Every finding on record at Parkview Julian Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain the dry food storage (keeping shelf-stable, non-perishable foods in a clean, cool, and dry environment that does not require refrigeration or freezing) room within 50 to 85 degrees F (Fahrenheit- a scale used to measure temperature) for safe food storage. This failure had the potential to result in residents to be served food that is compromised in quality and safety due to improper storage temperatures.Findings During an observation on 8/11/26 at 1:35 p.m. in the facility's dry food storage room, the temperature reading on the wall thermometer was 86 degrees F. On the left side of the dry food storage room, the shelves contained the following food items: bananas, watermelon, cantaloupe, oranges, carrots stored in a plastic bag, and potatoes stored on the bottom shelf. On the right side of the dry food storage room, there were onions in a covered container, a covered box of croissants, and packages of sliced bread. During an interview on 8/11/26 at 1:40 p.m. with the Dietary Services Supervisor (DSS), DSS stated, The temperature is 86 degrees F. When asked what the temperature should be, DSS stated, I do not know what the temperature should be per policy. DSS stated they were not doing any corrective action when the temperature goes out of range. DSS stated, It's [dry food storage room temperature] has always been like that. During an interview on 8/11/26 at 2:24 p.m. with Administrator, Administrator stated, The temperature is 86 degrees F and that is one degree higher than what is in the policy. Administrator stated there is no vent into the dry storage room at this time. During a review of the facility's Dry Food Storage Temperatures Log dated August 2026, the Dry Food Storage Temperatures Log indicated:a) On 8/1/26, from 5:00 a.m. to 9:00 a.m. the temperature was 86 degrees Fb) On 8/2/26, from 5:00 a.m. to 9:00 a.m. the temperature was 87 degrees Fc) On 8/3/26, from 5:00 a.m. to 9:00 a.m. the temperature was 86 degrees Fd) On 8/4/26, from 5:00 a.m. to 9:00 a.m. the temperature was 88 degrees Fe) On 8/5/26, from 5:00 a.m. to 9:00 a.m. the temperature was 87 degrees Ff) On 8/7/26, from 5:00 a.m. to 9:00 a.m. the temperature was 87 degrees Fg) On 8/8/26, from 5:00 a.m. to 9:00 a.m. the temperature was 86 degrees Fh) On 8/1/26, from 3:00 p.m. to 5:00 p.m. the temperature was 89 degrees Fi) On 8/2/26, from 3:00 p.m. to 5:00 p.m. the temperature was 88 degrees Fj) On 8/3/26, from 3:00 p.m. to 5:00 p.m. the temperature was 87 degrees Fk) On 8/4/26, from 3:00 p.m. to 5:00 p.m. the temperature was 87 degrees Fl) On 8/5/26, from 3:00 p.m. to 5:00 p.m. the temperature was 86 degrees Fm) On 8/6/26, from 3:00 p.m. to 5:00 p.m. the temperature was 87 degrees Fn) On 8/7/26, from 3:00 p.m. to 5:00 p.m. the temperature was 88 degrees Fo) On 8/8/26, from 3:00 p.m. to 5:00 p.m. the temperature was 89 degrees Fp) On 8/10/26, from 3:00 p.m. to 5:00 p.m. the temperature was 86 degrees Fq) On 8/11/26, from 3:00 p.m. to 5:00 p.m. the temperature was 86 degrees F During a review of the facility's Policy and Procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, Recommended temperature is 50 F-85 F-if dry food storage goes over 85 F take corrective action (see Corrective Action policy). During a review of the P&P titled, Corrective Action When Food In The Store Room Reaches Above 85 F, dated 2023, the P&P indicated, When temperature within the emergency or food storage room becomes higher than 85 F, corrective action must take place to ensure foods has not become compromised: 1. Maintenance and the Administrator will be alerted to evaluate the air conditioning system. 2.The Dry Food Storage Temperature Log will be started to monitor storage unit temperatures. 3. The Food and Nutrition Services (FNS) Director or designated personnel shall inspect all food that is in the storage room, looking for any signs of food damage.

Based on interview and record review, the facility failed to implement Urinary Tract infection (UTI-infection in any part of the urinary system [kidneys, ureters, bladder and urethra]) care plan for one of two sampled residents (Resident 1). This failure had the potential to result in repeated UTI infection for Resident 1 and unmet care needs.Findings:During a review of Resident 1's Care Plan (CP), dated 4/13/26, the CP indicated, The resident (Resident 1) has chronic Urinary Tract Infections. Interventions. Check at least every 2 hours for incontinence (involuntary or accidental loss of bladder or bowel control). Wash, rinse and dry soiled areas. Intake (fluids that enter the body) and output (fluids that leave the body).During a concurrent interview and record review on 5/5/26 at 1:03 p.m. with Director of Nursing (DON), Resident 1's medical records (MR), undated were reviewed. The MR indicated, there was no documentation the facility was checking and providing incontinence care for Resident 1 at least every two hours. The MR indicated, there was no documentation the facility was monitoring Resident 1's urine output. DON stated if there was no documentation, it was not done. DON stated the CP was not followed.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT (Interdisciplinary Team - group of professionals, along with the resident and the family who collaborate to create and manage a personalized care plan) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs.

Based on interview and record review, the facility failed to ensure the IDT (Interdisciplinary Team - group of professionals, along with the resident and the family who collaborate to create and manage a personalized care plan) met to review care plans quarterly for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1's unresolved concerns and unmet care needs.Findings:During a concurrent interview and record review on 5/6/26 at 11:42 a.m. with Director of Nursing (DON), Resident 1's medical records (MR), undated were reviewed. The MR indicated, Resident 1 had a quarterly (every three months) Minimum Data Set (MDS - an assessment tool) completed on 3/6/26. The MR indicated, there was no documentation the IDT met with Resident 1 and the family to review Resident 1's care plans. DON stated the IDT should have met with Resident 1 and the family upon readmission and quarterly. DON stated there should have been a care plan meeting done on 3/6/26 for Resident 1 and the family to be informed of Resident 1's current condition, current plan of care, and to involve Resident 1 and the family in updating Resident 1's care plan based on their preferences.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. The Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment, and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. The Care Plan must be prepared by the IDT team. The IDT team may include the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed Nurse who has responsibility of the resident; D. The Dietary Supervisor and/or registered dietician; E. Social Service staff member responsible for the resident; F. The Activity Director; G. Therapists as applicable; H. Consultants (as appropriate); I. The Director of Nursing (as applicable); J. Certified Nursing Assistants and/or RNAs responsible for the resident's care; K. The resident and/or his/her family or legal representative; i. If the resident and his/her resident representative participation is determined not practicable for the development of the resident's care plan, an explanation should be included in the resident's medical record.

Based on interview and record review, the facility failed to ensure an antibiotic (medication used to treat infection) was administered as ordered by the physician for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 developing sepsis (the body's extreme, life-threatening response to an infection).Findings:During a review of Resident 1's Order Listing Report (OLR), dated 5/6/26, the OLR indicated, Ertapenem (antibiotic). every 24 hours for infection for 15 days. Start Date. 4/12/26.During a concurrent interview and record review on 5/5/26 at 2:05 p.m. with Director of Nursing (DON), Resident 1's IV (Intravenous [into or within a vein]) MAR (Medication Administration Record), dated April 2026 was reviewed. The IV MAR indicated, the Ertapenem antibiotic was not administered to Resident 1 on 4/12/26 and 4/13/26. DON stated Ertapenem antibiotic should have been administered to Resident 1 within four hours of the physician's orders. DON stated if an antibiotic was not administered as scheduled, it would put Resident 1 at risk for unresolved infection and sepsis.During a review of the facility's policy and procedure (P&P) titled, Medication - Administration, dated 11/1/17, the P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician.

Based on observation, interview, and record review, the facility failed to ensure fingernails were trimmed for one of three sampled residents (Resident 2) with contractures (shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become stiff and rigid) on both hands. This failure had the potential to result in Resident 2 developing skin breakdown.Findings:During a concurrent observation and interview on 5/6/26 at 9:31 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 2's room, Resident 2 had contractures on both hands and had long (approximately quarter inch) fingernails touching her palms. CNA 1 stated Resident 2 had long and sharp fingernails that can cut Resident 2's palms and could cause Resident 2 to develop skin breakdown and infection on her palms.During an interview on 5/6/26 at 11:42 a.m. with Director of Nursing (DON), DON stated Resident 2 's fingernails should have been trimmed, filed, and cleaned every Sunday and as needed. DON stated Resident 2's long and sharp fingernails with contractures on both hands could cause impaired skin integrity and infection.During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, dated 11/1/17, the P&P indicated, Nail care is given to clean and keep the nails trimmed.

Based on interview and record review, the facility failed to provide care for midline catheter (a long, flexible, thin tube inserted into a vein in the upper arm used for delivering medications, fluids, or drawing blood samples) as ordered by the physician for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1 developing complications such as catheter blockage, infection, blood clots, and blood vessel damage.Findings:During a review of Resident 1's Order Listing Report (OLR), dated April 2026, the OLR indicated, Flush right upper arm Midline single lumen (one channel used to give one type of fluid or medication at a time) with 10 ml (milliliters [measure of volume]) saline (mixture of salt and water used for medical use) before and after IV (intravenous [into or within a vein]) medications every shift. Start Date 04/14/2026. Monitor Midline site for signs of inflammation (body's natural response to injury or infection) / (or) infiltration (fluid leaks out of the vein into surrounding soft tissue) two times a day. Start Date 04/14/2026During a concurrent interview and record review on 5/5/26 at 2:25 p.m. with Director of Nursing (DON), Resident 1's TAR (Treatment Administration Record), dated April 2026 was reviewed. The TAR indicated, there was no documentation the midline catheter site was monitored for signs of inflammation or infiltration on 4/16/26, 4/19/26, and 4/23/26 at 6:30 a.m. The TAR indicated, there was no documentation the midline catheter was flushed with 10 ml normal saline on 4/15/26 , 4/19/26, and 4/22/26 night shift (no time specified). DON stated if there was no documentation, it was not done. DON stated if the midline catheter site was not monitored as ordered by the physician, it would put Resident 1 at risk for phlebitis (inflammation of a vein), infiltration, blood clots, and damage to the nerves. DON stated if the midline catheter was not flushed as ordered by the physician, it would put Resident 1's midline catheter at risk for clogging resulting in Resident 1 not getting her medication.During a review of the facility's policy and procedure (P&P) titled, CARE OF PERIPHERAL INSERTERD CENTRAL LINES (PICC) - DRESING CHANGE AND SITE CARE, undated, the P&P indicated, Purpose. To minimize the possibility of local and systemic infection. Verify physician's order. Assess the insertion site, areas and the course of the vein for redness, tenderness, edema, and drainage.

Based on interview and record review, the facility failed to ensure treatments were done as ordered by the physician for one of three sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing further skin breakdown.Findings:During a review of Resident 2's Order Summary Report (OSR), dated 5/6/26, the OSR indicated, Apply skin barrier (thick cream used to protect skin from moisture damage) to coccyx (tailbone) every shift for Skin Maintenance. Calmoseptine (thick ointment used to treat and prevent skin irritation, rashes, and itching) . Apply to affected areas (unspecified) topically (applying a medication directly to a specific spot on the outside of the body) two times a day for skin maintenance. Cleanse with Normal Saline (mixture of salt and water used for medical use). Pat dry. Apply Betadine (medication used on the skin to treat and prevent infections) to periwound (skin and tissue surrounding a wound) maceration (softening and breaking down of skin caused by prolonged exposure to moisture), apply calcium ag (calcium alginate [used to treat wounds]) to wound bed and cover with dry dressing (absorbent bandage applied to a wound to keep it clean and dry). Change dressing daily and PRN (as needed) for loss of integrity/soiling every day shift for (left heel) Stage 3 PI (pressure injury [damaged skin and tissue caused by prolonged, uninterrupted pressure on a specific area]).During a concurrent interview and record review on 5/5/26 at 2:55 p.m. with Director of Nursing (DON), Resident 2's TAR (Treatment Administration Record), dated April 2026 was reviewed. The TAR indicated, there was no documentation skin barrier was applied to Resident 2's coccyx on 4/4/26 and 4/11/26. The TAR indicated, there was no documentation Calmoseptine was applied to Resident 2's affected areas (unspecified) on 4/4/26 at 9 a.m., 4/11/26 at 9 a.m., 4/23/26 at 5 p.m., and 4/26/26 at 9 a.m. The TAR indicated, there was no documentation treatment was done for Resident 2's left heel stage three pressure injury (tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible) on 4/4/26, 4/11/26, 4/26/26. DON stated if there was no documentation, the treatment was not done. DON stated, if the skin barrier was not applied to Resident 2's coccyx as ordered by the physician, it would put Resident 2 at risk for pressure injury. DON stated, if Calmoseptine was not applied to Resident 2's affected areas (unspecified) as ordered by the physician, it would put Resident 2 at risk for MASD (moisture-associated skin damage [skin irritation, inflammation, or breakdown caused by long-term exposure to moisture]). DON stated if the treatment for Resident 2's left heel stage three pressure injury was not done as ordered by the physician, Resident 2 could re-develop a stage four pressure injury (severe, deep, and open crater that has destroyed all layers of skin, exposing underlying muscle, tendon, or bone) on her left heel.During a review of the facility's policy and procedure (P&P) titled, Wound Management, dated 11/1/17, the P&P indicated, A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. the nurse will. Implement a wound treatment per physician's orders.

