's mobility. A review of Resident 20's Interdisciplinary Team (IDT) meeting notes dated 10/21/2022 indicated Resident 20 and his caregiver were present at the meeting and nursing staff addressed his concern regarding getting up and being out of bed more often. During an observation and interview with Resident 20 on 10/26/2022, at 11:44 AM, Resident 20 was lying in bed with blankets covering both legs. Resident 20 stated he was only assisted out of bed two times a week for baths and wanted to get out of bed more often. Resident 20 stated he told nursing staff numerous times he wanted to get out of bed more often, but not assistance was provided to get the resident out of bed more than two time a week. Resident 20 stated it was important for him to get out of bed often because it made him feel good and he wanted to go home. During an interview with Restorative Nursing Aide 1 (RNA 1) on 10/26/22, at 12:05 PM, RNA 1 stated Resident 20 spent most of the day in bed and got out of bed two times a week. During an interview with Certified Nurse Assistant 7 (CNA 7) on 10/26/22, at 1:13 PM, CNA 7 stated Resident 20 got out of bed about two times a week. During an interview and record review with the Assistant Director of Nursing (ADON), Minimum Data Set Nurse (MDSN), and Quality Assurance Nurse (QAN) on 10/26/2022, at 3:31 PM, the ADON, MDSN, and QAN confirmed there were no interventions in Resident 20's care plan to address the resident's mobility. The ADON, MDSN, and QAN confirmed Resident 20 required assistance in mobility and Activities of Daily Living [(ADL), basic activities such as eating, dressing, and toileting], was at risk for skin breakdown, and had a history of pressure ulcers (injuries to the skin and underlying tissue due to long periods of pressure). The ADON, MDSN, and QAN stated Resident 20 was at risk for further skin breakdown, contracture development, and a decline in mobility since interventions addressing mobility were neither care planned nor implemented. During an interview and record review of the IDT meeting Progress Notes with the Director of Nursing (DON) on 10/27/2022, at 4:14 PM, the DON confirmed Resident 20 informed staff he wanted to get out of bed more often. The DON stated a care plan for mobility should have been created and implemented to address Resident 20's wishes and needs. The DON stated if a resident's needs were not addressed and mobility was not care planned, the staff would not know to assist the resident out of bed which could potentially lead to an emotional and physical decline. C. During a review of Resident 19's Admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cervicalgia (neck pain), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 19's Minimum Data Set (MDS), an assessment and care-screening tool, dated 7/27/2022, indicated Resident 19 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 19 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as a bed or chair), dressing, eating, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for bathing. A review of Resident 19's Physical Therapy [(PT), profession aimed in the restoration, maintenance, and promotion of optimal physical function] Discharge Summary, dated 8/5/2022, indicated Resident 19 walked 100 feet with contact guard assistance (occasional physical contact provided to maintain balance or stability) to minimal assistance (about 25% physical assistance provided to perform the task) with a front wheel walker [(FWW) mobility device used for steadying assistance and support while walking] at the time of discharge. The PT discharge recommendations included a referral of Resident 19 to the Restorative Nursing Aide Program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] for ambulation (walking). A review of Resident 19's physician's orders, dated 8/3/2022, indicated order for RNA for ambulation. During an interview and record review of Resident 19's RNA order with the Director of Rehabilitation (DOR) on 10/26/22, at 1:29 PM, the DOR stated the physician's order for RNA did not indicate walking distance. The DOR stated the physician's order for Resident 19 ambulation with RNA did not indicate the distance thus allowed the resident to walk to the resident's own tolerance. DOR stated Resident 19 was not monitor for an improvement or decline in mobility. During an interview and record review of Resident 19's RNA order with the Director of Nursing (DON) on 10/27/2022, at 2:56 PM, the DON stated the physician's order for ambulation with RNA did not include monitoring the resident for improvement or decline in mobility because the order did not indicate a walking distance. The DON stated not monitoring Resident 19's mobility could lead to a potential decline in function, mobility, and activities of daily living (ADLs). During an interview and record review of Resident 19's RNA order with the Physical Therapist (PT) on 10/28/2022, at 11:01 AM, the PT stated residents were transitioned to RNA services to maintain function and prevent a decline in mobility. The PT stated the physician's order for RNA should contain the task, walking distance, frequency, and the assistive device used for walking to monitor whether a resident was maintaining mobility. D. During a review of Resident 81's Admission Record (AR), the AR indicated the facility admitted Resident 81 on 3/17/2022 with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), epilepsy (disorder that causes