Every finding on record at Querencia at Barton Creek

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #11, Resident #13, Resident #19, and Resident #36) reviewed for infection control. 1. MA A did not conduct hand hygiene after preparing medications and prior to administering the medications for Resident #11, Resident #13, Resident #19, and Resident #36. 2. MA A did not sanitize the blood pressure cuff before or after assessing the blood pressure for Resident #11, Resident #13, Resident #19 and Resident #36 during medication pass. These failures could place residents at risk for healthcare associated cross-contamination and infections.Findings included: 1. Review of Resident #11's admission record, dated 12/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic systolic heart failure (other conditions that affect the heart muscle and its ability to pump blood), atherosclerotic heart disease (arteries become narrowed and hardened due to buildup of plaque), type 2 diabetes mellitus with hyperglycemia (a condition that affects the way the body processes blood sugar causing high blood sugar levels), and constipation (the inability to have a bowel movement for a prolonged period of time). Review of Resident #11's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #11's care plan, dated 10/08/2025, reflected no care plans related to blood pressure or infection. Review of Resident #11's order summary, dated 12/18/2025, reflected the following orders: Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth in the morning for Hypertension [high blood pressure] Give half tab to = 12.5 mg. Hold for SBP <110.Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day. During an observation on 12/17/2025 at 09:07 AM, MA A grabbed a wrist blood pressure cuff from the top drawer of the medication cart, then approached Resident #11's room. She knocked on the door, then proceeded to enter the room, without performing hand hygiene. Resident #11 consented to having his blood pressure assessed. MA A applied the blood pressure cuff to Resident #11's right wrist, without sanitizing the blood pressure cuff prior to use, and assessed his blood pressure. MA A returned to the medication cart, placed the blood pressure cuff in the top drawer of the medication cart without sanitizing it. She proceeded to prepare medication for administration to Resident #11, without performing hand hygiene. She gathered all medications for Resident #11 and returned to his room, without performing hand hygiene. MA A administered Resident #11's scheduled medications, then went to Resident #11's bathroom and washed her hands. 2. Review of Resident #19's admission record, dated 12/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including essential hypertension (high blood pressure), acute kidney failure (the kidneys suddenly stop functioning leading to a build-up of waste products in the blood), and benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate that causes urinary symptoms such as frequency with urination). Review of Resident #19's admission MDS, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #19's care plan, dated 12/15/2025, reflected Urinary Tract Infection (UTI) with interventions that included Monitor/document vital signs as ordered per protocol. Notify Physician of significant abnormalities. Review of Resident #19's order summary, dated 12/18/2025, reflected the following orders: amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION Bisoprolol Fumarate Oral Tablet 5 MG (Bisoprolol Fumarate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. During an observation on 12/17/2025 at 09:21 AM, MA A retrieved the wrist blood pressure cuff from the top drawer, without sanitizing it, and walked to Resident #19's room and knocked on the door. MA A obtained permission to assess Resident #19's blood pressure and applied the wrist blood pressure cuff to Resident #19's right wrist. MA A told Resident #19 that the reading was low and asked to place the wrist blood pressure cuff to Resident #19's left wrist. MA A stated that doesn't seem right after the second blood pressure was obtained. She then went to the hallway to retrieve a large blood pressure machine on wheels and sanitized her hand when she left the room. MA A returned to the room and applied the new blood pressure cuff to Resident #19's left upper arm, without sanitizing it. MA A returned to the medication cart with the blood pressure machine on wheels and placed the wrist blood pressure cuff in the top drawer of the cart without sanitizing either machine or performing hand hygiene. She prepared Resident #19's medications and returned to his room without performing hand hygiene and administered medications to Resident #19. MA A then went to Resident #19's bathroom and washed her hands. 3. Review of Resident #36's admission record, dated 12/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including heart failure (the heart is no longer capable of pumping an adequate supply of blood to the body), chronic kidney disease, stage 3 unspecified (moderate kidney damage where the kidneys are not able to filter toxins appropriately), and benign prostatic hyperplasia without lower urinary tract symptoms (an enlarged prostate). Review of Resident #36's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #36's care plan, dated 8/18/2025, reflected no care plan related to infection or blood pressure. Review of Resident #36's order summary, dated 12/18/2025, reflected the following orders: Carvedilol Tablet 3.125 MG Give 1 tablet by mouth two times a day for Hypertension/CHF Hold for SBP<110 or HR <55 Sacubitril-Valsartan Oral Tablet 24-26 MG (Sacubitril-Valsartan) Give 0.5 tablet by mouth two times a day for Hypertension Give 0.5 tablet. Hold for SBP <110. During an observation on 12/17/2025 at 09:37 AM, MA A pulled the blood pressure machine on wheels to Resident #36's room without sanitizing it or her hands and obtained permission to assess Resident #36's blood pressure. MA A applied the blood pressure cuff to Resident #36's left upper arm. After obtaining Resident #36's blood pressure, MA A returned to the medication cart, put on gloves, grabbed Resident #36's nasal spray and approached Resident #36 and administered his nasal spray. She took off her gloves and sanitized her hands. MA A returned to the medication cart, replaced nasal spray into the cart, and prepared Resident #36's oral medications. She returned to Resident #36's room without performing hand hygiene and administered the medications to Resident #36. MA A went to Resident #36's bathroom and washed her hands. 4. Review of Resident #13's admission record, dated 12/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), hypertensive heart disease with heart failure (the heart's inability to work properly due to high blood pressure for a prolonged period of time), and atherosclerotic heart disease of native coronary artery without angina pectoris (a condition that occurs when plaque builds up in the arteries, hardening them and limiting blood flow to the heart without chest pain). Review of Resident #13's Quarterly MDS, dated [DATE], reflected a BIMS score of 03, which indicated severe cognitive impairment. Review of Resident #13's care plan, dated 12/11/2025, reflected The resident has Congestive Heart Failure with interventions Give cardiac medications as ordered. Review of Resident #13's order summary, dated 12/18/2025, reflected Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two time a day for HTN HOLD IF SBP <110, HR <60. During an observation on 12/17/2025 at 09:52 AM, MA A pulled the blood pressure machine on wheels to Resident #13's room, without sanitizing it or her hands, and obtained permission to assess Resident #13's blood pressure. MA A applied the blood pressure cuff to Resident #13's right upper arm. MA A sanitized her hands and returned to the medication cart with the blood pressure machine. Without sanitizing the blood pressure machine, MA A prepared medications for Resident #13. She put on gloves to open capsules then took the gloves off. She crushed all tablets. MA A then mixed all medications in some pudding. MA A returned to Resident #13 without performing hand hygiene and administered Resident #13's medications to her with a spoon. After administering all medications to Resident #13, MA A went into the bathroom to wash her hands. During an interview on 12/17/2025 at 10:04 AM, MA A stated she had worked at the facility for 10 years. She stated she had been trained on infection prevention and control. She stated she received her most recent in-service related to infection control a few days prior. MA A stated she was trained to wash her hands every two residents and to sanitize her hands between every resident. She stated she was not trained to perform hand hygiene after touching the medication cart and prior to administering the medication. She stated she was trained to sanitize the blood pressure cuff after use on each resident. MA A stated she thought about it at that moment but forgot to sanitize the blood pressure cuff. MA A stated sanitized shared equipment and hand hygiene are important because germs can be spread from one resident to another and they can get sick. During an interview on 12/18/2025 at 11:55 AM with the IPCP, she stated she had worked at the facility for 14 years and in the current position for the last 3 years. She stated she completed the infection prevention and control training provided by The Centers for Disease Control and Prevention. She stated she was responsible for training and monitoring infection control practices. She stated she did so by performing periodic audits on hand hygiene practices. She stated if staff do not pass the audit, then she provides more training. The IPCP stated she expected staff to perform hand hygiene at least 2-3 times for each resident during medication administration, prior to gathering medications, prior to administering medications and after administering medications. The IPCP stated the expectations were to sanitize the blood pressure cuff prior to each use, but sanitizing the blood pressure cuff after each use was also acceptable. The IPCP stated it was a standard of practice to perform hand hygiene and sanitize the blood pressure cuff between use because it could potentially introduce bacteria to the residents. She stated if staff did not touch the medication, then not sanitizing their hands should not be a problem. During an interview on 12/18/2025 at 01:11 PM with MA B, she stated she had worked at the facility for the past 6 months. She stated she was trained to administer medications. MA B stated she was trained to perform hand hygiene prior to preparing the medications and after administering medications to the resident. She stated she was trained to sanitize the blood pressure cuff with sanitizing wipe after each use. MA B stated not performing hand hygiene at appropriate times or not sanitizing the blood pressure cuff could expose residents to germs and spread infection. She stated she was unsure if anyone monitored these infection control practices. During an interview on 12/18/2025 at 01:23 PM with LVN C, she stated she was trained to perform hand hygiene before preparing medications, before administering medication, and after administering medications to the residents. She stated she had to do a skills lab once every 4 months to show competency. She stated she was trained to sanitize the blood pressure cuff immediately after each use. LVN C stated not performing hand hygiene at the appropriate times or not sanitizing the blood pressure cuff could spread germs and cause infection. During an interview on 12/18/2025 at 01:58 PM with the DON, she stated she had worked at the facility in her current position for the last 3 years. She stated she expected staff to perform hand hygiene before and after coming in direct contact with a resident. She stated if the staff member was only handling the medication cup and not touching the medication or the resident, then not performing hand hygiene prior to administering medication was appropriate. She stated nurse management monitor hand hygiene by performing annual and as needed audits. The DON stated if hand hygiene was not performed at the appropriate times, then germs could be passed from one resident to another. She stated she expected staff to disinfect the blood pressure cuff either before or after each use. The DON stated this was monitored by annual competency evaluations and as needed. She stated if the blood pressure cuff was not sanitized appropriately then there would be concerns for infection control measure and what that may present. During an interview on 12/18/2025 at 02:20 PM with the ADM, she stated she had worked at the facility for the past 10 years. She stated she was trained on infection control. When questioned about expectations for staff when it comes to hand hygiene and sanitizing the blood pressure cuff during medication administration, the ADM stated she expected the staff to follow policy. The ADM stated she was not a clinician and didn't know what specifically was going on with the residents or what could happen to them if policy was not followed. Review of facility policy titled Administering Medications, dated 2001 and revised April 2019, reflected Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of facility policy titled Hand Hygiene, dated 10/15/2017 and revised 06/05/2022, reflected PurposeHand hygiene is the most effective measure for preventing the spread of infection.ProceduresHand hygiene will be practiced by all team members working in a licensed health care entity or health center as indicated:Indications for hand hygiene: Before and after contact with a resident's intact skin;. After contact with environmental surfaces in the immediate vicinity of infected residents;. Anytime a team member touches contaminated resident-care equipment;.During orientation and on an annual basis thereafter, all team members working in a licensed health care entity or health center must complete a hand hygiene training module.

Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in locked compartments secured by a key for 1 of 5 (south side hall) medication carts and 1 of 4 (Resident #11) residents reviewed for medication storage. 1. The facility failed to ensure the south side medication cart was secured with a lock and key while unattended by MA A on 12/17/2025.2. The facility failed to ensure Resident #11 consumed all his medication prior to MA A leaving the room while administering medication on 12/17/2025.This failure could place residents at risk of harm due to unauthorized access and potential ingestion of medications not intended for the residents.Findings included: Review of Resident #11's admission record, dated 12/18/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic systolic heart failure (other conditions that affect the heart muscle and its ability to pump blood), atherosclerotic heart disease (arteries become narrowed and hardened due to buildup of plaque), type 2 diabetes mellitus with hyperglycemia (a condition that affects the way the body processes blood sugar causing high blood sugar levels), and constipation (the inability to have a bowel movement for a prolonged period of time). Review of Resident #11's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #11's care plan, dated 10/08/2025, reflected no care plans related to constipation or use of medications for constipation. Review of Resident #11's order summary, date 12/18/2025, reflected an order for Miralax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for Constipation *hold for loose stools/diarrhea. Administer with 4-8oz. fluid. Observation on 12/17/2025 at 09:07 AM, revealed MA A grabbed the blood pressure cuff out of the top drawer of the medication cart and shut the drawer. She appeared to have pressed the lock on the front of the medication cart. She approached Resident #11, in his room and out of sight from the medication cart and assessed his blood pressure. MA A then returned to the medication cart in the hallway and pulled the silver on the silver lock on the front of the cart (she did not use her keys) and opened the drawer to the medication cart. She gathered Resident #11's medications, which included mixing 17 g of Miralax powder in 8 ounces of water. She locked the medication cart and approached Resident #11. MA A administered all medications including Miralax mixed in 8 ounces of water to Resident #11. He consumed approximately 5 ounces of the medication mixed in water and MA A told Resident #11 she would leave the rest of the Miralax for him to finish. MA A then left the room to wash her hands. Resident #11 had approximately 3 ounces of medication mixed in water left in a cup on his over bed table when MA A was done washing her hands and left the room. Observation on 12/17/2025 at 09:21 AM, revealed MA A grabbed a blood pressure cuff from the top drawer of the south side hall medication cart and appear to push the lock in and walked into a resident's room. She then returned to the south side hall medication cart and pulled at the lock without using her keys, opened the top drawer and placed the blood pressure cuff back in the drawer. During an interview on 12/17/2025 at 10:04 AM, with MA A, she stated she had worked at the facility for 10 years. She stated she was trained to lock the medication cart anytime she walked away from it. She stated she did not secure the medication cart completely 2 times during the medication administration observation. MA A stated she just pushed the lock in part of the way. She stated she was not trained to lock the cart that way and it is not considered secured if the lock was not completely pushed in. She stated all staff monitor for unlocked medication carts when walking down the halls. She stated they would just lock the cart and let her know if she forgot to lock the medication cart. MA A stated if medication carts was not locked completely, then someone could get into the cart and take anything that is in there. She stated the medications could hurt a resident if they were not prescribed to them. MA A stated she was not supposed to leave any medication at the bedside unless it was ordered that way. She stated she left the medication, Miralax, at the bedside for Resident #11 because he was alert. MA A stated leaving medication at the bedside could leave the medication available for anyone to enter the room and consume the medication that was not meant for them. During an interview on 12/18/2025 at 11:55 AM with the IPCP, she stated she had worked at the facility for 14 years and had been in the same role for the past 3-4 years. The IPCP stated she had observed the medication administration skills check off for MA A. She stated it was the policy to lock the medication cart when leaving the medication cart unsupervised. She stated it was not within policy to only push the lock in 1/2 way for the medication cart. The IPCP stated anyone could come by and take any of the medications out if the medication cart was left unsecured. The IPCP stated it was the policy to ensure the residents swallow all their medication before leaving the bedside. She stated she did know that some of the residents were insistent on leaving the medication at the bedside, but she stated the medication aide should come back later to administer the medication. The IPCP stated it was never appropriate to leave Miralax at the bedside for the residents to consume at their leisure without an order. She stated if the medication was left at the bedside, then the resident may not take the medication and then would not receive the intended benefit from the medication. She stated the resident may also have a visitor who may consume the medication. During an interview on 12/18/2025 at 01:11 PM with MA B, she stated she had worked at the facility for 6 months and was trained on medication administration. She stated she was trained that it was never appropriate to leave medication at the bedside because anyone could come in and take the medication that wasn't meant for them. She stated the DON monitored to ensure they were administering medications appropriately occasionally. She stated she was also trained to lock the medication cart prior to walking away from it. She stated locking the cart prevented residents from accessing medications that was not meant for them. During an interview on 12/18/2025 at 01:23 PM with LVN C, she stated she was trained that it was never appropriate to leave Miralax at the bedside for a resident. She stated leaving the medication at the bedside did not ensure that the resident was getting the medication as ordered or anyone else could come into the room and take the medication that was not intended for them. LVN C stated she was trained to push the lock in all the way on the medication carts to ensure the medications are secured. She stated it was not appropriate to leave the lock only halfway pushed in. She stated doing so could allow someone to get into the cart and take some of the medications out of the cart. During an interview on 12/18/2025 at 01:58 PM with the DON, she stated she had worked at the facility for the past 3 years in her current position. She stated all medications should be behind a lock if left unattended by staff. She stated nursing management monitored to ensure the medication carts were locked during their walking rounds. She stated if nursing management observed a medication cart unlocked, they addressed it immediately. The DON stated the medication aides also had annual skills check offs. She stated if a resident realized that a cart was only partially locked and knew how to pull the lock open then there might be a question for safety of the residents. She stated that the resident may be able to access all the medications in the medication cart. The DON stated that unless the IDT providers have met and deemed the resident appropriate to self-administer medications, then she expected the medication aide to remain with the resident until they took all their medication. She stated at the time of the observation, Resident #11 had not been approved for self-administration of Miralax, but he was later approved by the IDT providers. The DON stated leaving medication at the bedside for residents who had not been previously approved by the IDT provider could affect the residents as safety could be questioned. She stated that it all depended on the circumstances. During an interview on 12/18/2025 at 02:20 PM with the ADM, she stated she had worked at the facility for 10 years. She stated she expected nursing staff to follow the policy when questioned about storing medications. She stated she was unsure if the policy addressed only partially locking the cart. The ADM stated if a medication cart was partially unlocked then anyone would have access to its contents. The ADM stated she expected staff to follow policy when asked about leaving medications at bedside for the residents to consume at their leisure. She stated she did not think leaving medication at the bedside would affect any residents since it's just sitting there. Review of facility policy titled, Administering Medications, dated 2001 and last revised April 2019, reflected Policy Statement Medications are administered in a safe and timely manner, and as prescribedPolicy interpretation and Implementation.19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other side closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of facility policy titled, Medication Labeling and Storage, dated 2001 and last revised February 2023, reflected Policy heading The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and ImplementationMedication Storage.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes for one (Resident #1) of nine residents reviewed for care plans. The facility failed to update Resident #1's care plan after a fall on 07/20/2025 with additional interventions to prevent another fall. The facility failed to update Resident #1's care plan after a physical therapy evaluation on 07/30/2025 determined Resident #1 should be transferred with two staff members. Resident #1 experienced a fall on 08/03/2025 and 48 hours later was diagnosed with a hip fracture from the fall and 24 hours later was in surgery for a full hip replacement. On 09/04/2025 at 12:21 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/05/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of not having their medical, nursing, mental and psychosocial needs met and ensuring safe care for each resident to prevent serious injuries. Findings included: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis including other spondylosis, lumber region (refers to degenerative changes in the lower back, often leading to symptoms like pain, numbness, and weakness due to nerve compression), age related osteoporosis without current pathological fracture (condition characterized by the weaking of bones due to aging), Alzheimer's disease (progressive decline in memory, thinking, and behavior), unsteadiness on feet, muscle weakness, and fracture of left femur. Record review of Resident #1's annual MDS , dated 05/29/2025, reflected a BIMS score of 01, which indicated cognition was severely impaired. Section GG - Functional Abilities reflected Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Section H - Bladder and Bowel reflected Resident #1's urinary and bowel continence was Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). Record review of Resident #1's care plan, dated 05/19/2022 and revised 06/24/2025, reflected the following, Current Functional Performance . Interventions, Resident performance: Transfer - Extensive assist/one-person physical assist. Further review of Resident #1's care plan, dated 12/14/2022 and revised on 05/12/2025, reflected the following, Resident #1 was on palliative care and request comfort care only and will remain free from pain/discomfort and live to the end of my life with dignity. Interventions Refrain from sending me to the hospital unless I (Resident #1) sustain a traumatic injury or my RP or I (Resident #1) request transfer. Further review of Resident #1's care plan reflected that the PT Evaluation & Plan of Treatment completed on 07/30/2025 did not reflect the physical therapy recommendation of a 2-person transfer outlined under Functional Assessment, Transfers = Max/2. Record review of Resident #1's incident report, dated 08/03/2025, revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. CNA was not educated on significant change of 2x person assist as the care plan was not updated prior to care being provided. CNA A was suspended immediately pending the facility investigation and resigned from her position prior to facility concluding their investigation as she made false statements. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline was Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). During an observation on 09/02/2025 at 12:15 PM Resident #1 was observed in the assisted dining room and staff was helping her eat. She was observed with her baby doll. Staff was communicating with resident, and she would not respond. She was observed trying to feed her baby doll her food. Resident #1 did not respond to surveyor. She was dressed well, groomed appropriately, and no odors. She was sitting in her walker with a food protector. During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 12:05 PM, CNA A stated she and other CNAs who cared for Resident #1 on 08/03/2025-08/05/2025 post-fall revealed Resident #1 was not her normal self after the fall on 08/03/2025. They stated she would not sit up in bed, did not eat and was not as interactive as usual. They stated they notified the charge nurse , but nothing was done for two days. They stated PRN Tylenol was administered. CNA A stated they believed the charge nurse was going to take care of concerns that were being addressed with them directly, so they did not go and speak to management. During an interview on 09/02/2025 at 1:38 PM, NP stated Resident #1 had advanced dementia and required assistance with most of her ADLs. He stated prior to this fall she was a 1 person assist transfer (as he was unaware of the recent change on 07/30/2025 to a 2x person transfer) and now he believed she was a 2x person assist transfer. The NP stated Resident #1 does have PRN Tramadol and was not having a lot of discomfort. He stated Resident #1 was s eating regularly, was doing well post operatively, was up in the wheelchair most of the day, and was participating in therapy. He stated this information does need to be passed along to the staff who work directly with the resident. During interviews on 09/02/2025 at 3:45 PM, CNA C stated he had been employed 18 months at the facility. He stated interventions to prevent falls includes skills check offs, review of the resident's electronic care plan (care plan), and monthly meetings. He stated he did not work directly with Resident #1 or Resident #2 and was not familiar with their care. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility. CNA J stated she had received in-service training on ANE , falls, and use of gait belts. She stated staff needed to know about each resident's care plan and become familiar with their care if they are to provide them services. She stated she would review Resident #1's electronic care plan to determine if there were any changes prior to the start of her shift. She stated if she did see a change in the resident's care, she would see it documented in the electronic care plan. She stated she was not present when Resident #1 fell. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she had been employed 6 months at this facility, was in-serviced on ANE, and provided examples of ANE. She stated she had also received in-services in the last 30 days on falls and gait belts. She stated she reviewed (care plan ADLs), to check if a resident was a mechanical lift, use of gait belt, 1x or 2x person assist. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/02/2025 at 5:15 PM, RN C stated she had been in-serviced within the last 30 days and the ADM was the Abuse Coordinator. She stated she was in-serviced on safety precautions and fall provisions. She stated on her shifts she directs the aids to check the electronic care plan (care plan ADLs) for resident care information. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/02/2025 at 5:41 PM, DON stated she was educated last month via online training site and she completed in-services regularly with nursing managers. She stated interventions or assistance needed to prevent falls included updating care plans, conducting in-services and education. She stated fall preventions that are usually in place for high-risk fall residents depends on what is in their care plan. She stated care plans are to be specialized in approach for each resident, it is a matter of what may benefit residents overall, each one is unique She stated Resident #1 was care planned as a 1x person transfer and staff are trained to use a gait belt with each transfer. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she received training on ANE, falls, and gait belt use during orientation. She stated prior to her shift she is provided specific information of a resident and their needs. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/03/2025 at 10:02 AM, RN E stated she has been employed with this facility for over 6 years, she stated she was in-serviced often, last month she completed in-service on ANE, and what to do during a fall. RN E stated staff should always check how the residents are transferred, review the care plan, determine if 1x or 2x person assist, or mechanical lift, make sure sling was the proper size for the resident, be aware of the care plan, always use body properly when transferring. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training a few days back, completed videos on resident rights, what to do to prevent a fall, reporting, and ANE. She stated fall prevention interventions are in the electronic care plan and POC. She stated she did not work with Resident #1 or Resident #2 directly and was not familiar with their care. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she had been employed 2 years at this facility, she was in-serviced last month on ANE, reporting, and the Abuse Coordinator was the ADM. She stated last month she completed an in-service which covered precautions for falls. LPCN B stated the electronic care plan is available at the nurse's station, which has information of residents' needs and helps CNAs and CMAs with residents' level of care and if requires 1x person or 2x person transfer or mechanical lift was needed. She stated she was the charge nurse the day Resident #1 fell. She stated CNA A was helping Resident #1 to the restroom and Resident #1 lost her balance and fell in the bathroom. She stated she assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and she notified the responsible party, and the NP was notified via copy of incident placed in provider box. She stated she was off the next morning and when she returned, she was informed Resident #1's fall resulted in a fracture and surgery. She stated she received a write up - management stated no documentation for assessments, ROM, communication to the NP, and documentation was not thorough . She stated she was not explaining what happened in documentation reports, the interventions that she did, all assessments were not in the incident report, and she was to contact the NP by phone immediately following the incident. She stated she did not notify the NP immediately as Resident #1 did not seem in distress or pain, in her opinion . LPCN B stated directions would have been to continue to monitor, now knowing of the fracture and surgery, and x-ray was ordered Monday, stated she performed all the assessments, but did not enter the incident report, reason for the write up. She stated she is expected to enter Progress Report (PCC) and Incident Report (risk management system). During a phone interview on 09/03/2025 at 12:05 PM CNA A, stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated the in-service emphasized needing to use gait belt with transfer and the protocol was to use a gait belt to prevent the resident from falling. She stated the purpose of the gait belt was to help keep residents safe and if a resident were to fall it would help them ease into the fall and the impact wouldn't be as hard. CNA A stated it is important to use proper procedures for transfer of resident to prevent injuries or skin tears. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. She stated she was not using a gait belt and did not know that Resident #1 required a 2-person She stated she was in a hurry and did not have a gait belt with her, so she assisted Resident #1 without a gait belt. She stated she does believe she is a 1-person transfer in her care plan, she was in-serviced on using gait belt immediately after the fall, and stated she does believe Resident #1's injury may have been prevented or lessened had the gait belt been used. CNA A stated rather than waiting for the facility investigation to conclude while on suspension she resigned via email. During an interview on 09/03/2025 at 1:20 PM, DOR stated she was the program manager under a third-party contract. She stated she doesn't receive training through the facility, but through her company. She stated a therapy evaluation was conducted after the fall on 07/20/2025. She stated the therapy evaluation on 07/30/2025 documented Resident #1 required 2x person transfer. She stated evaluation resulted in significant change and this information would be passed along in meetings and documented in Resident #1's EMR. DOR stated the next day after the therapy evaluation staff will notify the facility management team in the morning meetings that are conducted daily. DOR stated there is a form used for significant changes, incidents, written on piece of paper and scanned and presented to facility management to be entered into the care plan and MDS. She stated significant change of transfer status of 1x person to 2x person assist is considered significant and nursing staff need to be aware of this information to provide direct care services for the residents. DOR stated a therapy evaluation was conducted on Resident #1 on 0 7/30/2025 and it is documented that she required a 2-person transfer. She stated this information was passed along in the following morning huddle meeting with the nursing management team. She stated in this meeting this information was passed along to the management team at the facility and they in turn are responsible for entering into the electronic plan of care. During an interview on 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled, #594 Fall, dated 08/03/2025, 6:20 AM, revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 - 08/05/2025. Statements reflect late entries from 08/05/2025 - 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong. She was unable to bear weight I got assistance.to transfer into her bed so that I could change her. It was during this change that I noted her grimacing and noted the bruising to her hip. I then got her back up and into the wheelchair with assistance and she was at the nurse's station until lunch. She did not eat much at lunch. After lunch I again got assistance.to transfer her back to bed. I notified the nurse of my concerns, and she went and checked on her. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 LPCN C statement captured, I was the charge nurse for [Resident #1] on Monday 6a-2p.CNA I reported to me that the resident seemed to be in pain and was having a hard time transferring. I went and completed an assessment of her and noted bruising to her left hip. I did not complete a full range of motion because I could see she was in pain. I gave her some pain medication and put an ice pack on her hip. I did not say anything to the NP, but I did tell the oncoming nurse [RN A] about the bruising and pain complaints and to keep an eye on her. 08/04/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured that on her shift on she was notified by CNA F on this shift that before dinner that resident was unable to transfer or get out of bed.notified NP and he stated he already placed order for STAT x-ray. 08/04/2025 2 PM - 10 PM shift: 08/08/2025 CNA F statement captured, I worked on the hallway where [Resident #1] lives on Monday morning 6a-2p and was assigned to her on the 2p-10p shift.I noted that she was unable to bear weight and it took 3 people to assist her which was unusual.I saw her grimacing when I changed her. I notified my charge nurse [RN A]. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2021, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition. Record review of the facility's Resident Rights Policy, dated 10/10/2024 reflected the following: The facility is committed to providing a safe and secure environment for our residents. philosophy of care is founded upon its commitment to promote and protect the rights of each resident, is dedicated to enhancing residents' quality of life, treating residents as individuals with dignity, courtesy and respect, and promoting the right to choose the way they live and the care they receive. Record review of the facility's Assessing Falls and Their Causes Policy, dated March 2018 reflected the following: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 4.Residents must be assessed upon admission and regularly afterward for potential risk of falls. Record review of the facility's undated Provision of Quality-of-Care Policy, reflected the following: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4.Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 6.Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of Skilled Nursing In-Service: Kardex/Gait Belt Use, dated 08/05/2025 and conducted by DON and ADON, reflected all nursing team members must review the residents electronic care plan prior to delivering care to ensure they are following care plan. Failure to follow according to plan of care will result in disciplinary action and may result in potential harm to the resident. Additionally, failure to follow plan of care is considered neglect. Team members are allowed to use more assistance but never less. Notify on-call nurse manager immediately if you see someone was not care planned or needing updates to Kardex/care plan. This was determined to be an Immediate Jeopardy (IJ) on 09/04/2025 at 12:21 PM. The ADM was notified. The ADM was provided with the IJ template on 09/04/2025 at 12:21 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/2025 at 10:08 AM: On 9/3/25 Resident #1 assessed by RN, the comprehensive care plan reviewed by RN and Director of Therapy for accuracy of interventions post fall and functional performance. There were no new orders obtained from assessment and no new revisions to the care plan were required. On 9/4/25 The affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. On 9/3/25 All current residents care plans for transfer status were audited by the RN MDS Coordinator for accuracy. in comparison to Therapy documentation. The only changes that needed to be made were to upgrade residents transfer status due to improvements made in therapy. Those changes required were made at the time of the audit. The audit was documented on a resident roster. On 9/4/25 All current residents' care plans for fall interventions were audited by the RN MDS Coordinator for accuracy. No new interventions were required. The audit was documented on a resident roster. All residents with falls from 08/25/2025 through 9/4/2025 (past 10 days) are in the process of being audited by the DON for compliance with policy and procedure including evaluations, care plans and functional ability. Results of the audit will be reported and evaluated during the next monthly QAPI meeting. Documentation of the audit is being completed on the post fall audit form. The Director of Nursing, MDS Coordinator, and Administrator were educated on Comprehensive Care Plans by the Regional Director of Health Services on 9/4/2025. This was documented on an in-service form. Team members verbalized comprehension and signed acknowledgement of education. Starting on 9/4/2025 Licensed Nurses have been educated by Director of Nursing /Designee on assessment immediately after the fall, including updating the care plan with new preventative interventions per the Provisions of Quality-of-Care Policy. Staff verbalized comprehension and signed acknowledgement of education. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 9/3/2025, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Regional Director of Clinical Services, RN, [NAME] President of Health Services Operations, Executive Director, Regional [NAME] President of Operations, and Chief Clinical Officer to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 9/4/2025 the Director of Nursing or designee will monitor compliance daily (Monday through Friday) and Charge Nurse (Saturday and Sunday) by monitoring residents with falls for appropriate care plan revisions post fall. Care plan updates will be noted in the residents Electronic Health Record with an IDT note. Starting on 9/4/2025 the Director of Therapy and other therapists will notify the DON, ADON, MDS Coordinator and Administrator. An email was sent the Therapy Director and therapist outlining this procedure. The Therapist acknowledged receipt and understanding with a return email. The MDS Coordinator or his designee will update the resident's care plan. Staff will be educated to review each resident's electronic are plan at the beginning of their shift. Staff will verbalize comprehension and signed acknowledgement of education. Starting on 9/4/25 the Director of Nursing or designee will monitor compliance during the weekly QOC Meeting. Results of the audit will be reported to the QAPI committee. The Administrator/designee will monitor compliance by completing an audit of five (5) residents care plans per week for four (4) weeks. This was initiated on 9/4/2025. Documentation of this audit will be made on the post fall audit form. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Regional Director Health Services will provide oversight of the Administrator to ensure that the items on the plan of removal are reviewed and completed. 09/05/2025 4:20 PM DON, Discharge MDS 9/52025; prior to this one, ARD 8/24/2025 admission 5 day; 8/18/2025 Entry MDS/Accepted and completed; 8/24/2025 Admission/Medicare - 5 Day, In Progress; 9/5/2025 Discharge Return Anticipated in Progress. The Surveyor monitored the POR from 09/04/2025 - 09/05/2025 as followed: Record review of the facility's ADHOC meeting agenda, dated 09/03/2025, reflected ADM, DON, MD, and RDHS were in attendance. Record review of Resident #1's EMR and care plan, dated 05/23/2022 with revision on 09/04/2025 reflected review of interventions post fall and functional performance measures. Care plan updated to

Based on observations, interviews and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent avoidable accidents for 2 (Resident #1 and Resident #2) of 9 residents reviewed for quality of care. The facility failed to ensure CNA A used a gait belt when assisting Resident #1 with transfer on 08/03/2025 which resulted in Resident #1 falling and breaking her hip. The facility failed to ensure CNA A used two people assist with transfers as recommended on Resident #1's therapy evaluation on 07/30/2025, which determined Resident #1 should be transferred with two staff members. Resident #1 experienced a fall on 08/03/2025 and 48 hours later was diagnosed with a hip fracture from the fall. The facility failed to ensure CMA B used a gait belt when assisting Resident #2 with transfer on 09/02/2025. On 09/03/2025 at 7:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/05/2025, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of avoidable accidents resulting in serious harm and injury and a decreased quality of life. Findings include: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis including other spondylosis, lumber region (refers to degenerative changes in the lower back, often leading to symptoms like pain, numbness, and weakness due to nerve compression), age related osteoporosis without current pathological fracture (condition characterized by the weaking of bones due to aging), Alzheimer's disease (progressive decline in memory, thinking, and behavior), unsteadiness on feet, muscle weakness, and fracture of left femur. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 01, which indicated cognition was severely impaired. Section GG - Functional Abilities reflected Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #1's care plan dated 05/19/2022 and last revised 06/24/2025, reflected the following, Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist/one-person physical assist. Further review of Resident #1's care plan dated 12/14/2022 and last revised on 05/12/2025, reflected the following, Resident #1 is on palliative care and request comfort care only and will remain free from pain/discomfort and live to the end of my life with dignity. Interventions Refrain from sending me to the hospital unless I sustain a traumatic injury or my RP or I request transfer. Further review of Resident #1's care plan reflected that the PT Evaluation & Plan of Treatment completed on 07/30/2025 did not reflect the physical therapy recommendation of a 2-person transfer outlined under Functional Assessment, Transfers = Max/2.Record review of Resident #1's incident report dated 07/20/2025 revealed Resident #1 fell but did not suffer any injuries. Resident #1's care plan was not updated after the fall. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline is Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). Record review of Resident #1's PT evaluation conducted on 07/30/2025 revealed Resident #1 required two people to transfer and a gait belt. Record review of Resident #1's incident report dated 08/03/1015 revealed that CNA A was helping Resident #1 to the restroom and Resident #1 lost her balance and fell in the bathroom. LPCN B assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and Responsible Party was notified and NP notified via copy of incident placed in provider box. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of Resident #2's face sheet dated 09/05/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including arthritis (inflammation of the joints), dementia (loss of cognitive functioning), major depressive disorder, muscle wasting and atrophy (refers to the wasting or thinning of muscle tissue). Record review of Resident #2's annual MDS, dated [DATE], reflected a BIMS score of 09, which indicated cognition was moderately impaired. Section GG - Functional Abilities reflected Resident #2 required Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for sit to stand, chair/bed-to-chair transfer, and toilet transfer. Section J-Health Conditions reflected Resident #2 listed number of falls since admission/entry or reentry at 1 with no injury. Record review of Resident #2's care plan, dated 05/10/2024 and last revised 05/25/2025, reflected the following, The resident is risk for falls. Interventions Anticipate and meet the resident's needs and Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist / one-person physical assist' and Resident performance: Toilet use - Extensive assist / one-person physical assist. Record review of Resident #2's progress note, dated 04/07/2025, reflected resident had an unwitnessed fall in the bathroom, no injury occurred because of the fall. Record review of Resident #2's Physical Therapy PT Evaluation & Plan of Treatment dated 04/09/2025, reflected, Reason for Referral: Patient referred to OT due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate.reduced static and dynamic balance placing patient at risk for immobility, falls and further decline in function Record review of Resident #2's Fall Risk Evaluation, dated 05/20/2025, reflected no falls in past 3 months, level of consciousness/mental status at intermittent confusion, and no interventions were documented. Record review of Resident #2's IDT progress note dated 06/04/2025, reflected, Therapy notes, Resident requires extensive, one person, weight bearing assistance. See fall risk assessment 5/20/25 score 13 high risk. Record review of Resident #2's Kardex report dated 09/02/2025, reflected special instructions for CNAs and CMAs, Resident performance: Transfer - Extensive assist /one-person physical assist and Resident performance: Toilet use - Extensive assist /one-person physical assist. Interview with Administrator on 9/2/2025 at 10:32 AM revealed CNA A failed to use a gait belt, Resident #1 required one person to transfer, and nurses failed to document assessments entirely. During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. Observation on 09/02/2025 at 12:04 PM revealed CMA B assisting Resident #2 without a gait belt when assisting resident up from a sitting position to the restroom. During an interview on 09/02/2025 at 3:45 PM CNA C stated he has been employed 18 months at the facility, he has been in-serviced on the use of gait belts and fall procedures. He stated staff should always use gait belt when assisting residents during a transfer or walking regardless of 1x person or 2x person helper. He stated the gait belt is a chance to support a resident, assist the staff to break a fall, will not stop residents from falling but could help lessen the impact. He stated interventions to prevent falls include skills check offs, r eview, and monthly meetings. CNA C stated fall procedure are to ensure scene is secure, do not move the resident, call the nurse, pull the emergency light to get attention, let the nurse know resident is on the floor, nurse comes and completes an assessment, nurse will direct you to grab a belt to get resident up, you follow what the nurse tells you and any further instructions following fall. He was not familiar with Resident #1 or Resident #2's care . During an interview on 09/02/2025 at 3:57 PM CNA M stated she has been employed 18 months at this facility, she has received ANE, gait belt, and fall procedure training. She stated resident care information was in the electronic care plan, she was provided in-service on how to perform a transfer, 1x or 2x person assist transfer needs to have a gait belt. She stated the fall procedures include, if witnessed or not call the nurse, do not pick up the resident, nurse needs to assess the resident, will then help the nurse with directions to get them up. She stated Regardless of if 1x or 2 x person assist you need to use the gait belt as it is more secure for both resident and staff. Think of you and the patient. CNA M stated it is important to use proper procedures for transfer of a resident as you can harm yourself or you can harm the resident. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility, she has received in-service on ANE, she provided examples of ANE. She stated she also received in-service recently on falls and gait belts which covered how to get the resident up, ensure to use gait belt. CNA J stated Gait belt is in every room, staff given a gait belt during orientation, and expected to always use them for 1x and 2x person assists. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she's been employed 6 months at this facility, she has been in-serviced on ANE and provided examples of ANE. She stated she has also received in-services in the last 30 days on falls and gait belts. She stated if resident falls go and get the nurse and let them assess the resident. She stated she reviews the electronic care plan to check if resident is a mechanical lift, use of gait belt, 1x or 2x person assist. She stated it is important to use proper procedures for transferring a resident to not hurt self or resident. She stated she has assisted other aids with transferring Resident #1 and Resident #2. She stated residents require gait belt for transfer if 1x or 2x person assist. During an interview on 09/02/2025 at 5:15 PM, RN C stated she has been in-serviced within the last 30 days, in-services covered safety precautions, fall previsions, use of gait belt, she stated the purpose of the gait belt is to not harm the resident, not to lift them with the arms, to avoid injuries, transfers, and safety. RN C stated it is important to use proper procedures for transferring a resident to not hurt the resident or the staff. During an interview on 09/02/2025 at 5:24 PM, RN D stated depending on the resident's need for 1x or 2x person transfer to restroom, must follow rules, the gait belt is most important matter for the transfer . During an interview on 09/02/2025 at 5:41 PM, DON stated she was in-serviced last month on ANE, she completes in-services regularly with nursing managers. DON stated the policy for transferring/bathroom assisting a resident depends on assistance resident is needing, reviewing the electronic care plan, and best practice is to use the gait belt for 1x or 2x assist with mechanical lift. DON then stated the staff are in-serviced that the facility expects a gait belt, unless resident is refusing to be use. She stated it is encouraged overall to use the gait belt. Each of the rooms are to be supplied with a gait belt and located in the linen room. She stated the purpose of the gait belt is for safety measure, best practice if someone has a fall, can use to guide them to limit any further injuries that might occur. Helpful not to cause any other injuries when utilizing the gait belt, potential of pinching the skin or causing other issues, the device is to help with safety of the resident. She stated it is important to use proper procedures for transferring a resident keeping in mind safety first, maintaining ones' health and quality care. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she's received falls and gait belt training during orientation. She stated the electronic care plan provides information or rundown on resident and their needs. If independent have the gait belt, if weak, mechanical lift is 2x person, but no matter what they need to have a gait belt if transferring 1x or 2x person assist. She stated the gait belt protects the resident and helps to avoid injuries. She stated it is important to follow proper procedures for transferring a resident as you can hurt them, they are more [NAME], if they have minor injuries, you can make them worse. During an interview on 09/03/2025 at 10:02 AM, RN E stated staff should always check how the residents are transferred, review the care plan, determine if 1x or 2x person assist, or mechanical lift, make sure sling is the proper size for the resident, be aware of the care plan, always use body properly when transferring. She stated the importance of the gait belt is to prevent falls, safety, and proper transfers. RN E stated it is important to use proper procedures for transferring a resident to prevent injuries to self and the resident. She stated during orientation and in-services, the facility is stressing the use of gait belts. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training on fall prevention interventions are in and POC. She stated anyone assisting a resident with transfer needs to use a gait belt unless the resident has refused it, the purpose of the gait belt is to provide more ability to help the resident from falling. CNA, I stated it is important to use proper procedures for transferring a resident as anything can go wrong, make it less complicated as possible to avoid injuries to the resident. She stated she is familiar with Resident #1 and Resident #2's care. She stated Resident #1 requires 2x person assist with a gait belt, Resident #2 requires 1x person assist with a gait belt, she can walk. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she did not see a gait belt on Resident #1 after her fall on 08/03/2025 and when she was transferred from the floor to the wheelchair no gait belt was used. She stated CNA A got her dressed, she went to the dining room for breakfast and returned to her room her normal routine, then she went back out for lunch and back to her room. During a phone interview on 09/03/2025 at 12:05 PM CNA A, stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated the in-service emphasized needing to use gait belt with transfer and the protocol was to use a gait belt to prevent the resident from falling. She stated the purpose of the gait belt was to help keep residents safe and if a resident were to fall it would help them ease into the fall and the impact wouldn't be as hard. CNA A stated it is important to use proper procedures for transfer of resident to prevent injuries or skin tears. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. She stated she was not using a gait belt and did not know that Resident #1 required a 2-person She stated she was in a hurry and did not have a gait belt with her, so she assisted Resident #1 without a gait belt. She stated she does believe she is a 1-person transfer in her care plan, she was in-serviced on using gait belt immediately after the fall, and stated she does believe Resident #1's injury may have been prevented or lessened had the gait belt been used. CNA A stated rather than waiting for the facility investigation to conclude while on suspension she resigned via email. During an interview on 09/03/2025 at 1:20 PM, DOR stated Resident #1 was able to use a walker to walk with 1x person assist with 25% assistance, could use the walker to walk, gait belt is required on all residents. She stated her 3rd party company requires a gait belt. She stated if modified supervision all requires gait belt. DOR stated 3rd party company's policy is that all residents should use gait belt, and all physical therapists are required to use a gait belt regardless of type of transfer. She stated she believes facility aids are to use contact guard (hand on them) any resident listed as such needs a gait belt. She stated gait belt gives a safe place to hang on to, helps residents to be steady, staff could grab wrong area, gait belt helps to grab easily, steady them, safely lower to the floor if they fall. DOR stated PT will complete an evaluation and list the resident's interventions and recommendations. DOR stated a therapy evaluation was conducted on Resident #1 on 0 7/30/2025 and it is documented that she required a 2-person transfer. She stated this information was passed along in the following morning huddle meeting with the nursing management team. She stated in this meeting this information was passed along to the management team at the facility and they in turn are responsible for entering into the electronic plan of care. During an interview on 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled, #594 Fall, dated 08/03/2025, 6:20 AM, revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 - 08/05/2025. Statements reflect late entries from 08/05/2025 - 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong. She was unable to bear weight I got assistance.to transfer into her bed so that I could change her. It was during this change that I noted her grimacing and noted the bruising to her hip. I then got her back up and into the wheelchair with assistance and she was at the nurse's station until lunch. She did not eat much at lunch. After lunch I again got assistance.to transfer her back to bed. I notified the nurse of my concerns, and she went and checked on her. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 LPCN C statement captured, I was the charge nurse for [Resident #1] on Monday 6a-2p.CNA I reported to me that the resident seemed to be in pain and was having a hard time transferring. I went and completed an assessment of her and noted bruising to her left hip. I did not complete a full range of motion because I could see she was in pain. I gave her some pain medication and put an ice pack on her hip. I did not say anything to the NP, but I did tell the oncoming nurse [RN A] about the bruising and pain complaints and to keep an eye on her. 08/04/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured that on her shift on she was notified by CNA F on this shift that before dinner that resident was unable to transfer or get out of bed.notified NP and he stated he already placed order for STAT x-ray. 08/04/2025 2 PM - 10 PM shift: 08/08/2025 CNA F statement captured, I worked on the hallway where [Resident #1] lives on Monday morning 6a-2p and was assigned to her on the 2p-10p shift.I noted that she was unable to bear weight and it took 3 people to assist her which was unusual.I saw her grimacing when I changed her. I notified my charge nurse [RN A]. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2021, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition. Record review of the facility's Resident Rights Policy, dated 10/10/2024 reflected the following: The facility is committed to providing a safe and secure environment for our residents. philosophy of care is founded upon its commitment to promote and protect the rights of each resident, is dedicated to enhancing residents' quality of life, treating residents as individuals with dignity, courtesy and respect, and promoting the right to choose the way they live and the care they receive. Record review of the facility's undated Provision of Quality-of-Care Policy, reflected the following: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. 3. Responsibility for interventions on the care plan will be clearly identified. 4.Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices. 6.Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. Record review of the facility's Bathroom, assisting a Resident procedure, dated February 2018, reflected the following: The purpose of this procedure is to assist the resident with ambulating to the bathroom. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Steps in the Procedure 9. If necessary for support, use a gait belt for safety. Documentation The following information should be recorded on the resident's ADL record and/or in the resident's medical record: Any changes in the resident's ability to ambulate to the bathroom. Reporting Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's undated document titled, Assist to Chair and steps table provided for CNAs and MAs providing direct care to residents reflected the following: The following table lists the steps that are expected of you in order properly assist a patient into a chair. The table also provides rationales that explain why you perform some of these steps. Procedure Description Apply transfer belt. Be sure that it completely circles the waist. Rationale Transfer belt allow you to maintain stability of patient during transfer and reduces risk of falling. Record review of Skilled Nursing In-Service: Care plan/Kardex, communication, resident rights & providing appropriate care, dated 06/20/2025 and conducted by the DON, reflected all nursing staff are responsible for checking the electronic care plan prior to delivery of care to ensure following plan of care. Failure to follow according to plan of care will result in disciplinary action and is a safety concern. Record review of Skilled Nursing In-Service: Kardex/Gait Belt Use, dated 08/05/2025 and conducted by DON and ADON, reflected all nursing team members must review the residents electronic care plan prior to delivering care to ensure they are following care plan. Failure to follow according to plan of care will result in disciplinary action and may result in potential harm to the resident. Additionally, failure to follow plan of care is considered neglect. Team members are allowed to use more assistance but never less. Notify on-call nurse manager immediately if you see someone was not care planned or needing updates to the electronic care plan. It is a requirement to use gait belt for x1-x2 assist for transfers/ambulation due to safety reasons. This was determined to be an Immediate Jeopardy (IJ) on 09/03/2025 at 7:17 PM. The ADM was notified. The ADM was provided with the IJ template on 09/03/2025 at 7:17 PM. The following Plan of Removal submitted by the facility was accepted on 09/05/2025 at 10:08 AM: On 9/3/25 Resident #1 assessed by RN for change in condition and acute pain. There were no new orders obtained. Results of the assessment were documented in the resident's Electronic Health Record (EHR). On 9/4/25 the affected resident's responsible party was notified by the Administrator of alleged deficiencies and plan of correction. On 9/3/2025 all current residents were assessed by RN for change in condition and acute pain, no negative findings noted. Results of the assessment were documented in the resident's Electronic Health Record (EHR). The Medical Director was notified - no new orders were obtained. CNA A is no longer employed at the facility as of 8/7/2025. On 9/3/25 Director of Nursing/Designee completed 1:1 education with CNA C on the use of gait belt during ambulation with a resident who requires assistance with ambulation. CNA C performed return demonstration, verbalized understanding and signed acknowledgement of training. On 9/3/25 an audit of all resident rooms was conducted by the Executive Director to ensure that each room had one gait belt per resident hanging on the bathroom door. Additional gait belts can be located within Central Supply. The Central Supply Clerk is re