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) when interventions to manage contractures (shortening of muscles, tendons, skin, or nearby soft tissues that causes joints to become stiff and rigid) was not provided on both hands for one of three sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing worsened contractures.Findings:During a concurrent observation and interview on 5/6/26 at 9:31 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 2's room, Resident 2 had contractures on both hands, and did not have a device on both hands to manage her contractures. CNA 1 stated she was not sure if Resident 2 was supposed to have a device on both hands to manage her contractures.During a concurrent interview and record review on 5/6/26 at 11:42 a.m. with Director of Nursing (DON), Resident 2's medical records (MR), undated were reviewed. The MR indicated, there was no intervention to manage Resident 2's contractures on both hands. DON stated Resident 2 should have had hand rolls (soft, rolled-up device placed inside the palm to prevent fingers from curling into a tight fist) on both hands to prevent contractures, to restore muscle movement, and to protect Resident 2's skin.During a review of the facility's policy and procedure (P&P) titled, Contracture Prevention, dated 11/1/17, the P&P indicated, The Facility Implements interventions to prevent the onset of contractures and to prevent worsening of contractures for residents admitted with contractures.

Based on observation, interview, and record review, the facility failed to ensure a GT (Gastric Tube - tube inserted through the stomach to deliver food, liquids, and medication) site was covered with a T-drain dressing (specialized absorbent bandage to protect skin) as ordered by the physician for one of two sampled residents (Resident 2). This failure had the potential to result in Resident 2 developing skin irritation and infection.Findings:During a review of Resident 2's Order Summary Report (OSR), dated 5/6/26, the OSR indicated, Cleanse GT site to abdomen with normal saline (mixture of salt and water used for medical use), pat dry, apply T-drain daily.During a concurrent observation and interview on 5/6/26 at 9:55 a.m. with Treatment Nurse (TN) in Resident 2's room, Resident 2's GT site was not covered with a T-drain dressing. TN stated, It (GT site) needs a dressing. TN stated she did not know Resident 2's GT site did not have a dressing. TN stated Resident 2's GT site's T-drain dressing was supposed to be changed daily and as needed. TN stated Resident 2's GT site should be covered with a T-drain dressing to ensure the GT site was clean and to prevent infection.During an interview on 5/6/26 at 10:03 a.m. with Director of Nursing (DON), DON stated Resident 2's GT site was supposed to be covered to protect the skin and to prevent infection.During a review of the facility's policy and procedure (P&P) titled, Feeding Tube - Site Care, dated 11/1/17, the P&P indicated, Purpose To inspect and prevent skin breakdown and complications for residents with feeding tubes. Place a gauze drainage sponge around the site.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Resident Isolation - Categories of Transmission-Based Precautions when proper PPEs (personal protective equipment) were not worn and proper resident cohorting (to group individuals who have the same infection together) was not done for one of two sampled residents (Resident 3). These failures had the potential to result in the spread of germs in the facility.Findings:During a review of Resident 3's Order Summary Report (OSR), dated 5/6/26, the OSR indicated, CONTACT ISOLATION***R/T (related to) MRSA (Methicillin-resistant Staphylococcus aureus [type of bacteria that causes infections resistant to many common antibiotics]).During an observation on 5/5/26 at 10:31 a.m. outside Resident 3's room, a contact isolation sign (CIS) was posted on Resident 3's door. The sign indicated, CONTACT ISOLATION Prior to entering the room. CLEAN HANDS. GOWN. GLOVES. Resident 3 was cohorted with another resident without isolation precautions. Certified Nursing Assistant (CNA) 2 entered Resident 3's room without wearing a gown and gloves.During an interview on 5/5/26 at 10:31 a.m. with CNA 2, CNA 2 stated she was aware Resident 3 was on contact precautions. CNA 2 stated she did not wear a gown and gloves prior to entering Resident 3's room. CNA 2 stated she should have worn a gown and gloves according to the CIS on Resident 3's door.During a concurrent interview and record review on 5/6/26 at 3:10 p.m. with Director of Nursing (DON), the facility's CIS, dated 4/2/25 was reviewed. The CIS indicated, CONTACT ISOLATION Prior to entering the room. CLEAN HANDS. GOWN. GLOVES. DON stated when CNA 2 entered Resident 3's room without wearing a gown and gloves, the CIS was not followed, and the CIS should have been followed.During a concurrent interview and record review on 5/6/26 at 3:38 p.m. with the Infection Preventionist (IP), the facility's P&P titled, Resident Isolation - Categories of Transmission-Based Precautions, dated 11/1/17 was reviewed. The P&P indicated, Contact Precautions. The resident is placed in a private room when it is not feasible to contain drainage, excretions, blood or body fluids. When a private room is not available, the Infection Control Coordinator assesses various risks associated with other resident placement (e.g., cohorting) . gloves (clean, non-sterile) are worn when entering the room. a (clean, non-sterile) gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. IP stated Resident 3 was on contact precautions. IP stated Resident 3 was in a room with another resident without isolation precautions. IP stated the P&P was not followed.

Based on interview and record review, the facility failed to ensure care plans were updated for one of three sampled residents (Resident 2). This failure had potential for Resident 2's care providers not to be aware of care needs.Findings:During a review of Resident 2's Therapy Post-Fall Screen, (TPFS) dated 11/3/25, the TPFS indicated, Date of Fall: 11/1/25. Comments regarding the resident's usual pattern of interaction with the environment (mobility, self-care, communication, assistance provided by caregiver: Do not leave (Resident 2) in the W/C (wheelchair) unattended Frequent monitoring of staff . floor mat call light within reach at all times.During a review of Resident 2's Therapy Post-Fall Screen, dated 3/9/26, the TPFS indicated, Date of Fall: 3/7/26. Comments regarding the resident's usual pattern of interaction with the environment (mobility, self-care, communication, assistance provided by caregiver: . floor mat frequent monitoring of staff & check vitals educate (Resident 2) about safety during transitional movement.During a concurrent interview and record review on 4/21/26 at 3:09 p.m. with Director of Nursing (DON) Resident 2's Change of Condition, dated 11/1/25 and 3/7/26 were reviewed. DON confirmed both COC were for falls and Resident 2's falls happened while in bed. Resident 2's Therapy Post-Fall Screen, dated 11/1/25 and 3/9/26 were reviewed. DON reviewed Resident 2's high risk for falls care plan and confirmed the TPFS recommendations (11/1/25 and 3/9/26) were not updated in Resident 2's care plan. DON stated we go through falls during standup; we should have caught that and on stand and updated Resident 2's high risk fall care planned.During a review of the facility's policy and procedure (P&P) titled Response to Falls, revised 11/1/17, the P&P indicated To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. III. After each fall, a License Nurse will complete a Post-Fall Assessment & Investigation. The investigation will help to identify circumstance or factors contributing to the resident's fall. V. The Interdisiplinary Team (IDT) will review the investigative reports on a regular basis, as they may occur, and make systemic changes to reasonably limit future occurrences, consider change in POC interventions, system changes, . C. Following each resident fall, the Interdisciplinary Team (IDT)-Falls Committee will review the Post-Fall Assessment & Assessment within 72 hours, or as soon as practicable. i. Based on the Post-Fall Assessment & Investigation, the IDT-Falls Committee will review fall prevention interventions and modify the plan of care as indicated. viii. Revise resident's Care Plan as necessary.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on Fall Management Program, Refusal of Treatment, and Continence Management Guideline when:1. Certified Nursing Assistant (CNA) 1 did not notify a licensed nurse when one of three sampled residents' (Resident 1) refused to have her soiled brief changed.2. CNA 1 did not check and offer to change Resident 1's soiled brief after a refusal for one hour and 45 minutes.3. CNA 1 did not check and offer to change Resident 1's brief every two hours.These failures had the potential to result in Resident 1 falling from trying to go to the bathroom and sustaining right distal femur (lower part of the right thigh bone) fracture (broken bone) requiring hospitalization and surgery.Findings:During a review of Resident 1's admission Record [AR], dated 1/6/26, the AR indicated, DIAGNOSIS. MUSCLE WEAKNESS (GENERALIZED). NEED FOR ASSISTANCE WITH PERSONAL CARE. HISTORY OF FALLING. DISPLACED INTERTROCHANTERIC FRACTURE [a break in the upper part of the thigh bone] OF RIGHT FEMUR [right thigh bone].During a review of Resident 1's Minimum Data Set [MDS - an assessment tool], dated 12/4/25, the MDS indicated on section C, Resident 1 had a BIMS (Brief Interview for Mental Status) score of 3 (severe cognitive impairment - having problems with thinking abilities like memory, concentration, decision-making, and problem-solving). The MDS indicated on section GG, Resident was wheelchair-bound (unable to walk and uses a wheelchair for mobility), required total assist with toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and was unable to stand, walk, and transfer to the toilet. The MDS indicated on section H, Resident 1 was always incontinent to bowel and bladder (having no voluntary control over urination and defecation).During a review of Resident 1's Fall Risk Evaluation [FRE], dated 9/16/25, the FRE indicated, Resident 1 had a score of 17 (Director of Nursing [DON] stated on 1/13/26 at 9:25 a.m., score of 10 or higher indicates high fall risk).During a review of Resident 1's SBAR [Situation, Background, Assessment, Recommendation], dated 12/29/25, the SBAR indicated, Resident [1] was found with her legs off the bed and her body in the bed, [LVN 1] and CNA [1] assisted resident to the ground. [LVN 1] and CNA [1] assisted resident back to her bed were she was checked for bruising or injuries noted. Resident [1] verbalized having no pain. Resident [1] was asked what happen resident [1] stated I had to go to the restroom. Resident [1] reminded to use call light when in need of help call light is within reach and hydration. MD [Medical Doctor] and RP [Responsible Party] were notified about residents [1] recent fall.During a review of Resident 1's Care Plan [CP], dated 9/6/24 (date initiated), the CP indicated, Focus. The resident [1] is at risk for repeated falls r/t [related to] Deconditioning [decline in physical strength], Gait/balance problems, Psychoactive drug [drug that affects how the brain works] use, generalized weakness, s/p [status post] mechanical fall [a fall caused by an external factor or environmental hazard] at home resulting fx [fracture] to right femur with surgical intervention, impulsive behavior, episodes of crawling out of bed. Interventions. Anticipate and meet The resident's needs.During a review of Resident 1's RADIOLOGY [medical field using imaging technologies] SERVICES PATIENT REPORT [RSPR], dated 12/29/25, the RSPR indicated, RIGHT KNEE. IMPRESSIONS: A periprosthetic fracture [a broken bone around a joint replacement] of the distal femur. The age of the fracture is indeterminate [uncertain about when the event occurred].During a concurrent interview and record review on 1/6/26 at 2:38 p.m. with DON, Resident 1's Nurses Note [NN], dated 12/31/25 was reviewed. NN indicated, Resident stated 9/10 bilateral knees and right hip pain. Observed redness on right outer thigh and swelling on right knee. MD notified and given order to Send to [acute] Hospital for CT [computed tomography scan used to take detailed images of the body] scan. DON stated on 12/29/25, Resident 1 had an x-ray (medical imaging that uses radiation to take pictures of the inside of the body) done indicating an age-indeterminate fracture. DON stated on 12/29/25, Resident 1 had no swelling on her right knee and had no pain, but on 12/31/25, Resident 1 had swelling on her right knee and complained of pain. DON stated Resident 1 was sent to the hospital on [DATE] for a CT.During a review of Resident 1's ED [Emergency Department] Physician Notes [Acute hospital records], dated 12/31/25, the ED Physician Notes indicated, pt [patient] sent from [facility] for possible CT. pt fell when trying to get out of bed on 12/29 and pt now c/o [complained of] bilateral knee pain. CT Knee Rt [right]. There is periprosthetic fracture of the distal femoral metaphysis [the flared, widened area of the thigh bone just above the knee joint] with 1 cm [centimeter - metric unit of length] impaction [the broken ends of a bone are forcefully driven into each other]. Fracture site extends to the patellofemoral compartment [compartment in the front of the knee between the knee cap and thigh bone].During a review of Resident 1's Operation/Procedure Report [OPR] [Acute hospital records], dated 1/3/26, the OPR indicated, DIAGNOSIS: Right distal femur fracture. PROCEDURES. Application of retrograde intramedullary nailing [surgery where a metal rod is inserted backward into the hollow center of a long bone to stabilize a fracture], right femur.During an interview on 1/7/26 at 1:16 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 when Resident 1 fell on [DATE]. LVN 1 stated on 12/29/25 around 5:15 a.m., she was passing medications when CNA 1 called her to Resident 1's room. LVN 1 stated Resident 1 had most of her hip on the bed and Resident 1's legs were hanging off the bed. LVN 1 stated she assessed Resident 1. LVN 1 stated Resident 1 did not have injuries and did not complain of pain.During an interview on 1/12/26 at 11:43 a.m. with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 when Resident 1 fell on [DATE]. CNA 1 stated on 12/29/25 at around 5:15 a.m., when she passed by Resident 1's room, CNA 1 saw Resident 1 holding the bed rail and her left leg was bent on the floor mat. CNA 1 stated Resident 1 stated she was trying to go to the bathroom to pee. CNA 1 stated she checked Resident 1's brief, and it was wet and had bowel movement. CNA 1 stated she went to see Resident 1 on 12/29/25 at 3:30 a.m. and she saw Resident 1's brief indicator color had changed from yellow to blue, indicating Resident 1's brief was wet. CNA 1 stated she offered to change Resident 1 's brief but she refused. CNA 1 stated she did not notify LVN 1 when Resident 1 refused to be changed. CNA 1 stated she did not ask help from another CNA to change Resident 1. CNA 1 stated she did not come back to ask Resident 1 to change her brief until she passed by Resident 1's room around 5:15 a.m. and saw Resident 1 falling off her bed. CNA 1 stated during her shift on 12/29/25 night shift (10 p.m. to 6:30 a.m.), she only changed Resident 1 once right after the fall at around 5:15 a.m. CNA 1 stated she did not check and change Resident 1's brief every two hours because Resident 1 would usually refuse at night, CNA 1 stated she was supposed to offer to check and change Resident 1 every two hours to prevent falls and skin breakdown. CNA 1 stated when Resident 1 refused to be changed, she should have notified LVN 1 and asked for help from the other CNAs to help her change Resident 1.During a review of the facility P&P titled, Fall Management Program, dated November 2017, the P&P indicated, Purpose To prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. Policy It is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. Assist patient with toileting as appropriate.During a review of the facility's P&P titled, Refusal of Treatment, dated 11/1/17, the P&P indicated, When a resident refuses or discontinues treatment, the Charge Nurse or Director of Nursing Services (DNS) interviews the resident to determine what and why the resident is refusing or discontinue treatment. The Charge Nurse or DNS will attempt to address the resident's concerns and explain the consequences of the refusal or discontinuance of treatment.During a review of the facility's P&P titled, Continence Management Guideline, dated November 2017, the P&P indicated, incontinence care i. Pad/brief change every 2-4 hours.