episodes of seizures or altered consciousness), and Type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly. A review of Resident 81's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/23/2022, indicated Resident 81 had short term and long-term memory problems and had modified independence in cognitive skills (ability to think, understand, learn, and remember) for daily decision making with some difficulty in new situations only. The MDS indicated Resident 81 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as a bed or chair), dressing, toileting, and personal hygiene and required total assistance (full staff assistance) for bathing. Resident 81 did not walk during the assessment period. A review of Resident 81's Physical Therapy [(PT), profession aimed in the restoration, maintenance, and promotion of optimal physical function] Discharge Summary, dated 3/31/2022, indicated Resident 81 walked 150 feet with minimal assistance (about 25% physical assistance provided to perform the task) with a quad cane (mobility device with four tips that provides a broader base of support to assist with walking) at the time of discharge. A review of Resident 81's physician's orders, dated 4/1/2022, indicated a physician's order for Restorative Nursing Aide Program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] to perform ambulation (walking) exercises using a quad cane and ankle foot orthosis [(AFO), an orthotic device designed to correct or address problems with the ankle and foot] three times a week, as tolerated. During an interview and record review of Resident 81's RNA order with the Director of Rehabilitation (DOR) on 10/26/22, at 1:29 PM, the DOR stated the physician's order for RNA did not indicate a walking distance. The DOR stated the physician's order for RNA not indicating distance allowed residents to walk to their own tolerance and not being monitored for an improvement or decline in mobility. During an interview and record review of Resident 81's RNA order with the Director of Nursing (DON) on 10/27/2022, at 2:56 PM, the DON stated the physician's order for RNA did not include the resident's monitoring for improvement or decline in mobility because the order did not indicate a walking distance. The DON stated not monitoring Resident 81's mobility could lead to a potential decline in function, mobility, and activities of daily living (ADLs). During an interview and record review of Resident 81's RNA order with the Physical Therapist (PT) on 10/28/2022, at 11:01 AM, the PT stated the physician's order for RNA should contain the task, walking distance, frequency, and the assistive device used for walking to monitor whether a resident was maintaining mobility. During a review of the facility's policy and procedure (P/P) titled, Resident Mobility and Range of Motion, revised on 7/2017, the P/P indicated the residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P/P indicated the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion

Based on interview and record review, the facility failed to implement the physician orders and the resident's plan of care to provide adequate supervision for one of two sampled residents (Resident 1). Resident 1, who was confused and would constantly attempt to climb out of the bed, had a physician's order for a sitter/companion to be at the bedside to prevent falls and injuries. The physician's order was not implemented on 5/10/2021 on the night shift. This deficient practice resulted in Resident 1 falling out of the bed and sustaining pain, a left wrist fracture (broken bone), requiring a transfer to a general acute care hospital (GACH), and undergoing an open reduction and internal fixation ([ORIF] a surgical repair of a broken bone) of the left wrist and requiring a four-day hospital stay. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included intracerebral hemorrhage (bleeding in tissues of the brain), dementia (condition characterized by impairment of memory loss and judgement) and [CONDITION(S)] (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 3/5/2021, the MDS indicated Resident 1 was severely impaired in cognition (ability to learn, reason, remember, understand, and make decisions), exhibited continuous behavior of inattention (inability to pay attention to something), disorganized thinking (failure to think straight. Thoughts may come and go rapidly), required extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL) including bed mobility, transfers, walking, dressing, eating and personal hygiene. The MDS indicated Resident 1 was not steady for moving from seat to standing position, walking, turning around and transfers and was only able to stabilize with staff assistance. During a review of Resident 1's Care plan titled, Needs Companion at Bedside, dated 3/12/2021, the care plan indicated Resident 1 needed a companion at the bedside to minimize the resident from falling. The staff interventions included to provide the companion at the bedside to ensure a safe environment. During a review of Resident 1's Fall Risk Assessment (FRA), dated 5/1/2021, the FRA indicated Resident 1 had a high risk for falls. During a review of Resident 1's telephone physician's order, dated 5/1/2021, the physician's order indicated Resident 1 may have a companion until further orders. During a review of Resident 1's Licensed Progress Note (LPN), dated 5/5/2021, the LPN indicated Resident 1 had a previous fall on 4/30/2021 