Based on interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 9 residents reviewed for quality of care. The facility failed to notice a change in condition after Resident #1 experienced a fall on 08/03/2025 and had visible signs of pain for 48 hours before being sent to the ER for a broken hip.The facility failed to complete post-fall assessments per policy for Resident #1 which caused Resident #1 to have an untreated hip fracture for up to 48 hours before outside medical attention was sought. The facility failed to address Resident #1's pain which was evidenced by facial grimacing and other non-verbal signs of pain for 48 hours and failed to assess whether PRN Tylenol was sufficient to relieve pain caused by the fractured hip. These failures could place residents at risk of negative outcome to a resident's physical, mental, or psychosocial health or well-being Findings include: Record review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis including other spondylosis, lumber region (refers to degenerative changes in the lower back, often leading to symptoms like pain, numbness, and weakness due to nerve compression), age related osteoporosis without current pathological fracture (condition characterized by the weaking of bones due to aging), Alzheimer's disease (progressive decline in memory, thinking, and behavior), unsteadiness on feet, muscle weakness, and fracture of left femur. Record review of Resident #1's annual MDS, dated [DATE], reflected a BIMS score of 01, which indicated cognition was severely impaired. Section GG - Functional Abilities reflected Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #1's care plan dated 05/19/2022 and last revised 06/24/2025, reflected the following, Current Functional Performance. Interventions Resident performance: Transfer - Extensive assist/one-person physical assist. Further Record review of Resident #1's care plan dated 12/14/2022 and last revised on 05/12/2025, reflected the following, Resident #1 was on palliative care and request comfort care only and will remain free from pain/discomfort and live to the end of my life with dignity. Interventions Refrain from sending me to the hospital unless I (Resident #1) sustain a traumatic injury or my RP or I (Resident #1) request transfer. Further review of Resident #1's care plan reflected that the PT Evaluation & Plan of Treatment completed on 07/30/2025 did not reflect the physical therapy recommendation of a 2-person transfer outlined under Functional Assessment, Transfers = Max/2. Record review of Resident #1's MAR revealed Resident #1 was administered pain medication Tylenol PRN 325 mg two tablets as followed: 08/04/25 at 12:34 AM08/05/25 at 4:52 PM There was no documentation regarding effectiveness or pain level assessment. Record review of Resident #1's incident report dated 08/03/2025 revealed that CNA A was helping Resident #1 to the restroom and Resident #1 lost her balance and fell in the bathroom. LPCN B assessed Resident #1 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and Responsible Party was notified and NP notified via copy of incident placed in provider box. CNA A had not been notified of the resident's significant change prior to her fall on 08/03/2025. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of Resident #1's physician order, dated 07/21/2025, reflected the following: PT/OT eval and treat for fall/ADLs. Record review of Resident #1's Physical Therapy PT Evaluation & Plan of Treatment, dated 07/30/2025, reflected the following: Functional transfers PLOF (prior level of function) was CGA (contact guard assist) and Resident #1's functional transfer baseline is Max/2 (highest level of assistance required for a transfer, performed w/ minimal help or no assistance at all). During an interview on 09/02/2025 at 5:41 PM, DON stated the nurses should have completed assessments for 72 hours after the fall. If the nurses had done the ROM assessment post fall, they would have discovered the broken hip sooner or noted the pain Resident #1 was experiencing. DON stated she was in-serviced last month, she completes in-services regularly with nursing managers. DON stated the policy for transferring/bathroom assisting a resident depends on assistance resident is needing, reviewing the electronic care plan, and best practice is to use the gait belt for 1x or 2x assist with mechanical lift. DON then stated the staff are in-serviced that the facility expects a gait belt, unless resident is refusing to be use. She stated it is encouraged overall to use the gait belt. Each of the rooms are to be supplied with a gait belt and located in the linen room. She stated the purpose of the gait belt is for safety measure, best practice if someone has a fall, can use to guide them to limit any further injuries that might occur. Helpful not to cause any other injuries when utilizing the gait belt, potential of pinching the skin or causing other issues, the device is to help with safety of the resident. She stated it is important to use proper procedures for transferring a resident keeping in mind safety first, maintaining ones' health and quality care. DON stated the Resident's fall was reported to her the day it occurred. She stated the details of the fall were in the incident report. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/02/2025 at 1:38 PM, NP stated Resident #1 had advanced dementia and required assistance with most of her ADLs. He stated he was made aware that Resident #1 fell over the weekend. He stated he was at the facility making rounds on the afternoon of 08/04/2025 and was notified that Resident #1 had discomfort of her hip area and staff was unsure what side was hurting. He stated Resident #1 was non-verbal and showed discomfort with facial grimacing. The NP stated he ordered an x-ray on the afternoon of 08/05/2025 and the results were obtained the following morning, 08/06/2025 and Resident #1 had a fracture of left femur. Resident #1 is unable to provide details of her pain level, and she was not helpful to determine the severity of the injury. NP stated Resident #1's pain symptoms were not provided to him until about 4:00 PM on 08/4/2025 . Symptoms included facial grimacing. He stated the responsible party decided to have an orthopedic evaluation. Resident #1 was transferred to the emergency room. He stated an orthopedic surgeon evaluated her and determined she required surgery. He stated the following day Resident #1 had a total hip replacement surgery. He stated prior to this fall she was a 1 person assist transfer (as he was unaware of the recent change on 07/30/2025 to a 2x person transfer) and now he believed she was a 2x person assist transfer. He stated CNA A was assisting Resident #1 to the restroom, she was a 1x person assist at this time, gait belt required, The NP stated Resident #1 does have PRN Tramadol and was not having a lot of discomfort. He stated Resident #1 was s eating regularly, was doing well post operatively, was up in the wheelchair most of the day, and was participating in therapy. During interviews on 09/02/2025 at 3:45 PM, CNA C stated he has been employed 18 months at the facility, he was in-serviced on the use of gait belts and fall procedures. He stated charge nurse will complete an assessment of resident after a fall and will provide further instructions following fall on how to care for a resident. He stated he was not familiar with Resident #1's care. During an interview on 09/02/2025 at 3:57 PM, CNA M stated she has been employed 18 months at this facility, she has received ANE, gait belt, and fall procedure training. She stated if a resident falls staff are expected to call the nurse immediately, and the charge nurse will assess the resident and provide CNAs and CMAs with directions for care following the fall. During an interview on 09/02/2025 at 4:31 PM, CNA J stated she has been employed 6 months at this facility, she has received in-service on ANE, she provided examples of ANE. She stated she also received in-service recently on falls and gait belts which covered how to get the resident up, ensure to use gait belt, depending on injuries, if notice resident is in pain, act according in how to respond, getting them up, or if bleeding, check for everything, the nurse will come in and assess. CNA J said it was always best to keep an eye on residents and stay available. She stated she would constantly go back and forth to residents throughout her shifts. She stated staff should observe what is visible to their eyes and report ASAP. Nurse will assess the resident, check for neuro if resident can get up or if they need to be sent out. She cannot assess, this is the responsibility of the nurse. CNA J stated Resident #1 needs assistance with feeding, it is hard for her to communicate what she needs, she will nod, has limited communication, and she is unable to communicate pain and she is familiar with her body language, such as facial expressions when she doesn't want care or refuses care. She stated Resident #1 required the use of a gait belt as she was unsteady. During an interview on 09/02/2025 at 4:58 PM, CNA D stated she had been employed 6 months at this facility, she has been in-serviced on ANE and provided examples of ANE. She stated she has also received in-services in the last 30 days on falls and gait belts. She stated if resident falls staff are to go and get the charge nurse and let them assess the resident. During an interview on 09/02/2025 at 5:15 PM, RN C stated he has been in-serviced within the last 30 days, ADM was the Abuse Coordinator. He stated he was in-serviced on safety precautions, fall provisions, use of gait belt, not to move resident after a fall. He stated if he were to be notified that a resident has fall he is expected to assess for pain, ROM, if not complaining of pain, will use the gait belt to lift them up and sit them up, and this requires 2x person assist. If not witnessed would do facility protocol, which includes neurological checks, medicate resident for pain, call the NP and on call manager, and family members. If resident complains of any pain, then suggest to NP to conduct x-rays. RN C stated it is important to follow post-fall procedures with monitoring resident as this helps to know if there are concerns with resident. He stated he was familiar with Resident #1 but had not worked with her in more than six months. He stated he could not recall Resident #1's functional abilities and he was not present for the fall. During an interview on 09/02/2025 at 5:24 PM, RN D stated he was in-serviced on ANE and fall preventions and protocol. He stated as the charge nurse he is to immediately enter the room if notified of a resident fall. He stated he is expected to report how the fall occurred, what position the resident is in, what injuries were sustained. He stated he is expected to conduct assessments of resident, which include a head to toe, skin assessment, injuries, any fractures, ROM. other assessments competed include neurological assessments. He stated nurses are required to enter, reports in PCC, notify NP, RP, DON and family. The nurses are required to check the resident every 15 minutes, every 1 hours, 4 hours, and this is done daily, for 6 days. He stated he is required to complete the nursing report, progress report, and incident report in detail. RN D stated nurses are required to immediately notify the NP of any fall with and without injury. He stated falls could cause a fracture or bleeding and head to toe assessments after fall (72 hours) will help to identify any change of condition and help nurse to know what type of care to provide the resident. He stated other shifts such as the night shift the nurse must be careful as sometimes injuries appear with delay. He stated documentation is a good source for next shift and other staff. He stated he was not familiar with Resident #1's car and became familiar with her fall during in-service. During an interview on 09/02/2025 at 5:41 PM, DON stated she was in-serviced last month, she completes in-services regularly with nursing managers. She stated the procedures and protocols for falls are given by ADM, interventions in place to reduce falls, step by step, someone falls they need to make sure the charge nurse comes in immediately, provides an assessment, checking ROM, identify if major injury, don't want to move to make things worse, call NP, vitals, neuro if they hit their heads, interventions right away for nurse to investigate, nurse manager follows up with nurse interventions, and DON provides education to staff afterwards if need be. Nurses are required to conduct what is triggered on risk management, they have been educated to open risk management to place in progress fall, triggers assessment, skin, fall assessments, neurons if needed, if check off on risk management, what is clicked on will trigger for falls, check list for the nurses. Notifying NP with major injury then it should be immediately, if minor or no injuries it would be the following day or placed in the box for the NP to see the following day. She stated interventions or assistance needed to prevent falls include updates to the electronic care plan, in-service and education, if something all staff need to be notified of. The DON stated there is a risk to the resident's health and care if not conducting head to toe assessments, failure to provide could cause further harm to the resident if staff are not evaluating thoroughly as this could cause more concerns and this should be reported to the NP immediately. She stated if residents were to fall and injure themselves it could make them feel hurt and sad and cause mental anguish. She stated she was familiar with Resident #1's care, she typically goes off MDS, depending on and not sure of her care specifically. She stated she was not present for the fall on 08/03/2025, she was notified, unsure date and time specific. She stated interventions put in place during notification, notified x-rays, spoke to NP, not moving her when waiting for the x-rays, she was bedridden, any assistance was increased to 2x person, interventions then changed over to 2x person, updated for the interventions. DON stated nurses, RN A, LPCN C, LPCN B, and CNA M received verbal counseling regarding the concerns with post fall assessment, ROM to identify anything post fall for further injuries, skin assessment is also one of the post fall assessments, always good to assess, go through all triggered areas. She stated ROM was not identified, she stated LPCN B and CNA assisted Resident #1 back into the wheelchair, her ROM ability to get up and move her legs, she didn't suspect anything, full range of motion, full extremities assessment, post fall assessments. She stated the expectation is that post fall assessments include 48 hours of monitoring residents who have fallen. She stated the notification to the NP could have been quicker than 24 hours had the post ROM assessment been completed with the post fall assessments. DON stated it is difficult to say as resident doesn't indicate having any discomfort. DON stated she is unsure why only (2) nurses were counseled during the Provider Investigation Report as there were (4) nurses who were identified as not providing post fall assessments for each of their shifts. DON stated she was unaware Resident #1 was care planned for 1x person transfer. She stated the electronic care plan is updated from the MDS assessments that are updated by the MDS Coordinator. During an interview on 09/03/2025 at 9:45 AM, CNA H stated she has been working at this facility for 2 weeks, she received ANE, falls and gait belt training during orientation. She stated in-service covered not moving a resident if they were to fall, to get the charge nurse immediately to assess them. She stated it is important to verify what care is required for the resident via the electronic care plan provided. During an interview on 09/03/2025 at 10:02 AM, RN E stated she has been employed with this facility for over 6 years. She stated she was in-serviced last month on ANE, and what to do during a fall. She stated if an aid reports a resident fall, they are expected to leave the resident there and notify the charge nurse immediately. The charge nurse expected to assess the resident for any injuries, complete a skin assessment, performs ROM assessment, pain assessment. RN E stated if some residents are unable to be moved, she would decide to contact 911, followed by notification to the NP, DON, and family. RN E stated post fall expectations requires nurses to conduct 3-day checks/assessments on the resident. She stated assessments are conducted for 3 days, first every 15 minutes then 1 hour. She stated nurses are to assess the level of consciousness, delayed injuries, interventions, why the fall, place interventions in place, pain assessment is performed on every shift. She stated information is entered in EMR, TAR, skin assessment is every shift, ROM assessment every shift, or anytime the resident complains. She stated if anything else is noticed with resident, such as level of consciousness, any change of daily activities they are to be documented in the progress notes. She stated if post fall assessments are not performed staff could miss delayed bruising, delayed pain, miss dislocation, miss wounds, can miss decline in mental status. She stated she was not familiar with Resident #1's care. During an interview on 09/03/2025 at 10:20 AM, CNA I stated she has been employed for 2 and 1/2 years at this facility. She stated she received training a few days back, completed videos on resident rights, what to do to prevent a fall, reporting, and ANE. She stated she has completed online trainings that covered CNAs do not touch resident that falls until nurse comes in and does vitals and assessments, she just needs to notify charge nurse immediately. During an interview on 09/03/2025 at 10:40 AM, LPCN B stated she's been employed 2 years at this facility, she was in-serviced last month on ANE, reporting, and Abuse Coordinator is ADM. She stated last month she completed an in-service, which covered precautions for falls, attend promptly to call lights, VSG sensors, when one falls, skin assessment, ROM, assessing for pain, notify the physician and family. She stated witnessed and unwitnessed falls staff tells what occurred, nurses go and assess the resident, ensure not in pain, able to move extremities, conduct vital signs, skin assessment, if witnessed and they hit their heads, start neuro checks, contact doctor, family and nurse supervisor. Follow-up 3 days after - witnessed/unwitnessed, neuro assessment 15 minutes monitoring during shift, then shifts to 30/45/60 minutes every day for every shift; She stated the level of consciousness assessment is performed every shift, movement of extremities (ROM), 1st day 15 minutes for an hour, 30 minutes, every hour of each shift. LPCN B stated unwitnessed fall or witnessed fall, neuro checks are required, it will say vital signs, progress notes, goes on assessments. Follow-up 3 days once per shift, every shift check for pain, new injuries, check for bruising, skin