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Documentation - Nursing, for one of three sampled residents (Resident 1) when Resident 1's Nurse Advance Skilled Evaluation ([NAME]) documentation was inaccurate. This failure had the potential for Resident 1 to receive inappropriate care.Findings:During a concurrent interview and record review on 1/5/26 at 1:01 p.m. with Registered Nurse (RN), Resident 1's [NAME], dated 11/24/25 at 3:34 p.m. was reviewed. The [NAME] indicated, Respiratory: Difficulty breathing noted. Resident [1] reported respirations shallow. Nurse observed sternal retractions [a visible sign of respiratory distress] present. Shortness of breath noted. Resident [1] reported Shortness of breath (while lying flat). Nurse observed Shortness of breath (while lying flat). RN stated she documented in error. RN stated the documentation was for another resident (unknown).During an interview on 1/20/26 at 12:20 p.m. with Director of Nursing (DON), DON stated nurses should document accurately. During a review of the facility's P&P titled, Documentation - Nursing, dated 11/1/17, the P&P indicated, Purpose To provide documentation of resident status and care by nursing staff. Policy Nursing documentation will be concise, clear, pertinent, and accurate.

Based on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 30 and Resident 75) had comprehensive activities assessments and activities care plans developed specific to the preferences and interests of Resident 1, Resident 30 and Resident 75. This failure resulted in Resident 1, Resident 30 and Resident 75 not receiving activities specific to their preference or interests. This failure resulted in a decreased quality of life for Resident 1, Resident 30, and Resident 75.Findings: a. During an observation on 12/17/25 at 2:23 p.m. outside of Resident 1's room, activities staff (AS) was pushing a cart to resident rooms. AS visited multiple resident's rooms but did not attempt to enter Resident 1's room. During an interview on 12/18/25 at 8:45 a.m. with AS, AS stated she assumed Resident 1's son was in the room visiting the day before (12/17/25) and did not go in Resident 1's room. AS stated she does not go into Resident 1's room normally, because Resident 1 refuses activities. During a concurrent interview and record review on 12/18/25 at 8:57 a.m. with Activities Director (AD), Resident 1's [Facility Name] Quality of life Initial Assessment (QOLA - comprehensive activities assessments), dated 7/31/25 was reviewed. The QOLA indicated Resident 1 spent time at home cooking and cleaning but did not include any personal interests. AD stated activities staff should still check on and offer activities to Resident 1 each day. During a concurrent interview and records review on 12/18/25 at 9:01 a.m. with AD, Resident 1's Care Plan (CP), dated 7/31/25 was reviewed. The CP indicated, The resident [Resident 1] needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. AD stated the CP did not include personalized interests for Resident 1. b. During an interview on 12/17/25 at 1:27 p.m. with Resident 30, Resident 30 stated he was unable to get out of bed and attend activities. Resident 30 stated he used to be an avid reader but could not see well enough to read anymore. Resident 30 stated he would be interested in audio books but did not have access to any. Resident 30 stated he watched television (tv) most of the time but has difficulty seeing because the tv was so small and so far away. Resident 30 stated he had asked for a bigger tv but the facility had not provided one. During an observation on 12/17/25 at 2:16 p.m. AS was in Resident 30's room. AS told Resident 1 she would leave the Daily Chronicle (flyer with facility information and news) for him. Resident 1 responded to AS stating he was unable to read it since his eye sight was so bad. Resident 30 told AS he would like to have a bigger tv. AS responded to Resident 1 by laughing and teasing Resident 1 stating, What do you want an 85 inch big screen? During a concurrent interview and record review on 12/18/25 at 9:11 a.m. with AD, Resident 30's QOLA, dated 10/23/25 was reviewed. The QOLA indicated having books, newspapers and magazines to read was somewhat important but did not indicate what type of books, newspapers or magazines. The QOLA indicated listening to music he liked was very important to Resident 30 but did not indicate what type of music. The QOLA indicated doing his favorite activities was somewhat important to Resident 3 but did not indicate what specific activities. The QOLA indicated going outside and getting fresh air when the weather was good was very important to Resident 3 but did not indicate how the facility would accommodate his preference. AD stated the QOLA was not specific to the personal interests of Resident 30. During a concurrent interview and record review on 12/18/25 at 9:16 a.m. with AD, Resident 30's CP, dated 10/15/25 was reviewed. The CP indicated, The resident [Resident 30] needs a variety of activity types and locations to maintain interests. AD stated the CP was not specific to the personal interests of Resident 30. c. During an concurrent observation and interview on 12/17/25 at 2:06 p.m. with AS, AS entered Resident 75's room and left an iPad on the bedside table. AS stated the iPad was providing musical sensory activity for Resident 75. During a concurrent interview and record review on 12/18/25 at 9:03 a.m. with AD, Resident 75's QOLA, dated 11/18/25 was reviewed. The QOLA indicated unknown for demographic information (including birthplace, culture, pets, and occupations) and no response to activity preferences (including reading books, newspapers, magazines, listening to music, favorite activities and going outside). The QOLA indicated, Activity staff will provide room visits daily with sensory activities. AD stated Resident 75's QOLA was incomplete. AD stated she had attempted to contact Resident 75's family but was unable to provide documentation that attempt was made to contact a family member. During a concurrent interview and record review on 12/18/25 at 9:09 a.m. with AD, Resident 75's CP, dated 11/18/25 was reviewed. The CP indicated, The resident [Resident 75] needs 1:1 bedside/in-room visits and activities if unable to attend out of room events. AD stated Resident 75's CP was not specific to his personalized preferences for activities. During a review of the facility's policy and procedure (P&P) titled, Activities Program, dated 4/1/21, the P&P indicated, To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. I. The Facility provides an Activity Program designed to meet the needs, interests, and preferences of residents. The activities are varied to address the needs and interests identified through the assessment process. The Activity Program will address areas including, but not limited to: A. Social activities; B. Indoor and outdoor activities; C. Activities away from the Facility; D. Religious programs; E. Opportunity for resident involvement for planning activities; F Creative activities; Educational activities; and H. Exercise activities. II. A variety of activities are offered on a daily basis, which includes weekends and evenings. III. Activities are developed for individual, small group, and large group participation. Procedure I. Assessment. B. The initial Activity Assessment [QOLA] is completed by the Director of Activities, or his or her designee, withing seven (7) days of admission. The Director of Activities, or his or her designee, will conduct an interview with the resident or gather information to complete the Staff Assessment. II. Care Plan A. After completion of the initial Activity Assessment. an individualized Care Plan will be developed and implemented for each resident. D. As needed, activities are tailored to meet the needs of resident with cognitive impairment or other special needs.

Based on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions were followed when: 1. Two opened boxes of vegetables in the refrigerator in the dry storage room were not labeled with a received, opened and use by date. This had the potential for residents to be served unpalatable food.2. An opened unlabeled box of butter was stored in one of one refrigerator in the dry storage room. This had the potential for residents to be served unpalatable food.3. Food scoops were stored inside two of four dry good food containers. This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.4. One of one sampled ice cream scoop was not cleaned prior to being stored with clean utensils. This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.5. Two rolls of unlabeled meat were stored in one of one of the freezers in the hallway outside the kitchen. This had the potential for residents to be served unpalatable food.This failure had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food) for residents.Findings:1. During a concurrent observation and interview on 12/15/25 at 7:50 a.m. with Dietary Service Supervisor (DSS), in the dry storage room, an opened box of carrots was in the refrigerator. The box of carrots was not labeled with a received, opened, and used by date. DSS stated the box of carrots should have been labeled with the received, opened, and used by date.During a concurrent observation and interview on 12/15/25 at 7:50 a.m. with Dietary Service Supervisor (DSS), in the dry storage room, an opened box of lettuce was in the refrigerator. The box of lettuce was not labeled with a received, opened, and used by date. DSS stated the box of lettuce should have been labeled with the received, opened, and used by date.2. During a concurrent observation and interview on 12/15/25 at 7:50 a.m. with Dietary Service Supervisor (DSS), in the dry storage room, an opened box of butter was in the refrigerator. The box of butter was not labeled with a received, opened, and used by date. DSS stated the box of butter should have been labeled with the received, opened, and used by date.During a review of the facility's Policy and Procedure (P&P) titled, Labeling and dating of foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the date for product. Newly opened food items will need to be closed and labeled with an open date and used by date.Produce is to be dated with received date. 3. During a concurrent observation and interview on 12/15/25 at 8:09 a.m. in the kitchen with the facility cook, the food scoop was stored inside the dry flour bin. The scoop was touching the flour and was not stored separately outside the flour bin. [NAME] stated the scoop should be stored separately from the food bin.4. During a concurrent observation and interview on 12/15/25 at 8:11 a.m. in the kitchen with Cook, the food scoop was stored inside the dry oatmeal bin. The scoop was touching the oatmeal and was not stored separately from the oatmeal bin. [NAME] stated the scoop should be stored separately from the food bin.During a review of the P&P titled, Ingredient Bins, dated 2023, the P&P indicated, Scoops used in bins must not be left in the bin. If scoops are used, they are to be kept in a protected container/cover, conveniently located near the bins.5. During a concurrent observation and interview on 12/15/25 at 8:15 a.m. in the kitchen with the Certified Dietary Manager (CDM), an ice cream scoop with food particles and debris was stored in the clean kitchen utensils drawer. CDM stated the scoop was not cleaned properly and it should not have been stored with the clean utensils.During a review of the P&P titled, Dishwashing, dated 2023, the P&P indicated, Gross food particles shall be removed by careful scraping and pre-rinsing in running water. During a concurrent observation and interview on 12/15/25 at 8:29 a.m. in the hallway next to the kitchen with CDM, in the freezer located in the hallway next to the kitchen there were two unlabeled white rolls of frozen meat. CDM stated the meat was ground beef, but it was not labeled and stated the package should have been labeled. During a review of the facility's Policy and Procedure (P&P) titled, Labeling and dating of foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the date for product. Newly opened food items will need to be closed and labeled with an open date and used by date.Produce is to be dated with received date.