and the Interdisciplinary Care Team ([IDT] team members from different disciplines working collaboratively with a common purpose for the residents]) indicated Resident 1 was supposed to have a 1:1 companion (type of care/continuous observation provided to ensure safety) until further notice. During a review of Resident 1's LPN, dated 5/11/2021 and timed at 7:35 a.m., the LPN indicated the nurse noticed movement in Resident 1's room and went to see what was happening and saw Resident 1 on the floor scooting (slide in a sitting position) on her back. The LPN indicated Resident 1's left lower arm was disfigured with flesh (the soft substance consisting of muscle and fat, found between the skin and bones of an animal or a human) and bone exposed with minimal bleeding. The RN was notified and assessed the resident, 911 (emergency service) were called, the left arm was immobilized (restrained) and pain medication (Tylenol [mild pain reliever] 325 milligrams [mg] two tablets) was given as the resident was grimacing (a facial expression usually of disgust, disapproval, or pain) in pain. During a review of the GACH emergency room (ER) note, dated 5/11/2021 the ER note indicated Resident 1, who has dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) presented to the ER via ambulance from a skilled nursing facility after falling on her arm with a broken left forearm. During a review of Resident 1's GACH History and Physical (H/P) record, dated 5/11/2021 the H/P record indicated Resident 1 was reportedly agitated with history of restlessness at a nursing facility and was later found on the floor with a left forearm bone broken and exposed. Resident 1 underwent an ORIF of the left wrist on 5/12/2021. During a review of Resident 1's Operative Report, dated 5/12/2021, indicated the resident needed surgery for an emergency surgical treatment of a severely open injury to a widely displaced open fracture (break in skin near the site of broken bone, bone breaks into two or more places and moves out of alignment) of the left wrist. During a review of Resident 1's GACH Discharge Summary, dated 5/14/2021, Resident 1 was discharged back to the facility with diagnosis of an acute left forearm fracture secondary to a mechanical fall (any fall caused by gravity or by something other than a medical reason) after ORIF procedure. The plan was to continue post-op care and pain management. During an interview on 6/14/2021 at 7:04 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 was confused and did not use the call light for assistance. CNA 1 stated on 5/11/2021, Resident 1 was awake and lying-in bed at approximately 6:30 a.m. without a companion at the bedside. CNA 1 stated he left Resident 1's room and within minutes Resident 1 had fallen onto the floor. During an interview on 6/15/2021 at 3:06 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 5/10/2021 during the evening shift (time not specified), Resident 1 was restless and frequently attempting to get out of bed. LVN 1 stated medication was given to calm Resident 1 down and decrease the restlessness, as other interventions were not working. LVN 1 stated Resident 1 was confused, weak, and would jump out of the bed. LVN 1 stated Resident 1 required a companion for safety. During an interview on 6/22/2021 at 2:08 p.m., the Director of Nursing (DON) stated Resident 1 had a companion at the bedside every day and on all shifts since 5/1/2021. The DON stated the physician's order for a companion was not provided for Resident 1 on 5/10/2021, during the night shift. The DON stated, The IDT has not met since implementing the companion for the resident and the doctor was not notified prior to holding or discontinuing the companion at the bedside. During a review of the facility's undated Policy and Procedure (P/P) titled, Policy Interpretation and Implementation related to sitter use, the P/P indicated a sitter was a caregiver who provides companionship and observation to residents for as long as the physician determines that the companionship and observation is needed. According to the P/P, resident and/or representative will be informed of the plan to discontinue sitter as ordered by the physician.

Based on interview and record review, the facility failed to follow its abuse policy by ensuring one of three sampled residents (Resident 1) were free from physical abuse by a facility staff member (Certified Nurse Assistant 1 (CNA 1)) during care, and report the incident to the facility's abuse coordinator. CNA 3 witnessed CNA 1 forcibly holding both hands over Resident 1's mouth, during care to muffle (to wrap or cover something in order to suppress sound) Resident 1's cries of distress. The incident was not documented or reported. This deficient practice resulted in Resident 1 being physically abused by CNA 1. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. caused by an impaired supply of blood to the brain). A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/15/19, indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, and was somewhat able to make needs known and somewhat able to understand others. According to the MDS, Resident 1 required extensive assistance with bed mobility, and was totally dependent on staff for transferring, locomotion on and off the unit, and with personal hygiene. A review of Resident 1's care plan, initiated on 8/5/19, identified a problem with altered thought process and compromised memory recall ability with impaired decision making ability related to dementia as manifested by confusion, disorientation, and unawareness of time, place and was unable to recognize staff names, faces and significant others. The goal indicated Resident 1's activities of daily living ((ADLs) every day activities such as dressing, grooming, bathing, and eating) would need to be anticipated. The staff interventions included cheerful dialogue with Resident 1 while performing ADLs, use resident's name when talking or during care, pleasant interaction which reassures resident when confused, explain all procedures, verbal reminders which assist resident to orientation, and approach resident warmly and kindly. A review of Resident 1's care plan, initiated on 8/22/19, identified a problem with attempting to strike staff. The goal indicated that the resident would have no further episodes of striking staff members during the stay at the facility. The staff interventions included keeping Resident 1's environment peaceful with minimal stimulants, frequently instruct resident in a friendly tone on acceptable behavior per protocol and do not force resident to perform tasks per physician order. A review of a police report, dated 8/29/19 and timed at 11:36 a.m., indicated the police received a call about an incident that occurred on 8/26/19, and the suspect was an employee (CNA 1) and the victim was identified as Resident 1. The police report indicated another employee (CNA 3) witnessed the suspect put his hand over the victim's mouth because he was screaming. The police report indicated on 8/26/19, between the hours of 6:30 a.m. and 7 a.m., CNA 1 responded to Resident 1's room to assist CNA 2 with a patient (Resident 1). CNA 1 stated he wanted to assist CNA 2 because Resident 1 had a history of [REDACTED]. The police report indicated CNA 1 stated Resident 1 was screaming and cursing at him and CNA 2. CNA 1 stated he grabbed Resident 1's arms and crossed them in an X motion across his chest. According to the police report, CNA 1 stated he gently crossed his arms for safety and for CNA 2's safety due to Resident 1 being combative. CNA 1 stated Resident 1 was attempting to punch him and CNA 2 as they were trying to change his attire (clothing). CNA 1 stated Resident 1 had previously punched him in the face in the past, therefore he held his arms down. According to the police report CNA 2 stated she did not see anything. On 8/30/19 at 3:14 a.m., during an interview, Registered Nurse (RN 1) stated she was told by CNA 3 on 8/26/19 that CNA 1 was seen covering the mouth of Resident 1. RN 1 stated that Resident 1 was confused and was very combative, and went to check the resident and saw CNAs 1 and 2 cleaning the resident. RN 1 stated she asked CNA 1 if he was covering Resident 1's mouth. RN 1 stated that CNA 1 stated he only held down the resident's hands so that the resident would stop hitting him. RN 1 stated she looked at the resident and did not see any redness or bruising on Resident 1's mouth, and did not document the incident, or report the abuse allegation to the Director of Nursing (DON) or the Administrator (ADM), who was the abuse coordinator, because the resident was combative and she did not think it was a problem that needed to be reported. RN 1 acknowledged that she received abuse training, and was a mandated reporter, but that she assumed the Designated Staff Developer (DSD) would report the abuse allegation because he was told about the incident by another staff member. On 8/30/19 at 4:13 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 8/26/19 she was sitting at the nursing station when CNA 3 approached the station and told her and the RN supervisor (RN 1) he saw CNA 1 putting his hands over Resident 1's mouth. LVN 1 stated she went with RN 1 to check on Resident 1 and saw CNA 1 holding the resident down and CNA 2 cleaning him. LVN 1 stated Resident 1 always screamed during care so she did not think it was a problem. LVN 1 stated that she notified the DSD that morning about the abuse allegation regarding Resident 1 and CNA 1, but she did not document anything in the resident's chart or notify the DON or the ADM. On 8/30/19 at 6:48 a.m., during an interview, the DON stated he was notified about the abuse allegations concerning Resident 1 and CNA 1 on 8/29/19 after the Ombudsman ((OMB) an official appointed to investigate individuals' complaints against skilled nursing homes) visited the facility. The DON stated his staff did not report the abuse allegations to him, and it was their responsibility to report all abuse allegations to him. The DON stated Resident 1 was physically assessed and did not have any bruises or any other injuries. The DON stated Resident 1's family member and the police were contacted about the abuse allegations, and CNA 1 was suspended pending the conclusion of the facility's investigation. On 8/30/19 at 7:58 a.m., during an interview, the DSD stated when he arrived to the facility for his shift on 8/26/19, he was approached by RN 1 and was informed Resident 1's abuse allegations. The DSD stated he asked RN 1 if she completed the necessary reports for the incident and she replied yes. The DSD stated he reminded RN 1 to investigate the incident and interview all staff involved and she reassured him that she would. The DSD stated RN 1 had the abuse training many times, and because she was the RN supervisor she was aware that it was her responsibility