tears; ROM, pain, skin, alert, without neuro checks would be a progress note - incident reports (system). She stated if the post fall assessments are not completed by the nurses, then the resident can be in pain and their concerns weren't approached, a new injury or cut can get infected if no orders. She stated she was present for Resident #1's fall, she was the charge nurse for the morning shift. She stated at about 6:20 AM CNA A notified her Resident #1 was on the floor, said she did not hit her head, she was assessed Resident #1's skin and she had a small skin abrasion on her left elbow, she was nonverbal, unable to communicate pain. She stated the on-call nurse was notified, family was notified, and the NP communication note was left in provider box, which is checked daily when the NP is onsite at the facility. She stated she was off the next morning and when she returned, she was informed Resident #1's fall resulted in a fracture and surgery. She stated she received a write up - management stated no documentation for assessments, ROM, communication to the NP, and documentation was not thorough. She stated she did not explain what occurred in detail. She did not list interventions that she provided for the Resident. She stated she did not provide completed information on assessments, and they were not in the incident report. She stated she was to contact the NP by phone immediately following the incident. She stated she did not notify the NP immediately as Resident #1 did not seem in distress or pain. LPCN B stated she believes NP directions would have been to continue to monitor. She stated she performed all the assessments, but did not enter them in the incident report, which is the reason for the write up. She stated she is expected to enter Progress Report in PCC and Incident Report into the risk management system. During a phone interview on 09/03/2025 at 12:05 PM, CNA A stated she was employed for nearly 2 years at this facility before her resignation on 08/06/2025. CNA A stated she was in-serviced on ANE often, she was knowledgeable of ANE and provided examples. She stated she was in-serviced on falls but could not recall the date. She stated she worked with Resident #1 often, before the fall she was normally a 1x person assist, then after the fall she was a 2x person assist as she was unable to bear any weight. She stated she assisted Resident #1 to the toilet on 08/03/2025 and Resident #1 fell. CNA A stated the charge nurse did not instruct her to do anything different with Resident #1's care for the remainder of her 16-hour shift. She stated the resident went to breakfast, returned to her room about 1:00/2:00 PM she put her in bed as a 1x person assist, and Resident #1 was making a face, grimacing like her leg was bothering her. She stated she mentioned this change of condition to the Charge Nurse and Med Aide, who then administered Resident #1 Tylenol. She stated she changed Resident #1's brief before putting her in bed after dinner around 6:00 PM and she noticed she was grimacing. She stated she informed the overnight CNA that Resident #1 seemed to be in pain. During an interview on 09/03/2025 at 1:00 PM, LPCN C stated she has been employed 18 months with this facility, she has received training on ANE, resident rights, privacy, how to approach residents with dementia. She stated she has also been in-serviced on gait belts and fall procedures. She stated last month she was trained on fall and in-service covered completing ROM assessment, pain assessments following a fall to ensure there are no change of condition. LPCN C stated fall prevention interventions included training on an individual basis and review of Resident's care plan prior to performing care. She stated the procedures for falls are to first assess the resident and their breathing, check their vitals, perform ROM assessment, pain assessment and to notify doctor, family, and 911 if necessary. She stated post fall assessments are to be performed every shift every 15 mins, 30 mins, 60 mins. She stated post falls without neuro checks, initial injury, check a few times on their shifts, in a matter of hours things can change. She stated nurses are expected to, assess the resident and make sure they are not in pain, LPCN C stated post fall assessments include skin assessment, neuro, ROM, and are to be documented in incident reports and in the progress note to ensure it is documented. She stated a few times per shift nurses are expected to observe the resident and depending on injury, may get orders from doctor. She stated the general rule is to check them twice during shift along with aid checks. She stated there is a 3-day monitoring window, progress notes, vitals, pain assessment, skin, and ROM need to be completed on each shift. LPCN C stated what you see and what residents show you are documented. She stated staff are to report all falls to on-call charge nurse, NP, family, notify the doctor by phone -page them, if on the weekend or no injuries - notify NP with a note vs phone. She stated on weekdays NP was present and nurses can verbally inform them of change of condition. LPCN C stated if the post fall assessments are not completed staff can potentially miss an injury on that resident and they are super important after a fall. She stated she was familiar with Resident #1's care and stated when she came on shift on 08/03/2025 from 6 AM - 2 PM day shift, she was provided with limited report that resident slipped onto the floor from the bed and had no injuries, she was doing fine, on her shift, aid reported that Resident #1 was in pain about 12-1 PM, she went in resident's room and checked in on her and she was in a lot of pain. She stated she opted not to complete ROM as she didn't want to hurt her any further, she administered PRN pain medication and reported it to the next nurse coming on shift to page the doctor. She stated she didn't notify the doctor herself as Resident #1 was on her baseline, normal throughout the day, she was given an ice pack and PRN medications to make her comfortable. She stated she didn't believe Resident #1 displayed any concerns with pain. She stated ROM not done to not hurt Resident #1 further and no reason why she didn't notify the NP directly as he is next door to her, she stated it was stupidity on her part, she went off what she was told on report and did not do her own shift change report and comes to find out this is not what occurred at all with Resident #1's incident. She stated she has been a nurse a long time and she knows not to believe what another nurse tells you, don't assume, need to do your own assessments.During an interview on 09/03/2025 at 2:39 PM DON stated there is no mention during the 07/30/2025 thru 08/1/2025 morning management meetings where the Director of Rehab notified the team of ADL changes. She stated the team was not notified that Resident #1's evaluation had a significant change and a 2x person transfer was now required. She stated the MDS Coordinator is responsible for reviewing physical therapy updates. She reviewed Resident #1's EMR with Surveyor during this interview and confirmed there were no updates to the MDS Assessment or the care plan. Record review of Resident #1's incident report, dated 08/03/2025 at 6:20 AM revealed CNA A was helping Resident #1 to the restroom without the use of a gait belt and Resident #1 lost her balance as she was unable to bear weight and fell in the bathroom. LPCN B assessed Resident #1 immediately following the fall on 08/03/2025 and noted no indications of pain, conducted a skin assessment that revealed a small abrasion to L elbow 1.5 x .03 cm, vitals obtained, and responsible party was notified, and NP notified via copy of incident placed in provider box. Record review of Initial Post Fall Notification, dated 08/03/2025 revealed LPCN B documents initial post fall and notification to NP was via note to box. No phone call, no page message or text message notification was provided to NP. Record review of Resident #1's Health Status Note, dated 08/04/2025 at 4:52 PM revealed RN A's late entry progress note doesn't provide actual date and time of this entry). Note Text: Resident has an increasing pain on her left leg/hip possibly from her recent fall incident per report from the CNA. Resident was observed to have difficulty with transferring. NP notified of the pain and received order for STAT left hip x-ray. PRN pain medication administered. MAR Tylenol 325 MG administered at 4:52 PM. Record review of Resident #1's Physician Note dated, 08/05/2025 9:41 AM revealed NP Chief Complaint, Acute Issue - Fall, left hip pain. Record review of Resident #1's EMR on 8/2/2025 revealed there were no clinical records of x-ray results; however, interview with NP stated he received x-ray results the morning of 08/05/2025 and identified the fracture and started the process to transfer resident to the hospital. Record review of Resident #1's Hospital Transfer form dated 08/05/2025 at 2:19 PM revealed facility vitals last conducted before transfer to hospital. Record review of Resident #1's Hospital Trauma Transfer Report, dated 08/05/2025, reflected the following: Admit time 07:55 PM, trauma transfer, Resident #1 presented to the ED after a fall, patient ambulates with assistance from Aide at baseline, injury was deemed to be just bruising, however x-ray done showed a left femoral neck fracture. Plan: patient will be admitted to trauma service and orthopedic surgery the morning of August 6. Record review of facility document titled,#594 Fall, dated 08/03/2025, 6:20 AM, revealed this document served as the Incident Report for Resident #1's fall sustained on 08/03/2025. The individual statements provided by the nursing staff who were on shift for Resident #1's fall and post-fall shifts (72 hours) from 08/03/2025 - 08/05/2025. Statements reflect late entries from 08/05/2025 - 08/08/2025: 08/03/2025 2 PM - 10 PM shift: 08/06/2025 RN A statement captured, I worked Sunday [08/03/2025] 2p-10p, the same day resident had fallen. I received report from charge nurse [LPCN B] that resident fell but no concerns. I do not remember receiving any report from CNA A that resident was having pain or unable to bear weight.The CNA had transferred resident during shift, so I did not think there was a problem. I did not officially conduct skin assessment or ROM evaluation on resident on Sunday. RN A also added that she worked the following day, Monday 2 PM - 10 PM shift and she was notified before dinner that Resident #1 was unable to transfer or get out of bed. She did notify the NP following this information and the NP informed her that he was aware and had placed order for STAT x-ray. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 CNA E statement captured, I received report from CNA A.she did not say anything about the resident [Resident #1] having pain or issues with transferring. When I went to change her on my first rounds, I noticed that she did not seem comfortable due to her facial grimacing. I informed the nurse about the pain. On my second rounds with her [Resident #1] I felt she seemed like she was in more pain, so I moved her more gently and again I informed the nurse [RN B]. 08/03/2025 10 PM - 6 AM shift: 08/08/2025 RN B statement captured, I was the RN on the 10-6 shift on Sunday August 3rd.On my initial assessment I did not note any indicators of pain with Resident #1. Late in my shift the CNA informed me that the resident looked uncomfortable while being changed. I administered PRN Tylenol for pain. 08/04/2025 6 AM - 2 PM shift: 08/08/2025 CNA I statement captured, I worked as a CNA on Monday the 6a-2p shift with [Resident #1]. I did not get report from the 10p-6a shift.I arrived to the floor so I was unaware of the fall on the previous day.I noticed something was off when I went to get her out of bed that morning and she was unable to bear weight.I did not notice any visual or verbal signs of pain so I thought maybe she was just stiff from the night sleep. I noted that when I was assisting her with breakfast she was not eating well, and food was dropping out of her mouth. This was not unusual for her, but I did ask the other team members at the table if they felt there was something wrong

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens. The facility failed to ensure staff (the cook) covered their facial hair with a hair restraint in the main kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/18/2024 at 9:57 a.m. revealed the [NAME] in the main kitchen at the serving line placing uncovered sauces on the serving table while not wearing a beard restraint properly. The [NAME] was observed to have his facial hair restraint down around his neck. The [NAME] upon noticing the state surveyor placed his facial hair restraint over his mustache and beard. During an interview on 09/18/2024 at 10:04 a.m. with the [NAME] he stated staff were to use beard guards (facial hair restraints) so hair did not go into the food. The [NAME] further stated it prevents cross contamination. The [NAME] stated the beard guard (facial hair restraint) was to be worn when handling food or doing prep. During an interview on 09/19/2024 at 11:00 a.m. the Culinary Director stated the [NAME] was currently on a disciplinary action plan from August related to the [NAME] not wearing a facial hair restraint. The Culinary Director further stated due to the [NAME] not wearing his beard restraint properly on 09/18/2024 and having been written up regarding the issue previously a final disciplinary notice was issued. The Culinary Director stated the staff were to wear beard restraints (facial hair restraints) anytime they were handling and prepping food. During an interview on 09/20/2024 at 10:08 a.m. with the Culinary Director he stated hair restraints and facial hair restraints were to be worn to prevent hair from falling in the food or any other sort of contaminate that might be on the beard. The Culinary Director further stated hair falling into the food could cause food poisoning and many other issues. During an interview on 09/20/2024 at 10:16 a.m. the Dietician stated anytime staff were dealing with food items hair restraints should be used. The Dietician further stated hair and facial hair restraints were important in keeping hair out of the food during prep and service. Review of facility's policy Orientation and Education, Subject: Uniform Dress Code, revised date 01/2024, read Procedures: Associates Working with Food: Wear approved hair restraints when on duty regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents . Restrain all facial hair with a beard net/restraint. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #11) reviewed for pharmacy services . The facility failed to ensure Resident #11 had a stop date for PRN Alprazolam (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #11's face sheet dated 9/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: [Anxiety] a feeling of fear, dread, and uneasiness, [Hypertension], also known as high blood pressure, is a condition where the pressure in your blood vessels is too high. It's defined as a blood pressure of 140/90 or higher and [Hyperlipidemia] is a condition where there are high levels of lipids, or fats, in the blood. Record review of Resident #11's most recent comprehensive MDS assessment, dated 8/21/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #11's comprehensive care plan dated 8/14/24 revealed the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician. Record review of Resident #11's Order Summary Report, dated 9/19/24 revealed the following: - Alprazolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 24 hours as needed for anxiety disorder, with start date 8/12/24 and no stop date. Record review of Resident #1's Medication Administration Record for August 2024 revealed the following: - Alprazolam 0.25 mg was administered prn on 8/21/24. During an observation and interview on 9/19/24 at 11:01 a.m., Resident #11 was observed in bed awake and alert. Resident #11 stated she needed the anxiety medication sometimes. On 9/19/24 at 12:02 p.m., during an interview, LVN A disclosed that she had previously given Alprazolam to Resident #11 to help with anxiety. LVN A explained that psychotropic medications like Alprazolam should be used for a limited time, usually up to 14 days. After 14 days, the nurse is required to contact the physician to reassess the resident's need for the medication. LVN A was unsure why the order for Alprazolam for Resident #11 was written for an indefinite period, and she expressed concern that the resident was at risk of falls by taking the medication for more than 14 days. During an interview and record review on 9/20/24 at 11:19 a.m., the Director of Nursing (DON) revealed that Resident #11 required the use of Alprazolam as recommended by the physician due to the resident's diagnosis. The DON stated that if the medication was taken all the time, it could result in Resident #11 being overmedicated. After reviewing Resident #11's order summary, the DON confirmed that there was no stop date on the order for prn Alprazolam. The DON revealed that the order for Alprazolam was possibly overlooked, as Resident #11 had transferred from assisted living to skilled nursing on 8/12/24, and a different set of regulations apply in skilled nursing. The DON stated that she was currently responsible for overseeing that psychotropic drugs are limited to 14 days, and her Assistant Director of Nursing (ADON) was to start monitoring this monthly moving forward to prevent this from occurring again. Record review of the facility policy and procedure titled, Policy and Procedure for Psychotropic medication use, dated 2001, updated July 2022, revealed in part, PRN orders for psychotropic medication are limited to 14 days.