Based on observation, interview and record review, the facility failed to follow its policy and procedure (P&P) titled Miscellaneous Areas when one of three trash bins could not be closed. This failure had the potential to attract flies, vermin, and rodents that carry diseases which could infect the residents and cause an infestation in the facility.Findings:During a concurrent observation and interview on 12/15/25 at 8:25 a.m. with Certified Dietary Manager (CDM) in the outside area where the trash bins are located. One of three trash bins had the lid open, and the trash bags were overflowing from the top of the bin. CDM stated the staff should have put the trash in the trash bin that was empty. CDM stated staff know that they must be able to close the lid, to prevent attracting flies or rodents.During a review of the facility P&P titled, Miscellaneous Areas, dated 2023, the P&P indicated, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents.Fly and Vermin Control Flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department.

Based on observation, interview, and record review, the facility failed to ensure sanitary disposal of three used trash bags. This failure had the potential to result in the spread of infection to residents, staff, and visitors. During an observation on 12/15/25 at 8:38 a.m., in room [ROOM NUMBER]'s bathroom, a plastic trash bag containing trash was on the floor next to a trash can inside the resident's bathroom. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, in Resident 30's bathroom, trash was on the floor. LVN 2 stated, the certified nurse assistant should have placed the bag in the trash can, it should not be there on the floor.During an observation on 12/15/25, at 10 a.m., in Resident 52's room, looking out onto the patio area outside, a clear plastic bag was seen on the ground across the courtyard in the resident's patio area. The plastic trash bag contained a brown substance. During a concurrent observation and interview on 12/15/25 at 10:10 a.m., with Transportation/Help and Maintenance Supervisor (MS), Transportation/Help put on gloves and opened the plastic trash bag that was seen on the patio form Resident 52's room. Transportation/Help stated, it's poop [feces]. MS stated he was not sure how the trash bag got on there. During an interview with the Administrator on 12/16/25, at 8:28 a.m., the Administrator stated the outdoor patio area located between the resident rooms on C wing and resident rooms on B wing. Resident and their families can use the patio areas located outside of those rooms. During a concurrent observation and interview on 12/17/25, at 9: 10 AM, with Director of Staff Development (DSD), Infection Preventionist (IP), and Laundry Staff (LS), in the laundry room plastic bags were stored on the floor next to the washer. IP put on gloves and lifted the top plastic trash bag, underneath was a second trash bag. IP opened the trash bag. The first bag contained used mopheads, and the second trash bag contained used dirty towel. LS stated the bags of trash should not have been stored on the floor. A facility policy and procedure was requested, none was provided.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan (CP) for one of six sampled residents (Resident 89). This failure had the potential to result in Resident 89 having an unrecognized change in condition and adverse health outcome.Findings:During an observation on 12/16/25 at 8:58 a.m. with Resident 89, in Resident 89's room. Resident 89 was receiving oxygen though a nasal cannula (A lightweight tubing device that is placed in the patient's nose to deliver supplemental oxygen).During a review of Resident 89's Clinical Record (CR), the CR indicated Resident 89 had a Physician Order (PO) for Oxygen-continuously to start at 5 LPM (liters per minute) via nasal cannula to maintain Oxygen [O2]) sat [saturation - level of O2 in the blood] above 92% [percent] notify MD [Medical Doctor] if O2 drops below 92 %.During a concurrent interview and record review on 12/18/25 at 10:15 a.m. with Minimum Data Set Coordinator (MDSC), Resident 89's Care Plan (CP), was reviewed. MDSC stated Resident 89 was receiving oxygen via nasal canula and stated no care plan for oxygen was found in Resident 89's medical record. MDSC stated there should have been a care plan for oxygen.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 2017, the P&P indicated, A comprehensive person-centered care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. Each resident's care plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 75) was provided quality health care when: a. Resident 75's laboratory results were not reviewed and reported to the physician in a timely manner. This failure had the potential to result in delayed treatment and worsening of Resident 75's infection. b. Interdisciplinary Team (IDT - a group of health care providers) did not develop an individualized care plan (CP) for Resident 75's contact isolation (CI - infection control process for preventing germs from spreading through direct touch or contaminated surfaces). This failure resulted in staff not being aware of Resident 75's infection and the potential for the infect to spread to staff and other residents in the facility. c. Resident 75 was kept on contact isolation for 13 days after the physician order for contact isolation was discontinued. This failure resulted in unnecessary isolation had the potential to result in emotional distress for Resident 75. Findings: a. During a concurrent interview and record review on 12/18/25 at 2:54 p.m. with IP, Resident 75's Lab Results Report (LRR), dated 12/1/25 was reviewed. The LRR indicated multiple abnormal lab results. IP stated the LRR was received by the facility on 12/1/25. During a concurrent interview and record review on 12/18/25 at 2:56 p.m. with IP, Resident 75's Progress Notes (PN), dated 12/4/25 was reviewed. The PN indicated the physician was notified of the abnormal lab results on 12/4/25. IP stated the lab results needed to be reported to the physician on 12/1/25 when the facility received them. During a concurrent interview and record review on 12/18/25 at 3:30 p.m. with DON, Resident 75's medical record was reviewed. DON stated lab results were to be reviewed and reported to the physician as soon as possible. DON stated Resident 75's results were received on 12/1/25 and reported to the physician on 12/4/25 (three days later). DON stated the review and physician notification was not timely and care of Resident 75 was delayed. b. During a concurrent interview and observation on 12/15/25 at 8:39 a.m. with Housekeeper (HK), outside of Resident 75's room, a contact isolation sign was posted on the wall beside the door. Resident 75 was the only resident in the room. HK stated Resident 75 was on contact isolation but did not know what type of infection. During a concurrent interview and record review on 12/16/25 at 11:46 a.m. with Registered Nurse (RN), Resident 75's Physician Order (PO), dated 11/17/25 was reviewed. The PO indicated, Patient on Contact Isolation for ESBL [infection caused by bacteria that produce enzymes, Extended-Spectrum Beta-Lactamases (ESBL), which break down many antibiotics, making infections harder to treat.] in the urine. RN stated she did not know what type of infection Resident 75 and needed to review his medical record. RN stated Resident 75 was placed on contact isolation on 11/17/25. During a concurrent interview and record review on 12/16/25 at 11:48 a.m. with RN, Resident 75's PO, dated 11/14/25 was reviewed. The PO indicated, Meropenem [antibiotic used to treat serious bacterial infections] 1 GM [gram]. two times a day for ESBL UTI [urinary tract infection] for 2 weeks. RN stated the antibiotic treatment was completed on 11/29/25. RN stated there were no current orders for antibiotic treatment. RN stated she was not sure why Resident 75 was still on contact isolation. During a concurrent interview and observation on 12/17/25 at 8:32 a.m. with Licensed Vocational Nurse (LVN) 1, outside of Resident 75's room, a contact isolation sign was on the wall by the door. LVN 1 stated she did not know why Resident 75 was on contact isolation and could not identify the type of infection Resident 75 had. During a concurrent interview and record review on 12/18/25 at 12:17 p.m. with Minimum Data Set Coordinator (MDSC), Resident 75's CP, was reviewed. The CP did not indicate a care plan for Resident 75's contact isolation and infection. MDSC stated there was no CP for Resident 75's contact isolation and infection. During a concurrent interview and record review on 12/18/25 at 3:49 p.m. with DON, Resident 75's IDT Notes (IDT), dated 11/14/25 through 12/18/25 were reviewed. DON stated there were no IDT notes for Resident 75. DON stated it was the responsibility of the IDT to develop and implement care plans for each resident. c. During a concurrent interview and record review on 12/17/25 at 8:34 a.m. with Director of Nursing (DON), Resident 75's PO, dated 11/14/25 was reviewed. The PO indicated Resident 75 had completed his antibiotic treatment on 11/29/25. DON stated after antibiotic treatment was completed the resident would stay on contact isolation for three additional days to be sure the infection was gone. DON stated Resident 75 had not been taken off contact isolation. DON stated the IDT team was responsible for review of residents on isolation and antibiotics but had not reviewed Resident 75. During a concurrent interview and record review on 12/18/25 at 2:50 p.m. with Infection Prevention Nurse (IP), Resident 75's PO's were reviewed. The PO indicated Resident 75's order for contact isolation was discontinued on 12/4/25. IP stated the contact isolation sign outside of Resident 75's room should have been removed on 12/4/25. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/1/17, the P&P indicated, I. The Facility's Interdisciplinary Team (IDT) will develop a Comprehensive Care Plan for each resident. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, family and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

Based on interview and record review, the facility failed to ensure annual competencies were completed for one of six sampled employees (Certified Nursing Assistant [CNA] 1) was completed. This failure had the potential for the staff not be aware of their need for improvement in certain areas, which could affect resident care.During a concurrent interview and record on 12/18/25 at 10:48 a.m. with Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 1's personal file (PF), [undated] was reviewed. The PF indicated CNA 1 was hired on 6/5/24. The PF indicated there was no annual competency completed for CNA 1. DSD stated there should have been annual competency done in June of 2025 but there was none completed.During a review of the facility's P&P titled, Care Standards, dated 11/1/17, the P&P indicated, V. The DNS or designee evaluates staff competency in skills and techniques necessary to care for residents assessed needs.