as a mandated reporter. On 9/4/19 at 10:51 p.m., during an interview, CNA 3 stated he heard yelling on 8/26/19 in the hallway that suddenly became muffled. CNA 3 stated the other nurses nearby (RN 1 and LVN 1) heard the same yelling and screaming in a room close to the nursing station, but that he was the only staff member to respond. CNA 3 stated he entered Resident 1's room and upon entering, Resident 1's curtain was observed partially closed. CNA 3 stated he opened the curtain and observed CNA 1 on Resident 1's bed with both his hands over Resident 1's mouth pushing him down onto the pillow, telling the resident to shut up! in the presence of CNA 2. CNA 3 stated Resident 1 was still yelling, while CNA 1 was on top of him in the bed, and he asked CNA 1 what he was doing. CNA 3 stated at that time CNA 1 took his hands away from Resident 1's mouth, turned towards him with a shocked look on his face, but did not say anything. CNA 3 stated his stomach dropped and he was appalled (overcome with horror), disturbed and shaking as he rushed to the nursing station to notify RN 1 and LVN 1 at the nursing station of what he had just witnessed. CNA 3 stated RN 1 and LVN 1 did nothing and that he was unsure if Resident 1 had any injuries. CNA 3 stated he was a mandated reporter of abuse, and that there were several staff members aware of what happened. A review of the facility's policy titled, Requesting, Refusing, and/or discontinuing care or treatment, indicated residents have the right to refuse or discontinue treatment prescribed by his or her healthcare practitioner, as well as care routines outlined on the resident's assessment and plan of care. The policy indicated a resident is not forced to accept any medical or treatment and may refuse or discontinue care or treatment at any time. A review of the facility's policy titled, Abuse, revised 2/2019, indicated residents had the right to be free from abuse. The policy also indicated any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect or is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonably suspects that abuse occurred shall report the known or suspected instance of abuse by telephone immediately (within 2 hours) or as soon as practicably possible, and by sending a completed Report of suspected Adult/Elder abuse within 5 working days.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure adequate supervision was provided to prevent falls with injuries for one of three sampled residents (Resident 1). Resident 1, who was confused and had a high risk for falls, had a recent change in condition, after a one to one ((1:1) one on one supervision of a resident) sitter was discontinued, became agitated and was constantly attempting to get up out of bed unsupervised, fell and sustained injuries. (Cross referenced F580) This failure of not providing close supervision resulted in Resident 1 falling sustaining [MEDICATION NAME] head trauma with a right eye hematoma (collection of clotted blood in the tissues) and a right femoral neck (hip bone) fracture (broken bone) requiring a transfer to a general acute care hospital (GACH) and undergoing a surgical repair of the right hip. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 8/23/18, indicated the resident's cognition (ability to reason and make decisions) was impaired. According to the MDS, Resident 1 required extensive to total assistance with all activities of daily living (ADLs), which included a two-person physical assist for bed mobility, toilet use, and a one-person assist with eating and personal hygiene. A review of a physician's orders [REDACTED]. A review of an Admission Nursing Assessment, dated 8/14/18, indicated Resident 1 had vision impairment and required a one-person assist with ambulation, transfer, and partial weight bearing. A review of a Care Plan, dated 8/15/18 and titled, Potential for Falls or Injury, manifested by staff dependence for transfer and locomotion, cognitive deficit, and poor safety awareness. The goal was to minimize falls or injury every shift. The staff's interventions included to provide constant monitoring and notify the physician of any unusual observation and provide a 1:1 sitter to prevent injury from falling. A review of Resident 1's History and Physical, dated 8/15/18, indicated the resident did not have the capacity to understand and make decisions A review of a Physical Therapy Daily Treatment Note, dated 8/16/18, indicated Resident 1 required maximal verbal and tactile cues. The note indicated Resident 1 was retropulsive (loss of balance) with all functional mobility. A review of a Nurses Progress note, dated 8/22/18, indicated Resident 1's Last Cover Day ((LCD) the length of day the resident's health insurance can pay for services received) was 8/25/18. Resident 1 was to be discharged home with home physical therapy (PT) and to discontinue the sitter. A review of a Nursing Progress note, dated 8/22/18, indicated Resident 1 was alert and oriented without a sitter today, at fall risk. A review of a Nursing Progress note, dated 8/23/18 and timed at 2:40 a.m., indicated Resident 1 was awake and attempting to get out of bed several times. Another Nursing Progress note, dated 8/23/18 and timed at 5:15 a.m., indicated at approximately 3:55 a.m. 1 was found on the floor near the closet at the foot of the bed in a sitting position and complained of head and right hip pain. According to the note, there was a 4.5 