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens reviewed for proper food storage. The facility failed to ensure in the main kitchen pantry 2 partially used open boxes of corn starch, a partially used box of muffin mix, a box of California seedless raisins and a package of organic quinoa were properly sealed and dated with open date. The facility failed to ensure in the main kitchen pantry a partially used container of baking cocoa, and gelatin were dated with an open date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation on 07/27/2023 at 9:55 a.m. revealed in the main kitchen pantry 2 partially used opened boxes of corn starch, a partially used box of muffin mix, a box of seedless raisins, an opened to air package of quinoa not properly sealed or dated with an opened date. Observation further revealed a container of baking cocoa and gelatin without an opened date. Interview 07/27/2023 at 9:57 a.m. with the Chef revealed the kitchen had a lot of new employees and the items in the pantry should have been wrapped/closed with an opened date. Chef further stated the kitchen staff do go through an orientation and are trained to seal and date opened items before placing back in the pantry. Interview on 07/27/2023 at 2:24 p.m. the FSD stated by not ensuring the boxes and packages were properly sealed it could leave them open to air and attract anything. The FSD further stated the items should not have been brought back in the storage. Record review of the facility's policy titled Food Storage & Handling, revised March 19, 2014, revealed under Policy, revealed It is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 7 of 12 residents (#7, #8, #9, #10, #15, #19, and #34) reviewed for care plans, in that: 1a. The facility did not develop a care plan to address Resident #9 received oxygen. 1b. The facility did not develop a care plan to address Resident #9's use of bed rails (enabler bars) to reposition in bed and risk for injury. 2. The facility did not develop a care plan to address Resident #7's use of bed rails (enabler bars) to reposition in bed and risk for injury. 3. The facility did not develop a care plan to address Resident #8's use of bed rails (enabler bars) to reposition in bed and risk for injury. 4. The facility did not develop a care plan to address Resident #10's use of bed rails (enabler bars) to reposition in bed and risk for injury. 5. The facility did not develop a care plan to address Resident #15's use of bed rails (enabler bars) to reposition in bed and risk for injury. 6. The facility did not develop a care plan to address Resident #19's use of bed rails (enabler bars) to reposition in bed and risk for injury. 7a. The facility did not develop a care plan to address Resident #34's use of bed rails (enabler bars) to reposition in bed and risk for injury. 7b. The facility did not implement the care plan intervention of placement of a mat on the floor when Resident #34 was in bed to decrease the risk of injury if the resident fell out of bed. This deficient practice could place residents at risk for not receiving necessary care and services needed to maintain optimal health. The findings were: 1. Resident #9: 1a. Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's electronic consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's February 2022 TARs revealed it was checked the resident received oxygen daily from 2/1/22 to 2/28/22. Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed under Section O it was not checked the resident received oxygen. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Observation on 5/18/22 at 9:47 a.m. revealed Resident #9 received oxygen at 2 LPM via nasal cannula connected to an oxygen concentrator. In an interview on 5/18/22 at 10:15 a.m., Resident #9's Family Member E stated Resident #9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values) and he could not remember when she started to receive oxygen. In an interview on 5/19/22 at 11:46 a.m., after the MDS Nurse looked at Resident #9's oxygen order, stated the resident had received oxygen since December 2021. The MDS Nurse reviewed Resident #9's Quarterly MDS, dated [DATE] and said the MDS was not checked to indicate the resident received oxygen. The MDS Nurse stated he would look through the resident's clinical record to determine if the resident received oxygen and stated frankly, I missed that one. The MDS Nurse reviewed Resident #9's care plans and stated he did not see a care plan for the oxygen. 1b. Record review of Resident #9's Side Rail/Bed Evaluation assessment, dated 11/19/21 revealed the resident would use the left and right assist/grab bars (bed rails) for mobility and was initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #9's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 8 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #9's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/18/22 at 10:19 a.m. revealed Resident #9 was lying in bed and grabbed hold of the ¼ bed rails (assist/grab bars) that were on both sides of the bed near the head of the bed as CNA B and CNA C provided incontinent care to the resident. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #9's electronic clinical record and stated the resident had an assessment for the bed rails but did not have a consent and did not have a care plan for the bed rails. 2. Resident #7: Record review of Resident #7's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #7's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 7 out of 15, indication her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #7's care plan, revised 4/29/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:51 a.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 5:06 p.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #7's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent or a care plan. 3. Resident #8: Record review of Resident #8's face sheet dated 5/20/22 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Side Rail/Bed Evaluation assessment, dated 3/25/21 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #8's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed his BIMS score was 13 out of 15, indication of his cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #8's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:42 a.m. revealed Resident #8 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/17/22 at 4:00 p.m., Resident #8 stated he used the ¼ bed rails (assist/grab bars) for repositioning. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #8's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment and did not have a care plan for the bed rails. 4. Resident #10: Record review of Resident #10's face sheet, dated 5/20/22, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's Side Rail/Bed Evaluation assessment, dated 11/22/21 revealed the resident would use the left and right assist/grab bar (bed rails) for mobility which were initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #10's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #10's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 4 out of 15, indication of her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #10's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:19 a.m. revealed Resident #10 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #10's electronic clinical record and stated the resident had an assessment for the bed rails and did not have a consent or a care plan for the bed rails. 5. Resident #15: Record review of Resident #15's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's Side Rail/Bed Evaluation assessment, dated 3/11/22 revealed the resident would use the left and right assist/grab bar (bed rails), the assist/grab bars were initiated on admission for mobility. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #15's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #15's MDS, an Admission assessment dated [DATE], revealed her BIMS score was 9 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #15's care plan, revised 5/18/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:05 a.m. revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation and interview on 5/17/22 at 3:18 p.m., revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Resident #15 stated she used the ¼ bed rails to steady herself when she gets in and out of bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #15's electronic clinical record and stated the resident did have an assessment for the bed rails and did not have a signed consent or a care plan for the bed rails. 6. Resident #19: Record review of Resident #19's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #19's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 13 out of 15, indication of her cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #19's care plan, revised 3/16/22, revealed there was no care plan for the assist/grab bars (bed rails). In an interview and observation on 5/18/22 at 10:53 a.m., Resident #19 stated the ¼ bed rails (assist/grab bars) that were on both sides of her bed, had always been on her bed. Resident #19 stated she thought the bed rails came with them [the bed] and she used them to reposition herself in bed. Resident #19 stated she thought a family member had signed a consent for the bed rails when she was admitted to the facility. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #19's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent or a care plan for the bed rails. 7. Resident #34: 7a. Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's Side Rail/Bed Evaluation assessment, dated 1/25/22 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #34's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and Section P indicated bed rails were not used as a restraint. Record review of Resident #34's care plan initiated 1/24/22 and revised 4/15/22 revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 2:56 p.m., revealed Resident #34 was on her right side in bed with her head against one of the ¼ bed rails (assist/grab bars) that were on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #34's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment or a care plan for the bed rails. 7b. Record review of Resident #34's Fall Risk Evaluation, dated 2/2/22, revealed the resident was at risk for falls. Record review of Resident #34's Fall Risk Evaluation, dated 3/18/22, revealed the resident was at risk for falls. Record review of Resident #34's nurse's note written by RN H, dated 3/18/22, revealed Resident #34 was found on the floor with a small skin tear to her left elbow. The nurse cleansed the wound and completed an assessment. Record review of Resident #34's care plan for the focus area of The resident is high risk for falls, initiated 1/21/22 and revised on 4/26/22 revealed under Interventions, Due to fall on 3/18 [2022] resident will have a floor [fall] matt [sic] when in bed with an initiation date of 3/18/22. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired, required total dependence of 1 staff member to physically assist with bed mobility, and had 1 fall with minor injury since the last assessment. Record review of the facility's Occurrence Report (Incident/Accident Log) from 11/18/21 to 5/17/22 revealed Resident #34's last fall occurred on 3/18/22. Observation on 5/17/22 at 10:03 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/17/22 at 2:56 p.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/19/22 at 9:54 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. In an interview on 5/19/22 at 9:55 a.m., CNA F stated Resident #34 did not need a fall mat on the floor when she was in bed. In an interview on 5/19/22 at 9:58 a.m., LVN G stated when Resident #34 was in bed the bed would be in the lowest position and thought there should be a fall mat on the floor in case the resident fell out of bed, but she was not sure. LVN G looked at Resident #34's care plan and stated the care plan indicated a floor (fall) mat should be on the floor when the resident was in bed. Observation on 5/19/22 at 10:05 a.m. with LVN G in Resident #34's room, LVN G stated there was no fall mat on the floor and verified there was no fall mat in the room. In an interview on 5/19/22 at 10:12 a.m., LVN G stated the risk of not having a fall mat on the floor when Resident #34 was in bed could result in skin tears and increase the resident's risk for injuries. In an interview on 5/19/22 from 12:01 p.m. to 12:35 p.m., the DON stated Resident #34 had 1 fall from her bed. The DON reviewed Resident #34's care plan and stated after the 3/18/22 fall, the facility implemented a mat on the floor when the resident was in bed to decrease her risk of injury. The DON stated Resident #34 was no longer at risk for falling out of bed as the resident did not move much in bed and relied on staff to reposition her. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated Resident #34 could get injured if she fell out of bed and there was no fall mat on the floor next to the bed. The Administrator stated the fall mat was to decrease the resident's risk for injury. In an interview on 5/19/22 at 12:01 p.m., the DON stated she would periodically review the resident's care plans to ensure they were accurate. The DON stated if the care plan was not accurate it would not be detrimental to the resident as their daily care would still be the same. The DON stated the ¼ bed rails on the resident's bed were called enabler bars, were for the resident to move side to side in bed, the facility did not have to do an assessment or consent for them as the facility did not consider them to be bed rails and she did not see any risk of harm to the resident with the enabler bars on the bed. The DON stated if the enabler bars were considered a bed rail then yes, she would have that care planned as there are risks involved with that and you would have to have things in place. The DON then stated if the enabler bars were considered a bed rail then there would be a risk of entrapment to the resident. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated she relied on the DON and MDS Nurse to ensure the care plan was accurate and did not state what the risk would be to the residents if the ¼ bed rails (assist/grab bars) were not care planned. Record review of the facility's undated policy Care Planning revealed An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs is developed for each resident. Further review of the policy revealed 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes .6. Identifying problem area and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making .8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: .d. At least quarterly. Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps withing the bed system are within the dimensions established by the FDA .d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 (# 35, # 32 and # 9) of 11 residents reviewed for oxygen therapy in that: oxygen concentrator filters had grayish white particulate matter on them. This deficient practice could affect residents who receive oxygen therapy and could result in impaired delivery of effective and safe purified oxygen at the desired concentrations ultimately causing infection or respiratory compromise. The findings were: Record review of an undated Care and Use of Oxygen Concentrators policy revealed in Section E - Care and Maintenance of the Concentrator: Nursing Responsibilities 1. Once a week remove the filter .wash with soap and water, air dry and return to the concentrator. Record review of Manufactures' Service Manual, 2008, indicated on page 7 under Preventative Maintenance Summary instructions to clean air filter on back of unit weekly. On page 6 under Air Filter and Oxygen Outlet a Warning that operation .in extreme environments or without the air filter will prematurely occlude the intake .cause a decrease in the unit performance. Further, on page 9 under Simplified Troubleshooting, occluded filters can cause pressure to rise slowly or have low pressures; Additionally on page 10, Troubleshooting Chart A, indicates occlude filters can cause fluctuating oxygen flow, low oxygen concentration. 1. Record review of admission Record printed 5/20/2022 revealed Resident # 35 was an [AGE] year-old woman with an initial admit date of 1/23/2017; pertinent diagnoses included: history of COVID-19; obstructive sleep apnea [characterized by episodes of complete or partial collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep]; chronic obstructive pulmonary disease [inflammatory lung disease causes breathing difficulty, mucus production and wheezing]. Record review of quarterly MDS date 4/29/2022 for Resident # 35 revealed in Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 10 [indicative of moderately impaired cognition]. In Section O - Special Treatments, Resident # 35 received oxygen while a resident of this facility. Record review of Care Plan, with a last reviewed date of 05/02/2022, for Resident # 35 revealed Focus Area for oxygen therapy related to respiratory illness with interventions: 02 via nasal cannula at 2 liters continuous humidified, with a revision date of 4/16/2022. Record review of Physicians' Orders for Resident # 35 revealed orders for oxygen at 2 liters per minute via nasal cannula continuous with a start date of 2/19/2021; May increase up to 5 liters per minute via nasal cannula for respiratory distress with a revision date of 7/17/2021; clean oxygen concentrator air filter weekly and PRN, every night shift Sundays for patency and as needed with a start date of 5/6/2021. Record review of treatment administration record for Resident # 35 revealed positive documentation that the oxygen concentrator filter was cleaned on the following dates: 3/6/2022, 3/13/2022, 3/20/2022, 3/27/2022, 4/3/2022, 4/10/2022, 4/17/2022, 4/24/2022, 5/1/2022, 5/8/2022, and 5/15/2022; with no documentation indicating PRN entries. In an observation on 5/17/2022 at 10:24 AM, Resident # 35 had a red sign attached to her door frame indicating oxygen in use; Resident # 35 was sitting up in her wheelchair dressed appropriately for the weather; oxygen concentrator was powered on; nasal cannula positioned appropriately; external filter on the oxygen concentrator had white particulate matter interspersed across its surface. 