Based on interview and record review, the facility failed to follow one of three sampled residents (Resident 1) care plan (personalized plan of care outlining a person's needs and how they will be addressed) to ensure Resident 1 who was high risk for falls (to move downward, typically rapidly and freely without control, from a higher to a lower level), had history of falls, and had Alzheimer's disease (progressive and fatal brain disorder that causes memory loss, cognitive decline [gradual decrease in mental abilities, such as memory, attention, reasoning, and judgment], and behavioral changes), had a floor mat (cushioned floor covering designed to reduce the impact of a fall, minimizing the risk of injury) to the right side of the bed and was wearing nonskid (designed to prevent sliding or skidding) socks when he got out of bed. These failures resulted in Resident 1 sustaining a fall and experiencing pain to the right hip. Resident 1 was transferred to the acute hospital requiring admission and operation for the acute (new) intertrochanteric (bony bumps on the upper part of the thigh bone) right femoral (relating to the thigh) fracture (broken bone). Findings: During a review of Resident 1's Admission Record (AR), dated 3/13/25, the AR indicated, Resident 1 was admitted on [DATE]. The AR indicated, Diagnosis. Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Other Cerebrovascular Disease (condition that affects blood flow to the brain) Affecting Left Non-Dominant Side (side of the body that is not used as much as the other side for everyday tasks) . Muscle Weakness (Generalized). Other Abnormalities of Gait and Mobility (change in walking pattern) . Alzheimer's disease. During a review of Resident 1's Quarterly Minimum Data Set (MDS - an assessment tool), dated 2/3/25, the MDS indicated, under Section C (Cognitive Patterns - the ways people think, process information, and make judgments) Resident 1 had a BIMS (Brief Interview for Mental Status) score of 5 (score of 0 - 7 indicates severe cognitive impairment [decline in one or more mental abilities that affects a person's daily functioning]). The MDS indicated, under Section GG (Functional Abilities - a person's capacity to perform everyday activities) Resident 1's admission performance required substantial or maximal assistance (helper does more than half the effort) with putting on or taking off footwear. The MDS indicated walking was not attempted due to safety concerns (Resident 1 was not walking at the time of assessment). During a review of Resident 1's Fall Risk Evaluation (FRE - process used to identify factors that increase an individual's likelihood of falling), dated 2/1/25, the FRE indicated Resident 1 had a score of 15 (score of 10 or higher indicates high risk for falls). During a review of Resident 1's Care Plan (CP), dated 10/14/24 (current care plan on 3/5/25), the CP indicated, High risk for repeated falls. Interventions. Ensure that the resident is wearing appropriate footwear when ambulating. During a review of Resident 1's CP, dated 10/28/24 (current care plan on 3/5/25), the CP indicated, High risk for repeated falls. Interventions. Floor mat to Right side of bed (Resident 1's left side of the bed has the window, and his right side of the bed has the floor space between his bed and the roommate's bed). During a review of Resident 1's Post Fall Evaluation (PFE - assessment after a fall to identify factors contributing to the fall to determine the necessary course of care), dated 11/12/24, 12/22/24, and 12/25/24, the PFE indicated on: a. 11/12/24, Fall occurred in the Resident's room. Floor mat was on floor: Yes. Footwear at time of fall: Non-skid shoes/socks. b. 12/22/24, Fall occurred in the Resident's room. Activity at the time of fall: resident trying to get up from bed. Floor mat was on floor: No . Footwear at time of fall: Non-skid shoes/socks. c. 12/25/24, Fall occurred in the Resident's room. Activity at the time of fall: trying to go back to bed by hiself [sic]. Floor mat was on floor: No . Footwear at time of fall: shoes. During a review of Resident 1's Nurses Note (NN), dated 3/5/25, the NN indicated, CNA (Certified Nursing Assistant [CNA 1]) reported that a resident (Resident 1) was found on the floor. This writer (Licensed Vocational Nurse [LVN] 1) immediately went to resident room and resident was found on the floor laying on his right side. resident c/o (complained of) pain to his right hip. Notified MD (medical doctor). Received an order to send him to hospital for further evaluation and treatment. During a review of Resident 1's 5-day Investigation Summary (FIS), dated 3/10/25, the FIS indicated, On March 5, 2025 at approximately 6am, (Resident 1) was found on the floor lying on his right side near his roommate's bed. (Family Member [FM]) 1 informed Director of Nursing (DON) that (Resident 1) told (FM 1) that he wanted to go to the bathroom but when he got up from the bed, he felt dizzy and fell . (Resident 1) is a high risk for falls. Interventions such as. landing mat on the right side of the bed. have been implemented prior to this fall incident. During a review of Resident 1's PFE, dated 3/5/25, the PFE indicated, Did an injury occur as a result of the fall: Yes. Did fall result in an ER (emergency room ) visit/hospitalization : Yes. Right hip. Pain score: 7 (7 - 10 indicates severe pain) . Contributing Factors. Floor mat was on floor: No . Footwear at time of fall: Bare feet. During a review of Resident 1's (Acute hospital) Orthopedic (medical specialty that focuses on the care of bones, joints, muscles, and associated structures) Consultation (OC), dated 3/6/25, the OC indicated, presents after mechanical ground-level fall (fall on the same level due to an external force or event) . Patient has a right hip intertrochanteric fracture. Need surgical fixation (process of stabilizing and joining bones or other tissues using surgical methods) . scheduled for right hip open reduction internal fixation (ORIF - surgical procedure that treats severe bone fracture or dislocation [a separation of two bones where they meet at a joint] by realigning the bones and stabilizing them with internal hardware [tools or devices used in medical procedures]) later today. During a review of Resident 1's NN, dated 3/7/25, the NN indicated, came back to (facility) from (acute hospital) . discharge diagnosis: Intertrochanteric fracture of right hip. SURGERY ORIF FEMUR (thigh bone) RIGHT HIP. During an interview on 3/13/25 at 12:42 p.m. with DON, DON was informed Resident 1 was not wearing nonskid socks at the time of fall (3/5/25). DON stated Resident 1 was supposed to wear at least nonskid socks . DON stated Resident 1's care plan for falls (to have nonskid socks, dated 10/14/24 [current care plan on 3/5/25]) was not followed. During an interview on 3/13/25 at 2:55 p.m. with LVN 1, LVN 1 stated on 3/5/25, she noted Resident 1 was lying on his right side on the floor (on the right side of the bed), with no floor mat on the right side of the bed and was bare feet. LVN 1 stated she did not know what was on Resident 1's care plan for falls. LVN 1 stated Resident 1 needed to wear nonskid socks so he would not fall. LVN 1 stated Resident 1 needed a floor mat on the right side of the bed so he won't hit his body hard on the floor and to prevent injury. During an interview on 3/18/25 at 3:56 p.m. with CNA 1, CNA 1 stated on 3/5/25, I just came in for morning shift. I never took over. I was making rounds, and I found (Resident 1) on the floor (on the right side of the bed). CNA 1 stated, There is no floor mat (on the right side of the bed). CNA 1 stated she did not know if Resident 1 was at risk for falls. CNA 1 stated, If (Resident 1) is fall risk, he is supposed to have a floor mat (on the right side of the bed) for preventing injury. During an interview on 3/21/25 at 9:18 a.m. with DON, DON stated, (Resident 1) has been falling. DON stated Resident 1 should have a floor mat on the right side of the bed to prevent injury. DON stated Resident 1's care plan (to have a floor mat on the right side of the bed, dated 10/28/24 [current care plan on 3/5/25]) for falls was not followed. During an interview on 3/24/25 on 12:53 p.m. with Nurse Consultant (NC), NC stated LVN 1, and CNA 1 should have known Resident 1 was at risk of falls and his care plan interventions for falls. NC stated the facility staff, especially nursing staff (licensed nurses and CNAs), should know the residents who are at risk for falls and their care plan interventions for falls. During a review of the facility's policy and procedure (P&P), titled Care Planning, dated 11/1/17 (current P&P on 3/5/25), the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT (Interdisciplinary Team - group of professionals who assess, coordinate, and manage each resident's comprehensive needs) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P), titled Trauma [event that causes long-lasting mental or emotional damage] Informed Care: Screening [assess for risk factors], Training, and Care Integration Program, when: 1. Medical Records (MR) staff and Dietary Aide (DA) 3 did not respond to one of one resident's (Resident 22) request to identify themselves. This failure resulted in Resident 22 weeping and expressing fear when his trauma response was triggered by staff. 2. Social services did not screen newly admitted residents for a history of trauma for five of six sampled residents (Resident 417, Resident 115, Resident 10, Resident 38, and Resident 39). 2. This failure resulted in the facility not being aware of Resident 417's, Resident 115's, Resident 10's, Resident 38's, and Resident 39's history of trauma or their triggers and resident specific trauma informed care not being provided. Findings: 1. During a concurrent observation and interview on 4/3/23, at 6:46 AM, with Resident 22, in Resident 22's room, MR and DA 3 were cleaning out the refrigerator behind a privacy curtain. Resident 22 was heard calling out, Stop it, who's there, what's happening. MR and DA 3 left the room without responding to Resident 22. Resident 22 stated, I think I'm having a bad dream, I have PTSD [Post Traumatic Stress Disorder- mental disorder that may occur in people who have experienced or witnessed a traumatic event] sorry I shouted. Resident 22 was crying. Resident 22 wiped his eyes with a napkin. Resident 22 stated, he thought he was hearing the radio. Resident 22 stated, when he hears the radio he hears the voices of soldiers who were killed calling out for their mother in the form of radio transmissions. During an observation on 4/3/23, at 8:44 AM, in Resident 22's room, Resident 22's privacy curtain was pulled around his bed. Maintenance Supervisor (MS) checked the temperature of Resident 22's room. Resident 22 stated, hello? when he heard the footsteps of MS. MS did not respond to Resident 22. During an interview on 4/6/23, at 8:46 AM, with the Director of Nursing (DON), DON stated, staff should knock and introduce themselves before entering; staff should try to approach residents in a calm way and honor resident preferences. During an interview on 4/6/23, at 11:54 AM, with MR, MR stated, Resident 22 was part of her assigned room rounds. MR stated, she was cleaning out the refrigerator in the room when she heard Resident 22 say get out, stop it. MR stated, I don't know why we didn't respond to him, I thought he was maybe talking in his sleep. I should have done better; I know he has a history of trauma. During a review of Resident 22's Order Summary Report, dated 4/4/23, the Order Summary Report indicated, Resident 22 had a diagnosis of Post-Traumatic Stress Disorder, Chronic [long term]. During a review of Resident 22's Care Plan (undated), Care Plan indicated, staff will Approach resident in a calm unhurried manner and provide 1:1 interaction. while providing care. 2. During an interview on 4/5/23, at 4:11 PM, with the Social Services Assistant (SSA), SSA stated, We do not complete any trauma screening tool on admission, I have never even seen that assessment. SSA was unable to find a facility trauma screening tool. During an interview on 4/6/23, at 8:46 AM, with DON, DON stated, the trauma screening tool should be done, but it was not. During an interview on 4/6/23, 3:40 PM, with Resident 417, Resident 417 stated, facility did not screen him for PTSD or trauma upon admission. Resident 417 stated, he does experience PTSD related to living on the street and being homeless. Resident 417 stated, he had witnessed suicides and his trauma was triggered by loud noise, a lot of traffic, and too many people in his personal area. During a review of Resident 417's Care Plans, (undated) no trauma or PTSD care plans were developed or implemented for Resident 417. 40516 During an interview on 4/3/23, at 11:29 AM, Resident 115 stated, he was a Vietnam veteran and was diagnosed with delayed PTSD and sometimes hearing the nurses speaking in another language triggers feelings of anxiousness. Resident 115 stated, he was not asked if he had PTSD or any trauma in his history when he was admitted to the facility on [DATE]. During an interview on 4/6/23, at 8:52 AM, with Registered Nurse (RN) 1, RN 1 stated, there were no questions about PTSD or history of trauma on the resident initial assessment form. During an interview on 4/6/23, at 9:49 AM, with DON, DON stated, the facility currently had no method to assess for PTSD or trauma. During a concurrent interview and record review on 4/6/23, at 10:01 AM, with MR, Resident 115's medical record was reviewed. MR stated, she was unable to find a trauma assessment for Resident 115. During an interview on 4/6/23, at 3:41 PM, with Resident 10, Resident 10 stated, she was not asked at the time of her admission if she had a diagnosis of PTSD or any life trauma. Resident 10 stated, she suffered trauma as a child from her parents constantly yelling at each other. Resident 10 stated, the yelling forced her into a shell. Resident 10 stated, she lost her vision about six years ago and now her hearing was heightened. Resident 10 stated, when residents yell in the hallway, she feels the same frightened feelings she did as a child. 45654 During an interview on 4/6/23, at 3:34 PM, with Resident 38, Resident 38 stated, she does not remember if the facility provided a form or questions about any post traumatic stress disorder. Resident 38 stated, in her past she was abused . 46939 During an interview on 4/6/23, at 3:46 PM, with Resident 39, Resident 39 stated, I have had traumatic events in my past. I was active duty in a war, and my jeep exploded. I do not think I was asked about traumatic events when I was admitted . During a review of the facility's P&P, titled Trauma Informed Care: Screening, Training, and Care Integration Program, dated 6/28/19, the P&P indicated, The facility will ensure residents who are trauma survivors receive culturally competent, trauma informed care; account for resident experience and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. A Trauma Screen Tool (SS-03 Form B) will be completed by Social Services upon admission.