centimeter (cm) by 5 cm [MEDICAL CONDITION] (an accumulation of an excessive amount of watery fluid) lump observed above the right eye. Vital signs were indicated as Temperature (T) -98.8, pulse (P) -67, Respirations (R) -18, Blood Pressure (BP) -169/76, SPO2-95, and Blood sugar (BS) -161. A review of a physician's orders [REDACTED]. A review of a Nurses Progress note, dated 8/22/18, indicated Resident 1 was disoriented to place, time, situation, easily distracted, frequently incontinent (unable to control bowel and bladder function), and forgetful. A review of a Nurses Progress note, dated 8/23/18, indicated a large hematoma measuring at 4.5 cm by 5 cm above Resident 1's right eye. Resident 1 complained of right hip pain of 8 out of 10 on a pain measuring scale (8/10) with movement and tender to touch. A review of a SBAR ((Situation, Background, Acknowledgement, and Recommendation) internal communication tool) Communication Form and Progress Note, dated 8/23/18, indicated Resident 1 made attempts to get out of bed during the night shift. The assigned Certified Nurse Assistant (CNA), who had 15 other residents to care for, left Resident 1's room to speak with an LVN, at which time a noise was heard and Resident 1 was found sitting on the floor against the closest. Swelling was noted on Resident 1's right forehead which measured 4.5 cm by 5 cm, and Resident 1 had complaints of right hip pain. A review of the GACH Admission Record, dated 8/23/18, indicated Resident 1's X-ray results was positive for the displaced right hip femoral neck fracture. Resident 1 was admitted for a hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint). The GACH record indicated Resident 1 was recently discharged from the GACH a week prior for rehabilitation status [REDACTED]. During a telephone interview, on 9/6/18 at 11:30 a.m., Resident 1's family member (FM 1) stated that he did not receive any prior notification regarding discontinuation of the 1:1 sitter. FM 1 stated, My mom could not walk without assistance that was why she had a sitter every day. She had a bruise on her forehead and broke her hip. She was confused in the facility that was why she had a sitter. She had a sitter why in the hospital prior to admission into facility and continued to have a sitter while admitted into facility. The only time the Nurse Practitioner took the sitter away that was when she fell and sustained a [MEDICAL CONDITION] with bruises on forehead, and the condition is worst. On 9/10/18 at 8:50 a.m., during a face-to-face meeting, FM 1 stated Resident 1 was transferred to the facility from the GACH on 8/14/18. FM 1 stated on 8/22/18 at around 4:30 p.m., during a visit to the facility, Resident 1 was in the room without a sitter. FM 1 stated Resident 1's roommate FM, who was also visiting, stated Resident 1 had been very agitated trying to get out of bed, so he went to get some of the nurses because the resident was trying to get out of bed. During an interview on 9/6/18 at 10:12 a.m., Certified Nurse Assistant 1 (CNA 1) stated, I was doing all I could to take care of the resident (Resident 1). I stepped out for about 10 minutes and I heard a loud noise and ran back into the room and found the resident (Resident 1) sitting on the floor. CNA 1 stated it was her first night of taking care of Resident 1. CNA 1 stated she heard the resident did have a sitter, but the sitter was discontinued. CNA 1 stated she had 15 other residents that night. CNA 1 stated Resident 1 was supposed to be a one-to-one, but she was not at the time incident happened. CNA1 stated the Charge Nurse had discussed with her that Resident 1 was supposed to be a one-to-one, but had no sitter, so we have to do our best to take care of the resident. CNA 1 stated she stepped out to ask the Charge Nurse a couple of questions but did not ask for someone for relief. CNA 1 stated in the future in order to prevent this kind of incident, the facility needed to provide a one-to-one sitter the resident. CNA 1 stated Resident 1 sustained a big bump on the forehead with pain at the time of the incident. During an interview, on 9/6/18 at 12:22 p.m., CNA 2 stated, We were monitoring Resident 1, usually she had sitters. I was watching the resident with another CNA, when we went out to do our runs we heard a loud noise and we ran into the resident's room and found the resident in a sitting position with a bump on her forehead. CNA 2 stated they called the Registered Nurse supervisor (RN) who brought ice to apply to the bump. CNA 2 stated Resident 1 was a 1:1 care on assignment, but the facility could not provide the resident with one. CNA 2 stated if there was a bed alarm that would have prevented the fall. On 9/6/18 at 1:01 p.m., during an interview, the Director of Nursing (DON) stated, After 2 p.m., on 8/22/18, Resident 1 did not have a sitter anymore and was taken to the activity room. The DON stated Resident 1 had history of multiple falls prior to admission to the facility. The DON stated, With the resident being confused, I would say it was not okay to take the resident off 1:1 monitoring. The DON stated that the two CNAs assigned to care for Resident 1 during the night shift had other residents during the night and were alternating care in between. On 9/27/18 at 8:52 a.m., during an interview, the Nurse Practitioner (NP) stated, When Resident 1's behavior changed on the afternoon of 8/22/18 by getting agitated and trying to get out of the bed the nursing staff should have called me or the physician to re-order a sitter for resident and this fall would have been prevented. The NP stated, I rely on the report of the nurses and the documentation of the (PT) to make decisions. During an interview, on 9/27/18 at 10:02 a.m., the Case Manager (CM) stated, Safety of the resident is the facility's responsibility. CM stated FM 1 came to my office and asked who decided to remove the sitter from Resident 1. The CM stated she told FM 1 did not know who made the decision, I reiterated it was the responsibility of the facility to keep residents safe. During an interview on 9/27/18 at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, On the day of incident (8/23/18), I was in the nursing station when I heard a loud noise and we all ran to Resident 1's room and found the resident sitting on the floor with a bump on the forehead. There was no staff in the room when the resident fell . LVN 1 stated the 3-11 p.m. staff endorsed that Resident 1 was trying to get out of bed and they just said to keep an eye on the resident. LVN 1 stated if Resident 1 had a sitter the whole time she was in the facility this would not have happened. During an interview, on 10/18/18 at 2:59 p.m., Registered Nurse 1 (RN 1) stated Around 3 p.m., on 8/22/18, Resident 1 started to become agitated and was trying to get out of the chair and bed. RN 1 stated she had the resident with her at the nursing station. RN 1 stated at approximately 4:30 p.m. on 8/22/18, the CM was leaving and RN 1 asked if there could be a sitter for Resident 1 because she could not be the sitter for the resident and work at the same time. RN 1 stated CM told her to observe the resident overnight and see how the resident does without a sitter. A review of the facility's undated policy and procedures titled, Policy Interpretation and Implementation, indicated the nursing staff may serve as a sitter, when approved by the Director of Nursing Services. The resident and/or representative will be informed of the plan to discontinue sitter as ordered by the physician. Upon discontinuation of sitter, resident will be placed on close observation by the facility staff for at least 72 hours to ensure that the discontinuation of a sitter is appropriate.

Based on observation, interview, and record review, the facility failed to ensure that one of four residents was free of accidents hazard and received adequate supervision to prevent accidents (Resident 1). Resident 1, who had a high risk for falls, was not assessed for of all environmental hazards identified and received a two-person physical assist during bed mobility, as required and indicated in the resident's assessment. The facility also failed to ensure the side rails were locked prior to turning the resident without assistance. These failures resulted in Resident 1 falling over the side rail from the bed and onto the floor sustaining facial trauma with bruising to the face, right elbow, bilateral (both) knee, and fractures (broken bone) to the distal (end)right femur and left femur (long thigh bone). The resident's fall required a transfer to a general acute care hospital (GACH) for evaluation and treatment 13 hours later. While in the emergency room , Resident 1 complained of pain of 9.5, on a scale of 0-10, (0 being no pain, and 10 being the worse), after receiving Norco (narcotic pain medication). The resident was admitted to the GACH for three days due to severe pain requiring intravenous (IV) pain medications of Morphine sulfate (narcotic pain medication). Findings: The Department received an entity reported incident (ERI) on 1/20/15, alleging a resident (Resident 1) was receiving care using a one-person assist, but required a two-person assist, and fell over the side rail out of the bed to the floor. Resident 1 complained of pain 8/10 at the right knee and leg. The physician was notified with orders obtained for x-rays to be done. The x-ray was positive for a comminuted (the bone involved in the fracture is broken into several pieces) fracture at the right distal femur (long leg bone), with severe tissue swelling, age of an undetermined time and an acute fracture of the left distal femur. On 2/3/15 at 7 a.m., a complaint investigation was initiated and the administrator was informed of the nature of the visit. A review of the Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/9/14, indicated Resident 1 was alert and oriented, required a two-person extensive assistance with bed mobility and personal hygiene. According to the MDS, Resident 1 had functional limitation in range of motion to the lower extremities and was incontinent (loss of control) of both bowel and bladder functions. The MDS also indicated the resident was non-ambulatory for the last eight years due to a previous injury. A review of a care plan, titled, Potential for fall or injury, dated 8/25/14, indicated Resident 1 had poor safety awareness and was dependent on staff for transferring. The staff's intervention included to keep the environment free from hazards. There was no documented evidence in the plan of care that the facility specifically addressed that the resident's use of a low air loss mattress (LAL), being as high as the side rails created a potential fall risk. Another plan of care, dated 8/25/14, and titled, Resident Refuses Care- indicated Resident 1 refused the assistance of a two-person assist for repositioning and turning while in