Based on interview and record review, the facility failed to develop and implement a care plan for one of three sampled residents (Resident 1) with a known history of wandering, which resulted in Resident 1 wandering outside of the building and sustaining a fall. This required the resident to be transported to the hospital where the resident was diagnosed and treated for a fracture ( break in bone) of C1 and C2 (cervical vertebrae -bone at the top of the spine [neck] at the base of the skull) and nasal (bone in nose) tip fracture. Findings: During a review of Resident 1 ' s Admission Record (AR) the AR indicated Resident 1 was admitted on [DATE], with a diagnosis of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), difficulty walking, reduced mobility, need for assistance with personal care, and the presence of an artificial hip joint (hip prostheses). During a review of Resident 1 ' s Wandering Risk Scale, (WRS - assessment containing a series of questions which is used to determine if a resident is at risk of wandering) dated 9/30/22, the WRS indicated Resident 1 scored a 9 (a score of 9-10 indicated the resident is at risk to wander). During a review of Resident 1 ' s Elopement (unsupervised wandering which leads to the resident leaving the facility) Evaluation, (EE - an evaluation containing a series of questions used to determine if a resident is at risk of elopement) dated 9/30/22, the EE indicated Resident 1 scored a 0( 0 indicated no risk of the resident to elope). During a review of Resident 1 ' s Minimum Data Set, (MDS - an assessment tool) dated 10/5/22, the MDS indicated Resident 1 ' s BIMS (Brief Interview for Mental Status - a screen used to assist with identifying a resident's current cognition) score was 7 (a score of 0 to 7 suggests the resident's cognition is severely impaired). The MDS indicated, Resident 1 had a fall with fracture in the last 6 months and a fall within the last month. Resident 1 required extensive assistance (resident involved activity, staff provided weight-bearing support) to transfer (how a resident moves between surfaces including to or from bed, chair, wheelchair, and standing position) with one person assistance and required extensive assistance with walking with one person assistance. During a review of Resident 1 ' s Post Fall Evaluation (PFE) dated 10/19/22, at 6:28 AM, the PFE indicated Resident 1 had an unwitnessed fall, at 4 AM. PFE indicated, Activity at the time of fall: wandering Reason for fall was evident. Reason for fall: confused Fall Details Note: (Resident 1) was found outside a couple of door down [outside] from room lying on left side. Noted to left side of face large hemotoma [sic] (hematoma- a mass of usually clotted blood that forms in a tissue) near eye . During a review of Resident 1 ' s PFE, dated 10/19/22, at 8:17 PM, the PFE indicated, Resident 1 had an unwitnessed fall (second fall on 10/19/22), at 6:50 PM. The PFE indicated fall location was outside west of the facility near the linen carts. The PFE indicated, [Resident 1] injury details: laceration (deep cut or tear in the skin) to nose bridge, left upper face. The PFE indicated Resident 1 was sent to the emergency room for and an evaluation and treatment of the laceration of the nose bridge. During a review of Resident 1 ' s SBAR [situation background assessment recommendation- communication tool], dated 10/19/22, at 7:08 PM, the SBAR indicated, Resident 1 was sent to the hospital for treatment and evaluation. The SBAR indicated, Recommending a 1:1 supervision to this patient since the same situation (Resident 1 wandered outside the facility and sustained a fall) already happened twice in the same day. During an interview on 11/1/22, at 2:14 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was working 10/19/22 and was familiar with Resident 1. CNA 1 stated, Resident 1 would try to go outside of the facility through his bedroom door. CNA 1 stated, on the day of the occurrence Resident 1 ' s nurse and CNA were on break. CNA 1 heard yelling outside of the facility and when she went outside toward the yelling, Resident 1 was sitting on his buttocks. CNA 1 stated, she was informed of Resident 1 ' s behavior of wandering during the change of shift report. The previous shift staff informed her to keep a close eye (frequent visual checks) on the resident . During an interview on 11/1/22, at 2:28 PM, with CNA 2, CNA 2 stated, she did not work with Resident 1 often but she remembered Resident 1 was confused and staff were informed someone should always be watching the resident. During a concurrent interview and record review, on 11/1/22, at 2:57 PM, with Director of Staff Development (DSD), DSD reviewed the elopement binder (binder used which contained information of the residents with a known history of elopement). DSD confirmed Resident 1 was one of the residents in the elopement binder which meant the resident was a resident who had an elopement risk. During a concurrent interview and record review, on 11/1/22, at 4:26 PM, with Administrator and DON reviewed Resident 1 ' s WRS dated 9/30/22. DON and Administrator confirmed Resident 1 was identified as a resident who was at risk for wandering. Administrator and DON reviewed Resident 1 ' s medical record and confirmed no care plan was developed for the resident's wandering behavior. DON stated, the expectation was for the residents who were identified as a wandering risk, a care plan would be developed and interventions implemented to reduce the risk of wandering. DON and Administrator confirmed Resident 1 sustained a fall with fractures on 10/19/22. Administrator stated, We do our best. Sometimes you do not know it is an issue until something happens. During an interview on 11/5/22 at 11:22 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 confirmed she worked with Resident 1 on 10/19/22, at 4 AM. LVN 1 stated, she was doing rounds when they went to search for Resident 1 due to the yelling. LVN 1 stated, Resident 1 exited through his sliding door of his bedroom and the staff found him a few rooms down from his room, outside of the facility. He was on the ground on his left side. LVN 1 stated, she was made aware he was a wanderer. LVN 1 stated, [Resident 1] was on that list [wandering/elopement list]. LVN 1 stated, the CNAs kept a close eye on Resident 1 but He just got away (on the day of the occurrence). During a review of the hospital documentation, dated 10/19/22, the computerized tomography (CT- scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images [slices] of the bones) results indicated, Resident 1 sustained anterior (front of bone) and posterior (back of bone) fractures of the C1 and C2 arches, type 3 odontoid fracture (fracture through the body of the C2 vertebrae) and a nasal tip fracture. During a review of the facility policy and procedure (P&P) titled, Wandering & Elopement, revised 11/1/17, the P&P indicated, Purpose To enhance the safety of residents of the Facility.The Facility will identify residents at risk for elopement and minimize any possible injury because of elopement. I. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of a significant change condition .to determine their risk of wandering/elopement. VIII. Return of a Resident . B. The Licensed Nurse will initiate or update the resident ' s Care Plan and implement immediate intervention (s) to prevent further wandering/elopement by the resident.

Based on observation, interview, and record review, the facility failed to ensure nutritional needs were met for one of eight resident's (Resident 1) on enteral feedings (nutrition provided through a tube into the stomach). This failure resulted in Resident 1's developing elevated blood sugar levels (blood sugar over 180) and a weight gain of 22 pounds in six and one-half months. Findings: During an observation on 8/10/21, at 1:52 PM, in Resident 1's room, Resident 1 received a continuous enteral feeding of [MEDICATION(S)] 1.5 by a pump. The pump indicated 75 cc (cubic centimeters, milliliters [ml] unit of measurement) of [MEDICATION(S)] 1.5 and 50 cc's water was was administered every hour. During a review of Resident 1's Admission Record, dated 5/8/20, the Admission Record indicated, Resident 1 admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 had a feeding tube in place (stomach) when admitted to the facility. During a review of Resident 1's Nutrition Risk Assessment, dated 5/8/20, the Nutrition Risk Assessment indicated, Overall Assessment A 1. Diet Order (include supplements, snacks, vitamins, minerals) Puree diet with honey thick liquids for oral gratification ordered 5/19/20 Glucerna 1.5 (liquid nutrition for blood sugar control) at 50 ml/hr (milliliters per hour, rate of flow) x 20 hr (for 20 hours a day) .B 1 a. Controlled diseases: d. Diabetes Mellitus .Weight 152.0 Date 5/10/2020 .J 14 Drug nutrient interactions: N/V [nausea/vomiting] Dry mouth, anorexia [eating disorder, fear of gaining weight] Wt [weight] loss/gain, diarrhea: [MEDICATION(S)] [heartburn medication] losartan [ blood pressure medication] [MEDICATION(S)] [blood sugar medication] [MEDICATION(S)] [cholesterol medication] J 20 b Other (please specify) To meet estimated energy and fluid needs: Increase Glucerna 1.5 to 60 ml/hr x 20 hours .G: provide adequate nutrition and hydration to meet EEN [estimated energy needs], no significant weight changes .Care plan reviewed During a review of Resident 1's telephone physician order, dated 5/19/20, the physician's order indicated, Enteral feed order every shift NPO [nothing by mouth] YES X .FORMULA [MEDICATION(S)] 1.5 @ [at] 60 cc/hr off @8am and on 12pm continues 20 hr/24 hrs [for 20 hours out of 24 hours] IF TOLERATED. 1200ml/1800Kcal [total milliliters and total calories provided in 20 hours]. During a review of Resident 1's Nutrition Risk Assessment, dated 5/7/21, the Nutrition Risk Assessment indicated, Overall Assessment A 1. Diet Order (include supplements, snacks, vitamins, minerals) NPO TF [tube feeding] order [MEDICATION(S)] 1.5 @ 75 ml/hr x 20 hours to provide 1500 ml formula, 2247 kcal, 96g protein, 139 ml water with 50 ml water q[every] hr [hour] .Weight 180.0 Date 05/03/2021 11:16 . J 14 Drug nutrient interactions: N/V, Dry mouth, anorexia, Wt loss/gain, diarrhea: [MEDICATION(S)], [MEDICATION(S)], aspirin, [MEDICATION(S)] [blood pressure medication], losartan, [MEDICATION(S)] [blood sugar medication], [MEDICATION(S)] [blood pressure medication] . During a review of Resident 1's Weights and Vital Summary, dated 5/2021, the vital Blood Sugar, indicated, staff obtained Resident 1's blood sugar twice daily The vital Blood Sugar, dated 5/21, indicated results averaged 208. The vital Blood Sugar, dated 6/21, indicated results averaged 203. The vital Blood Sugar, dated 7/21, indicated results averaged 363. Resident 1 was admitted to the hospital 8/1/21 due to being lethargic, (lack of mental alertness). Resident 1 was readmitted back to the facility 8/9/21. The vital Blood Sugar, dated 8/10/21 indicated, Resident 1's blood sugar results were 240 and 382. During a review of Resident 1's hospital's medical record, the Emergency Department (ED) physician notes, dated 8/1/21, indicated, Resident 1 was lethargic, obtunded [mentally dulled] .Accu-chek [blood sugar] en route [by paramedics in ambulance] was critically high. (The blood sugar result was 575, from the hospital laboratory.) Final diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the American Diabetic Association article, Management of [CONDITION(S)] in Type 2 Diabetes: A Patient-Centered Approach, dated 2/1/13, the article indicated, Type 2 diabetes remains a leading cause of cardiovascular disorders, [CONDITION(S)], end-stage renal failure, amputations, and hospitalization s. The American Diabetic Association recommended blood sugar levels be consistently under 180 if the person was eating (Resident 1 was on a continuous tube feeding). During an interview on 8/12/21, at 12:25 PM, with DON, DON stated, Resident 1's formula had been changed this morning at 7:30 AM to Glucerna. DON stated, It's because his blood sugar has been running high. DON stated, The nurses reported to the doctor when it [Resident's blood sugar] was above 300, as he ordered. It's the responsibility of the Registered Dietitian (RD) to communicate with the physician in regard to the appropriate formula for residents. During a review of Resident 1's Dietary Progress Notes, dated 12/7/20, the Progress Notes indicated, Resident 1's weight on the date of admission (5/10/20) was 152 pounds (lbs.) and on 11/3/20 was 166 lbs. Resident 1 gained 14 lbs. or 9% in 180 days. Resident was receiving [MEDICATION(S)] 1.5 at 85 ml per hour. RD 1 documented the weight gain was planned and beneficial. During a review of Resident 1's Dietary Progress Notes, dated 1/18/21, the Progress Notes indicated, Resident 1 had a Weight Warning (concerning change in weight), Resident 1's weight was 177 lbs. RD 1 documented the weight gain was planned and beneficial. During a review of Resident 1's Dietary Progress Notes, dated 1/25/21, the Progress Notes indicated, Resident 1's weight was 177 lbs. RD 1 documented Resident 1's weight was at goal. Continued weight gain not indicated. Intervention reduce [MEDICATION(S)] 1.5 to 75 ml per hour. During a review of Resident 1's Dietary Progress Notes, dated 4/29/21, the Progress Notes indicated, Resident 1's weight was 181 lbs. Fingerstick blood sugar 118 - 290, usually in 100's. RD 2 documented, Weight gain appropriate due to previous underweight status. Goal may be weight stabilization Will continue to monitor. During a review of Resident 1's Dietary Progress Notes, dated 6/25/21, the Progress Notes indicated, Resident 1's weight was 187 lbs. (a 10 lbs weight gain (5.6%) from desired weight over five months) According to Resident 1's laboratory report, dated 6/10, Resident 1's blood glucose was 296 High Blood glucose range over seven days was 115 to 301. RD 3 documented No changes indicated at this time. During a review of Resident 1's Dietary Progress Notes, dated 7/9/21, the Progress Notes indicated, Resident 1's weight was 186 lbs. RD 3 documented, No new labs to review at this time. Blood glucose range x 7 [first 7 days of July] days: 85-271 .no nutrition interventions, continue current POC [plan of care .Current goals are no significant weight changes x [for] 30 days . During a review of the hospital Emergency Department (ED) Physician Notes, dated 8/1/21, the Physician Notes indicated, Resident 1 was sent to the ED for altered mental status. EMS reported nursing home was concerned about decreased declining level of consciousness. Accu-Chek (blood sugar test) in route was critically high. The blood sugar test done in the ED on 8/1/21 at 12:48 indicated, Resident 1's blood sugar level was 575. During a review of Resident 1's GLYCOHGB (HA1C, blood sugar levels averaged over previous three months), dated 8/10/21, the HA1c indicated Residents level was 8.0 H (high, normal is below 5.7). During an interview on 8/20/21, at 11:35 AM, with RD 4, RD 4 stated, she did review Resident 1's previous RD assessments from 1/25/21. RD 4 stated, I didn't find the [MEDICATION(S)] an appropriate tube feeding formula. RD 4 stated [MEDICATION(S)] had been started as Resident 1's tube feeding formula on 5/19/20. The Nutrition Risk Assessment, dated 8/12/21, RD 4 documented Resident 1's weight as 199 lbs (12.43% weight gain since in six and one/half months) and indicated, Comments Poorly controlled DM [diabetes]. RD 4 stated, she was unaware Resident 1 had gained 47 pounds in 15 months. RD 4 stated, The weight gain exposed the patient to poorly controlled diabetes. During a review of the manufacturer's instructions for use (MIFU) for [MEDICATION(S)] 1.5 Cal (calories), the MIFU indicated, [MEDICATION(S)]@ 1.5 Cal is calorically dense .Concentrated calories (1.5 Cal/mL) to help tube-fed patients gain and maintain healthy weight. During a review of the MIFU for Glucerna 1.5 Cal, the MIFU indicated, Specialized high-calorie nutrition for enhance glycemic [blood sugar] control .For patients with type 1 or type 2 diabetes. During a review of the facility policy and procedure (P&P) titled, Nutrition & Weight Variance Committee,dated 11/1/17, the P&P indicated, Purpose To ensure that each resident maintains acceptable parameters of weight and nutritional status, such as body weight and protein levels .II. Prior to each meeting, the Director of Nursing Services or designee will complile a list of residents who are at risk for, or in need of, weight change Residents that meet the following criteria may be included on the list for discussion .B. 2% weight change in 1 week C. 5% weight change in 1 month D. 7.5% weight change in 3 months, E 10% weight change in 6 months .Objectives of the Nutrition & Weight Varianve Committee may include .B. Assessing changes in diet .VI. Residents on the list will be reviewed monthly until their weight has stabilized.