bed. The care plan indicated the resident preferred specific nurses and would become sarcastic when risks and benefits were explained. The staff's interventions included to anticipate the resident's physical needs, but the interventions did not include how the staff would implement the plan of care intervention. A Fall Risk Evaluation, dated 12/8/14, indicated Resident 1's score was 15 with a total score of 10 or above representing a high risk for falls. A review of a nurse's note, dated 1/18/15, and timed at 2:15 a.m., indicated CNA 1 asked Resident 1 to turn over to the left side. According to the note, the resident used the side rail to turn, but slid over the side rail and fell to the floor. The resident complained of pain (right knee and leg) of 8 on a pain scale of 8/10 (0 indicating no pain and 10 being the worst) that required pain medication of (Norco 10/325 milligram (mg)) which was administered several times. The physician was notified and ordered several x-rays (bilateral hips, bilateral femur, bilateral humerus (long bone in the upper arm) and the right ankle). The x-ray results, dated (1/18/15) and timed at 1:40 p.m., indicated an acute fracture of Resident 1's distal left femur. According to a nurse's note, at 3:05 p.m., on 1/18/15, almost 13 hours later, Resident 1 was transferred to the GACH. On 2/3/15 at 2:48 p.m., during an interview, a certified nurses assistant (CNA 1) stated at approximately 2 a.m., on 1/18/15, during the care of Resident 1, she pushed Resident 1 to turn to the side while the side rail was up. Although the side rail was up, the resident fell out of the bed. CNA 1 stated the resident had a LAL mattress (used for pressure sore prevention) on the bed and it was slippery and almost at the level of the top of the side rail. When asked, CNA 1 stated she could not remember if she checked to see if the side rail was locked prior to giving care before pushing the resident to the side. CNA 1 also stated she did not ask another staff to assist with repositioning the resident, because the resident tend to refuse other staff ' s help. On 2/3/15 at 3:30 p.m., Resident 1 was observed lying on a low bed with both side rails up. Resident 1 was asked if she remembered what happened when she fell . The resident stated CNA 1 did not check to see if the side rail was locked before she pushed her over to the side and that was why she fell on the floor. The resident stated when she fell on the floor she hit her face and leg, which resulted in bruising and a lot of pain. Resident 1 stated she was sent to the hospital, but did not have surgery. When she was asked about the need for a two-person assist to reposition her, she stated, I would refuse the other staff member, because they would stand around, and stare at me. A review of an investigation form written by the charge nurse, dated 1/18/15, was incomplete. The charge nurse indicated not applicable under the section for environmental hazards that could contribute to the resident's fall incident, and the causal factors indicated unknown. CNA 1's statement under the cause of the incident and preventable factors to ensure the incident from recurring, was left blank. The investigation and the conclusion failed to indicate a thorough investigation of Resident 1's fall incident. A review of the facility's undated policy titled, Accidents and Incidents-Investigating and Reporting, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises shall be investigated and reported to the administrator. On 2/3/15 at 3:14 p.m., during an interview and record review, the director of nursing (DON) was shown the incomplete investigative report, the DON also could not provide an answer as to why the resident's fall incident was not thoroughly investigated. The DON also did not respond to questions asked as to why the environmental risk factors such as; side rails and slippery LAL mattress at the level of the side rails were not evaluated/considered and care planned for Resident 1 to reduce the risk of fall. A review of an undated facility's policy and procedure titled, Fall Risk Assessment indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls. The staff will seek to identify environmental factors that may contribute to falling. The staff and the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the x-rays taken on 1/18/15, at the GACH indicated the following: 1. Left femur: a non-displaced fracture of the distal femur. 2. Right femur: severely comminuted fracture of the distal femur. A computed tomography or computerized axial tomography scan ((CAT scan) combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images) of Resident 1's right knee was performed at the GACH on 1/19/15 and indicated there was an extensive comminuted fracture of the distal third of the right femur, extending to the femoral condyle (one of a pair of large flared prominence's on the distal end of the femur) and an oblique (left to right: transverse) fracture seen at the proximal tibia laterally. A review of the GACH's Discharge Summary note, dated 1/21/15, and timed at 11:12 a.m., indicated Resident 1's primary discharge [DIAGNOSES REDACTED]. The note indicated surgery was not indicated at that time, only a knee immobilizer. The resident was discharged on Dilaudid (opiate pain reliever) 4 mg by mouth every four whenever necessary for pain control. Resident 1 was discharged back to the facility on [DATE], three days after the fall incident.