Based on observation, interview, record review, the facility failed to address the needs of one of one sampled resident (Resident 25), with unplanned weight loss, when: 1. Physician orders [REDACTED]. 2. Food intake was not recorded. 3. Quarterly and Annual Nutrition Reviews were not completed. 4. Care plans (CP) were not accurately updated and implemented. These failures resulted in the continuous weight loss of Resident 25 and had the potential for adversely affecting her health condition and wellness. Findings: 1. During a review of Resident 25's monthly medication regimen review (MMR - a pharmacist's evaluation of a resident's medications), dated 12/9/19, Resident 25's MMR, indicated: a. Continues to lose weight on [MEDICATION NAME] (appetite stimulator). The MD (medical doctor) needs to consider using alternative/additional measures to improve the resident's appetite. b. [MEDICATION NAME] (medication used for dementia) can cause .a poor appetite. This resident is experiencing a poor appetite and/or a weight loss. Suggest D/Cing (stopping) the [MEDICATION NAME] in an attempt to improve the resident's appetite .Give [MEDICATION NAME] at bedtime to avoid GI (stomach) upset and loss of appetite. During a review of Resident 25's pharmacist's recommendation for [MEDICATION NAME], dated 12/9/19, Resident 25's pharmacist's recommendation indicated, [MEDICATION NAME] can cause .a poor appetite. This resident is experiencing a poor appetite and/or a weight loss. Suggest D/Cing the [MEDICATION NAME] in an attempt to improve the resident's appetite. Resident 25's pharmacist's recommendation for [MEDICATION NAME] was checked I agree with pharmacist's recommendations, signed by the MD and date stamped 1/21/20. During a review of Resident 25's Order Summary Report (OSR - monthly compilation of current, active physician orders [REDACTED]. a. [MEDICATION NAME] Capsule 2.5 MG (milligrams, unit of measurement) .Give 1 capsule by mouth at bedtime for Appetite Stimulation. b. [MEDICATION NAME] Tablet 10 MG .Give 1 tablet by mouth at bedtime related to Dementia During a concurrent interview and record review, on 2/12/20, at 5:42 PM, with the Director of Nursing (DON), Resident 25's MMR, dated 12/9/19, was reviewed. DON confirmed the pharmacist recommendations to stop both [MEDICATION NAME] and [MEDICATION NAME] due to Resident 25's continued weight loss. DON confirmed the MD checked I agree with the pharmacist's recommendations. for [MEDICATION NAME]. DON stated, this was a PO that should have been entered for Resident 25. DON was unable to provide documentation of the MD's agreement or disagreement for the [MEDICATION NAME]. DON stated, the consultant pharmacist's recommendation should have been signed and in Resident 25's clinical record. DON reviewed the physician orders [REDACTED]. DON was unable to provide documentation of a PO to stop [MEDICATION NAME]. DON reviewed Resident 25's Medication Administration Records (MAR), dated 1/20 and 2/20. DON confirmed Resident 25's MARs indicated, both [MEDICATION NAME] and [MEDICATION NAME] continued to be administered to Resident 25 on a regular basis since 1/21/20 for a total of 41 days. During an interview on 2/12/20, at 5:42 PM, with DON, DON stated the facility process for Gradual Dose Reductions (GDR) was: a. Pharmacist provided the GDR report with recommendations to DON, b, The pharmacist recommendations were sent to the appropriate MD. c. MD was expected to indicate if the recommendation was agreed with or declined with a reason. d. MD returned the form to the facility for the order to be carried out. e. If MD had not completed and returned the form to the facility in a few day, the facility would follow up with the MD. f. If MD agreed with the pharmacist's recommendation, a nurse would enter the new order. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/12, the P&P indicated, Medications must be administered in accordance with orders . 2. During an observation on 2/10/20, at 1:11 PM, Resident 25 was asleep in her bed, with the head of the bed raised to approximately 60 degrees. On the bedside table, in front of Resident 25 was an uncovered lunch plate. The lunch plate contained two large mounds of green beans, and a small roll. Next to the plate was a small bowl of chopped fruit, a bowl of pudding, a glass of water and a glass of milk. During an observation on 2/10/20, at 1:30 PM Certified Nursing Assistant (CNA) 1 attempted to awaken Resident 25 by touching her and calling out her name. Resident 25 did not respond. During an observation on 2/10/20, at 1:41 PM, CNA 2 attempted to awaken Resident 25. Resident 25 did not respond. CNA 2 removed Resident 25's lunch tray. CNA 2 confirmed Resident 25 had not eaten any of her lunch. During a review of Resident 25's Meal Percentage Eaten Log, dated 1/15/20 through 2/13/20, Resident 25's Meal Percentage Eaten Log indicated, on 2/10/20, no meal percentage or refusal was recorded for breakfast; lunch was recorded as refused at both 12:26 PM and 1 PM, no meal percentage or refusal was recorded for dinner. During a review of Resident 25's Meal Percentage Eaten Log, dated 1/15/20 through 2/13/20, for a total of 90 meals (30 days x 3 meals each day) Resident 25's Meal Percentage Eaten Log indicated, the following: No meal percentage or refusal was recorded for 19 out of 90 expected meals. Meal Refused was recorded for 14 out of 78 meals intakes recorded, 0 to 25% eaten was recorded for 31 out of 78 meals intakes recorded, 26% to 50% eaten was recorded for 22 out of 78 meals intakes recorded, 51% to 75% eaten was recorded for 20 out of 78 meals intakes recorded, 76% to 100% was recorded for 2 out of 78 meals intakes recorded. Resident 25 was not marked as NPO (nothing by mouth) or not available during this time frame. 3. During a review of Resident 25's Annual Nutrition Risk Assessment, dated 1/31/19, the Annual Nutrition Risk Assessment indicated: a. Resident 25 was at Moderate Risk for insufficient nutrition. b. Resident 25 needed assistance with meals and reminders to eat. c. Resident 25's blood work identified one or more indicators of poor nutrition. d. J. Overall Assessment: Resident 25's weight had been stable at 108 pounds (lbs) for six months, Resident 25's meal intake was 25%-50% recently with refusal of two meals, 100% of supplement intake and no indication of the percentage of snack intake. Dietary recommendation was to Continue interventions and goals for plan of care. During a review of Resident 25's Quarterly Nutrition Review, dated 7/25/19, the Quarterly Nutrition Review indicated, Resident 25's current weight was 104 lbs. (a weight loss of four lbs in six months) and Resident 25's ideal body weight range (IBWR) was 104 lbs to 127 lbs. No additional dietary notes, Quarterly Nutrition Assessments or the 2020 Annual Risk Assessment were provided. During a concurrent interview and record review on 2/13/20, at 8:40 AM with Restorative Nursing Assistant (RNA) 1 the list of residents on the RNA program for meal assistance was reviewed. RNA 1 stated, Resident 25 was not on the list for RNA meal assistance. During a concurrent interview and record review on 2/13/20, at 11:16 AM with the DON, Resident 25's Nutrition Risk Assessment, dated 1/31/19, was reviewed. DON stated, Resident 25 was not on RNA dining. DON stated, Resident 25 had been off and on monitoring depending on Resident 25's weights. 4. During a review of Resident 25's Care Plan (CP) for Unplanned Weight Loss, dated 10/29/19, the CP indicated, Resident 25's weight will return to baseline range (IBWR 104 lbs to 127 lbs.) by review date. The target date was 4/16/20. The CP indicated, the following interventions: a. Alert dietitician (sic) if consumption is poor for more than 48 hours. Resolved b. If weight decline persists, contact physician and dietician (sic) immediately. Resolved c. Labs as ordered. Report results to physician and ensure dietician (sic) is aware. Resolved d. Monitor and evaluate any weight loss e. Determine percentage (of weight) lost . f. Monitor and record food intake at each meal During a concurrent interview and record review on 2/13/20, at 8:50 AM, with Certified Dietary Manager (CDM), Resident 25's Care Plan (CP) for Unplanned Weight Loss, dated 10/29/19 was reviewed. DS stated, Resident 25 had gained weight and then lost weight again. CDM confirmed the above three interventions were marked Resolved. CDM stated, those interventions should not be marked Resolved as Resident 25 has continued to lose weight. During a review of Resident 25's Weights and Vitals Summary, dated 6/2/19 through 12/1/19, Resident 25's Weights and Vitals Summary indicated, Resident 25's weight on the following dates: On 6/2/19, 108 pounds (lbs); On 9/7/19, 96 lbs, (an 11.11% weight loss in 3 months); On 11/8/19, 95 lbs (a 12.04% weight loss in 4 months); On 12/1/19, 93 lbs (a 13.89% weight loss in 6 months). The American Society for [MEDICATION NAME] (food intake other than through the intestines, such as by an intravenous (in the vein) route) and Enteral (food intake through the intestines, either orally or by tube feeding) Nutrition (organization which provides the standards in nutrition support) indicated Adults should be considered at risk if they have any of the following: Involuntary weight loss of 10% or more of usual body weight within 6 (six) months, or involuntary loss greater than or 5% (five) or more of usual body weight in 1 (one) month. Involuntary loss or gain of 10 (ten) pounds within 6 (six) months .Altered diets or diet schedules. Inadequate nutrition intake .

Based on interview and record review, the facility failed to implement it's suicide prevention policy for one of one sampled resident (1), who verbalized suicidal ideation (thoughts). This resulted in Resident 1 attempting suicide and then emergently transferred to an acute hospital. Findings: The clinical record for Resident 1 was reviewed. Resident 1 was admitted with [DIAGNOSES REDACTED]. The social service initial assessment for Resident 1 dated 10/30/15, indicated Social History: HX (history) OF SUICIDAL ATTEMPTS X 2 IN PAST. MOOD, feeling down at times, tired, poor appetite, and feeling restless. Focus: The resident has mood problems AEB (as evidence by) feeling down, feeling tired, having poor appetite and feeling restless r/t (related to) Depressive Disorder, COPD. The order summary report for Resident 1 dated 2/1/16, indicated Resident 1 was on Sertraline (anti-depressant) for statements of hopelessness related to depressive episodes, lorazepam (anxiety medication) for anxiety, and Ambien (insomnia (sleeping disorder) medication because Resident 1 was unable to sleep. The Minimum Data Set (MDS- a comprehensive assessment tool) for Resident 1 dated 2/5/16, indicated under Brief Interview for Mental Status (BIMS-a short assessment of cognitive ability-the mental process of knowing, including aspects such as awareness, perception, reasoning, and judgment), a score of 14 indicating Resident 1 was cognitively intact. The Resident Mood Interview indicated Resident 1 was feeling down, depressed, or hopeless. The psychological consultation progress note for Resident 1 dated 2/3/16, at 5:11 PM, indicated Response: Patient was resistive to treatment interventions. Patient appears to be regressing. The Nurses note for Resident 1 dated 3/5/16, at 11:55 PM, indicated Approximately 2345 (11:45 PM), noted resident is not responding . called to Doctor . order to send resident to ER (emergency room ) for further evaluation and treatment. During a review of the hospital clinical record for Resident 1, the doctor's discharge summary dated 3/10/16, at 2: 45 PM, indicated She (Resident 1) admitted that she took a lot of Tylenol PM (a combination of acetaminophen-pain reliever and diphenhydramine-a sleep aid that causes drowsiness) because she felt depressed. The hospital clinical note by the social service staff, dated 3/7/16, at 2:34 PM, indicated Pt. (patient-Resident 1) acknowledges attempting to OD (Overdose) again on Tylenol . Pt. indicates she had thought about taking the pills For a few days and finally decided to take them due to continuing to struggle with her breathing . Pt. indicated I thought if I took the pills (Tylenol) I wouldn't have to wake up and worry about my breathing again. Pt. indicates that the staff at the SNF (facility) .administers meds (medication) to her but she had hidden a bottle of Tylenol in her purse . Pt. expresses feeling hopeless and states, I'm 71 yo (years old), I can't do anything. I can't even walk down the hall because I can't breathe. When I woke up here in the hospital I was upset that I didn't die. During a concurrent interview and record review with the Director of Nurses (DON), on 3/29/16, at 2:13 PM, the DON stated the incident happened on 3/5/16, at approximately 11:45 PM, when the nurse found Resident 1 unresponsive. The nurse attempted to wake up Resident 1 and was unsuccessful. The DON reviewed Resident 1's clinical record and was unable to find documented evidence where the facility Social Service staff and/or the nursing staff performed follow-up assessments on Resident 1's emotional state during her stay in the facility. The DON stated she was aware of Resident 1's prior suicide attempts. She stated the daughter informed her of suicide attempts during Resident 1's admission to the facility. The DON stated the facility's Suicide Prevention Policy was not put in place to keep Resident 1 safe from possible suicide attempts. The DON stated the facility provided no safety teaching for Resident 1, staff, and family members to ensure safety for Resident 1. During an interview with Resident 1's Responsible Party (RP), on 4/15/16, at 2:42 PM, she stated she informed the facility of her mothers prior suicide attempts on 10/30/16, Resident 1's first day of admission. The RP stated she informed the social service person, nurses, and the Director of Nurses. During an interview with Licensed Vocational Nurse (LVN) 2, on 4/20/16, at 1:14 PM, she stated I didn't know that she had suicide attempts in the past. I didn't look at her diagnosis, so I didn't know . No one told me. During an interview with LVN 3, on 4/20/16, at 4:45 PM, she stated, I didn't even know that she had suicide attempts in the past. I didn't look at her diagnoses. During an interview with LVN 1, on 4/20/16, at 4:53 PM, she stated, One day a doctor came and was speaking with her (Resident 1). When he (doctor) finished speaking with her (Resident 1), he (doctor) came and spoke with me to make sure the sleeping pills were kept in the medication cart because he said she had a history of [REDACTED]. I didn't think anything about what he said until it happened. I was surprised. LVN 1 stated she did not document the conversation with the doctor in Resident 1's clinical record to ensure all nurses were aware of the precaution. During an interview with the Social Service Designee, on 4/21/16, at 1:21 PM, she stated, Because she (Resident 1) verbalized hopelessness and sadness didn't mean that she was suicidal. She had no access to anything to commit suicide. I did not follow up on her (Resident 1's) emotions. I let the Psychologist do that. I didn't do anything. The facility policy and procedure titled Suicide Prevention Policy, undated, read in part Criteria to be Considered for Suicide Potential: Prior attempts . Major Depression . 1. Suicide precautions may be initiated by the attending physician, psychiatrist, psychologist, director of nursing or charge nurse with a doctors order . 4. The IDT will collaboratively determine the following levels of observation the resident shall be placed on: a. 1:1 observation, b. Line of sight, c. Every 15 minute observation . 10. Perform mouth checks when administering oral medication, 11. Residents on suicide precaution will have room and person searches for the following contraband .g. personal medication . 13. The resident will be reassessed each shift for suicide impulses . 14. Resident and family . will be educated about the suicide precautions .

Based on interview and record review, the facility failed to ensure licensed nurse assessments resulted in appropriate interventions being implemented for one of one sampled resident (1) who had a a fall. This failure resulted in Resident 1 experiencing worsening hip pain from an undetected [MEDICAL CONDITION] and a delay in medical treatment for [REDACTED]. Findings: During an interview with the Registered Nurse (RN) 1, on 4/30/15, at 2:40 PM, she stated Certified Nursing Assistant (CNA) 1 told her on 4/4/15, that Resident 1 was on the floor next to his wheelchair. RN 1 stated, We were assuming he was trying to get out of his wheelchair (wc) when he fell . Nobody witnessed the fall. During an interview with the Licensed Vocational Nurse (LVN) 1, on 4/30/15, at 3:20 PM, she stated, A CNA called that (Resident 1) fell (on 4/4/15). I saw the resident on the floor, one leg on top of the other kind (sic), a sitting position. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS, assessment tool) dated 2/21/15, indicated he had a Brief Interview for Mental Status (BIMS - a brief screener that aids in detecting cognitive impairment) score of 14/15 (cognitively intact). The MDS indicated Resident 1's balance in moving from seated to standing position, walking, and surface to surface transfer were not steady and he was only able to stabilize with staff assistance. He had no impairment in his functional range of motion. The Physicians Order dated 6/2/14, read, Tylenol (for pain) tablet 325 mg (milligram) ([MEDICATION NAME]) Give 2 tablet (sic).by mouth every 6 hours as needed for pain. The nurse's notes dated 4/5/15 at 5:36 PM, indicated Resident 1 was complaining of pain and was given Tylenol. The Nurses progress Notes dated 4/6/15, at 16:28 (4:28 PM), read, .assessed the Resident verbalized pain in the right hip. Resident stated that he is unable to move his right hip. new order received for an X-ray of the right hip. The X-ray report dated 4/6/15, indicated Resident 1 did not have an acute fracture but had an old healed [MEDICAL CONDITION]. The nurses notes dated 4/7/15, at 6:48 AM, indicated Resident 1 received Tylenol because he was complaining of right hip and thigh pain. The Restorative Nursing Assistant (RNA) note dated 4/7/15 at 4:44 PM, indicated Resident 1 refused to ambulate because of pain and the licensed nurse was notified. The RNA note dated 4/8/15 at 4:22 PM, indicated Resident 1 could not ambulate because of pain and the licensed nurse was notified. The RNA note dated 4/9/15 at 6:17 PM, indicated Resident 1's therapy was withheld due to him complaining of pain and the licensed nurse was notified. There was no indication during the above dates, the licensed nurses notified the attending physician of Resident 1's refusal to ambulate because of right hip and leg pain following his fall on 4/4/15. During an interview with the family member, on 6/8/15, at 8:40 AM, she stated, My daughter picked him (Resident 1) up on Easter (4/5/15). I noticed his leg was swollen when he got here. So I called, they said he fell the day before. I asked for an X-ray, they said no. No need for one. I said well the leg is really swollen. So that didn't occur (the X-ray) until Monday 4/6/15. (X-ray) Showed no fracture. But for the next two weeks, he (Resident 1) complained of pain and no weight bearing on that leg (right leg). The only treatment was Tylenol 325 mg. I told them it's not working. They increased to Tylenol # 3 with [MEDICATION NAME]. Finally, he could only transfer via Hoyer lift (an equipment used to aid a person getting from one spot to another). Red flag to me. So I took him to (name of hospital), X-ray there was fracture. The physician's orders [REDACTED].# 3 Tablet 300-30 MG ([MEDICATION NAME]-[MEDICATION NAME] use to treat moderate to severe pain) Give 1 tablet by mouth every 8 hours as needed for pain for 30 days. There were no indications in Resident 1's record that the nursing staff requested any further X-rays or interventions from the treating physician or that the nursing staff informed the treating physician of Resident 1's decline in ambulation. The RNA note dated 4/11/15 at 3:33 PM, read Res (resident) AMB (ambulation) was withheld twice this week due to res complaining of pain. Nurse notified. The RNA note dated 4/19/15 at 5:51 PM, read Resident has refused all food today, encouraged by RNA to eat and (he) refused all food including desserts. The RNA note dated 4/22/15 at 2:55 PM, read Resident is unable to hold up weight and take steps due to hip pain. Nurse has been notified of pain. There were no indications the treating physician was notified of Resident 1's continued right leg pain and decline in ambulation due to pain for the above timeframe. The nurse's notes dated 4/26/15 at 6:36 AM, indicated Resident 1 was given pain medication for his complaint of right hip pain with a 9/10 level of pain (an objective value of subjective pain value between 0 and 10 ascribed by the patient to the pain experience, where 0 equals no pain at all, and 10 equals the worst pain experienced or imaginable). There was no indication the treating physician was notified of Resident 1's hip pain. The nurse's notes dated 4/26/15 at 12:52 PM, indicated a telephone call was received from Resident 1's wife informing the facility she had taken the resident to the hospital where he was diagnosed with [REDACTED]. The care plan for Resident 1 titled Pain dated 6/2/14, read Evaluate for decline in physical functioning. Pain assessment on admission, and Q (every) quarter, and/or with change in condition. Notify MD of change in condition pain. The History and Physical from the hospital dated 4/26/15, read, Admitting Diagnoses: [REDACTED]. The X-ray was done at the skilled nursing facility where he resides. The pain continued to worsen and now he is unable to walk because of it .he had CT (Computed Tomography-a radiological imaging that uses computer processing to generate an image of tissue density in slices through the patient's body) of the right femur that showed the presence of fracture with impaction. PHYSICAL EXAMINATION: .EXTREMITIES: Unable to move the right hip because of the pain. DIAGNOSTIC WORKUP AND LABORATORY TEST: CT of the pelvis without contrast shows acute [MEDICAL CONDITION] femoral neck with associated impaction and posterior angulation. During a concurrent review of the clinical record for Resident 1 and interview with the Director of Nursing (DON), on 6/1/15, at 3:45 PM, the DON verified the above documentation. She stated, With that issue (pain not relieved by medication) I should have done a new intervention like calling the doctor for a new order. During an interview with the RNA, on 6/1/15, at 4 PM, she stated, I told her (charge nurse) that Resident 1 was having pain and not able to ambulate. Yes, we were two staff assisting him but he couldn't do steps, like he was doing before (the fall). During an interview with LVN 2, on 6/1/15, at 4:10 PM, she stated, If a Resident's X-ray was negative for fracture but he is still complaining of pain and unable to walk, I'll inform the doctor of the continuing pain so he can do something further like imaging or CT. During an interview with the DON, on 6/3/15, at 9:35 AM, she stated, We did not have IDT (Interdisciplinary Team) meeting for him (Resident 1-concerning his continued pain). Actually, we don't have formal meetings where we sit down and discuss. We do this informally but it's not documented. I'm working on this for improvement. The facility policy and procedure titled Change in a Resident's Condition or Status under Policy Interpretation and Implementation read, 1. The charge nurse will notify the resident's attending physician when:. b. There is a significant change in the resident's physical, mental or psychosocial status, c. There is a need to alter the resident's treatment significantly. 6. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted by the resident assessment nurse and the IDT team.