2. Record review of admission Record printed 05/23/2022 revealed Resident # 32 was a [AGE] year-old woman with an initial admit date of 7/3/2019; with pertinent diagnoses: chronic obstructive pulmonary disease; pulmonary hypertension [high blood pressure affecting the arteries of the lungs, right side of the heart resulting in chest pain and shortness of breath]. Record review of annual MDS, dated [DATE], for Resident # 32 revealed in Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 10 [indicative of moderately impaired cognition]. In Section O - Special Treatments, Resident # 32 received oxygen while a resident of this facility. Record review of Care Plan, with a last reviewed date of 05/04/2022 for Resident # 32 revealed Focus Area for oxygen therapy related to ineffective gas exchange related to COPD; interventions included: administer O2 as ordered, initiated 5/19/2022. Record review of Physicians' Orders for Resident # 32 revealed orders for oxygen at 1-3 liters per minute via nasal cannula continuous with a start date of 3/11/2020; clean oxygen concentrator air filter weekly and PRN, every night shift Saturdays and as needed with a start date of 3/11/2020. Record review of treatment administration record for Resident # 32 revealed positive documentation that the oxygen concentrator filter was cleaned on the following dates: 3/5/2022, 3/12/2022, 3/19/2022, 3/27/2022, 4/2/2022, 4/9/2022, 4/16/2022, 4/23/2022, 4/30/2022, 5/7/2022, and 5/14/2022; with no documentation indicating PRN entries. In an observation on 5/17/2022 at 11:56 AM Resident # 32 was sitting up in her wheelchair dressed appropriately for the weather; oxygen concentrator was powered on; nasal cannula positioned appropriately; external filter on the oxygen concentrator had white particulate matter covering its surface. 3. Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition when the heart can't supply the cells with enough blood which results in fatigue and shortness of breath). Record review of quarterly MDS, dated [DATE] revealed Resident # 9 was a [AGE] year-old woman admitted [DATE]. Under Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 8 [indicative of moderately impaired cognition]. Section J - Health Conditions indicates shortness of breath with exertion. Under Section O - Special Treatments, oxygen was not checked. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Record review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 12/3/21 for oxygen via nasal cannula (device used to deliver supplemental oxygen through a lightweight tube with one end splits into two prongs that are placed in the nostrils and the other end of the tube is connected to an oxygen generator) at 2 LPM at bedtime for apnea (difficulty breathing) and as needed for apnea. Further review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 3/13/22 to Clean Oxygen Concentrator Air Filter on the night shift every Sunday and as needed. Record review of Resident #9's May 2022 TARs revealed it was checked the oxygen filter was cleaned on Sunday 5/15/22. Observation on 5/17/22 at 10:46 a.m. revealed the oxygen concentrator in Resident #9's room had 2 filters which were covered with white lint. The oxygen concentrator was off, and oxygen was not being administered to Resident #9 at the time of the observation. Observation on 5/18/22 at 9:47 a.m. revealed Resident # 9 received oxygen at 2 liters per minute via nasal cannula connected to the oxygen concentrator with the 2 filters covered with white lint. Observation and interview on 5/18/22 at 10:01 a.m. with LVN A in Resident # 9's room as the resident received oxygen via nasal cannula connected to the oxygen concentrator with the filters covered with lint. LVN A removed the filter on Resident #9's oxygen concentrator and picked off some of the lint, stated it was dirty. LVN A replaced the filter covered with lint back on to the oxygen concentrator without cleaning it, stated she did not know whose responsibility it was to clean the concentrator's filters. Resident # 9 continued to receive oxygen via nasal cannula that was connected to the oxygen concentrator with the filters covered with lint. In an interview on 5/18/22 at 10:15 a.m. with Resident # 9's Family Member E in Resident # 9's room as the resident received oxygen via nasal cannula connected to the filters covered with lint, Family Member E stated Resident # 9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values). In an observation on 5/18/2022 between 10:25 and 10:35 AM with CNA B and CNA C during peri-care, Resident # 9 was receiving supplemental oxygen via nasal cannula that was connected to an oxygen concentrator with a dirty filter. In an interview on 5/18/22 at 10:38 a.m., LVN A stated the nurses who worked the night shift were responsible for cleaning the filters on the oxygen concentrators. In an interview on 5/18/22 at 6:00 p.m. the DON stated the oxygen filters on the oxygen concentrator were cleaned on the night shift once a week and did not know why the filters were dirty when observed by the surveyors. The DON stated the risk to the residents of having a dirty filter on the oxygen concentrator was that the oxygen concentrator could result in overheating. In an interview on 5/20/2022 at 12:17 PM with the ADON she stated it is the responsibility of the night nurse assigned to whichever residents receive oxygen to change the oxygen filters on the designated night. The ADON stated documentation of task completion is done on the Treatment Administration Record. The ADON stated that it is her responsibility as an ADON to check that duties are completed. The ADON stated she did not know what the outcome could be if the filters are dirty but could negatively impact the resident in some way. If oxygen concentrator alarms are sounding, and cannot be cleared, she stated it would be removed from the floor as out of service, and oxygen tanks could be used instead. .

Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 8 of 8 residents (Resident #9, #7, #8, #15, #19, #34, #33, and #10) review for bed rails in that: 1. Resident #9 did not have a consent for the quarter bed rails on her bed. 2. Resident #7 did not have a consent and initial assessment for her quarter bed rails on her bed. 3. Resident #8 did not have a consent for his quarter bed rails on his bed and had an initial assessment for bed rails, but the assessment indicated bed rails would not be used. 4. Resident #15 did not have a consent for the quarter bed rails on her bed. 5. Resident #19 did not have a consent and initial assessment for her quarter bed rails on her bed. 6. Resident #34 did not have a consent for her quarter bed rails on her bed and her assessment indicated bed rails would not be used. 7. Resident #33 did not have a consent for the quarter bed rails on her bed. 8. Resident #10 did not have a consent for the quarter bed rails on her bed. These failures could affect residents who utilized some type of bedrail in the facility and could put the residents at risk for potential injuries. The findings were: 1. Resident #9: Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's Side Rail/Bed Evaluation assessment, dated 11/19/21 revealed the resident would use the left and right assist/grab bars (bed rails) for mobility and was initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #9's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 8 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #9's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/18/22 at 10:19 a.m. revealed Resident #9 was lying in bed and grabbed hold of the ¼ bed rails (assist/grab bars) that were on both sides of the bed near the head of the bed as CNA B and CNA C provided incontinent care to the resident. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #9's electronic clinical record and stated the resident had an assessment for the bed rails but did not have a consent. 2. Resident #7: Record review of Resident #7's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #7's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 7 out of 15, indication her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #7's care plan, revised 4/29/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:51 a.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 5:06 p.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #7's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent. 3. Resident #8: Record review of Resident #8's face sheet dated 5/20/22 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Side Rail/Bed Evaluation assessment, dated 3/25/21 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #8's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed his BIMS score was 13 out of 15, indication of his cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #8's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:42 a.m. revealed Resident #8 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/17/22 at 4:00 p.m., Resident #8 stated he used the ¼ bed rails (assist/grab bars) for repositioning. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #8's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment. 4. Resident #15: Record review of Resident #15's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's Side Rail/Bed Evaluation assessment, dated 3/11/22 revealed the resident would use the left and right assist/grab bar (bed rails), the assist/grab bars were initiated on admission for mobility. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #15's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #15's MDS, an Admission assessment dated [DATE], revealed her BIMS score was 9 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #15's care plan, revised 5/18/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:05 a.m. revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation and interview on 5/17/22 at 3:18 p.m., revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Resident #15 stated she used the ¼ bed rails to steady herself when she gets in and out of bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #15's electronic clinical record and stated the resident did have an assessment for the bed rails and but did not have a signed consent. 5. Resident #19: Record review of Resident #19's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #19's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 13 out of 15, indication of her cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #19's care plan, revised 3/16/22, revealed there was no care plan for the assist/grab bars (bed rails). In an interview and observation on 5/18/22 at 10:53 a.m., Resident #19 stated the ¼ bed rails (assist/grab bars) that were on both sides of her bed, had always been on her bed. Resident #19 stated she thought the bed rails came with them [the bed] and she used them to reposition herself in bed. Resident #19 stated she thought a family member had signed a consent for the bed rails when she was admitted to the facility. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #19's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent. 6. Resident #34: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's Side Rail/Bed Evaluation assessment, dated 1/25/22 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #34's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and Section P indicated bed rails were not used as a restraint. Record review of Resident #34's care plan initiated 1/24/22 and revised 4/15/22 revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 2:56 p.m., revealed Resident #34 was on her right side in bed with her head against one of the ¼ bed rails (assist/grab bars) that were on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #34's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment. 7. Resident #33: Record review of Admission Record printed 5/20/2022, revealed Resident #33 had an initial admitted [DATE] with the following pertinent Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of quarterly MDS [Minimum data set] with a target date of 05/03/2022, revealed in Section C - Cognitive patterns a summary score of 15 [13 to 15 points indicative of intact cognition] for the Brief Interview for Mental Status. Section P - Restraints and alarms revealed bedrail not used as physical restraint. Record review of Side Rail/Bed Evaluation dated 1/24/2022, revealed Resident #33 had left and right Assists/Grab Bars on admission for mobility during transfers to enable mobility. In an observation on 05/17/2022 at 11:04 AM, Resident # 33 was sitting up in her wheelchair at bedside table, dressed appropriately for weather including foot ware, independently feeding self. Quarter bedrails at head of bed. In an interview on 05/18/2022 at 6:25 PM, Resident # 33 stated she use those [bedrails] to move around in bed, or when I am first getting out of bed for balance. 8. Resident #10: Record review of Resident #10's face sheet, dated 5/20/22, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's Side Rail/Bed Evaluation assessment, dated 11/22/21 revealed the resident would use the left and right assist/grab bar (bed rails) for mobility which were initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #10's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #10's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 4 out of 15, indication of her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #10's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:19 a.m. revealed Resident #10 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #10's electronic clinical record and stated the resident had an assessment for the bed rails and did not have a consent. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON stated the ¼ bed rails on the resident's bed were called enabler bars and were for the resident to move side to side in bed, the facility did not have to do an assessment or consent for them as the facility did not consider them to be bed rails and she did not see any risk of harm to the resident with the enabler bars on the bed. The DON stated if the enabler bars were considered a bed rail then yes, she would have that care planned as there are risks involved with that and you would have to have things I place. The DON then stated if the enabler bars were considered a bed rail then there would be a risk of entrapment to the resident. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on, and the facility did not have to complete any paperwork (bed rail assessment or obtain consent) since they were enabler bars. The Administrator verified the facility did not obtain consents or complete a bed rail assessment for residents who had enabler bars (bed rails) on their beds. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator then asked the surveyor if the enabler bars were bed rails. Record review of an undated bed brochure provided by the facility revealed the bed came with an assist device (assist bar/bed rail). Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps within the bed system are within the dimensions established by the FDA .d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility, in that: 1. One of two clothes dryers was inoperable. This deficient practice could result in residents not having access to hygienically clean laundry and the prevention of transmissions of disease or infection could be inhibited. The findings were: In a record review of documents provided by facility revealed a credit card receipt dated 5/11/2022 with service technicians' business card. In a record review of documents provided by facility revealed email dated 5/19/2022 that service technician would be at the facility on Saturday [5/21/2022] at 8AM to check on dryer #1. In an observation on 5/20/2022 at 10:35 AM in the laundry area one of two clothes dryers was not running. In an interview on 5/20/2022 at 10:40 AM with Housekeeper J, she stated Dryer 1 has not worked for about 3 weeks now. She stated it could affect residents receiving laundry on time. Housekeeper J stated it has not affected residents because she and other [unnamed] staff work longer hours now to complete all the laundry using only one dryer. In an interview on 5/20/2022 at 11:20 AM with the Executive Director, he stated Dryer 1 was not functioning, service technician was on site 5/11/22 to service both dryer 1 and dryer 2, but dryer 1 needed a part to complete servicing. He stated the part has been ordered, and the technician is scheduled to return to the facility tomorrow morning [5/21/2022] at 8:00 AM. The Executive Director stated that it is important to the residents' dignity and for infection control to have hygienically clean laundry. He stated having only one operable dryer has not affected the residents, instead the facility has extended the hours of the laundry operations. The Executive Director stated that if Dryer 2 breaks down before Dryer 1 is repaired, the facility can utilize the residential dryers on the Assisted and Independent Living side of the facility to ensure residents have access to hygienically clean laundry. Policy and procedure for functional equipment was not received prior to survey exit. Facility did not provide a work order for when the Dryer 1 stopped working. .

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication refrigerators in 1 of 2 medication storage rooms for the facility, in that: The facility failed to ensure Refrigerator #1 [Medication Fridge North] maintained a safe storage temperature. This deficient practice could lead to residents being exposed to medications that do not produce the expected therapeutic effects or produce negative reactions. The findings were: In a record review on 05/19/22 at 3:58 PM of Refrigerator Temperature logs for the north hallway were completed up to the current date; no missing entries, and no entries were outside of safe temperature ranges [36-41 degrees Fahrenheit]. This log included the Medication, Specimen and Snack refrigerators on the north hallway. In a record review of Storage of Medications policy, undated, revealed in step #2 nursing staff shall be responsible for maintain medication storage .in a clean, safe and sanitary manner. Further, in step #11, Medications requiring refrigeration .3. Monitored for temperature at least one time per day; and 4. Temperatures above 41 degrees F[ahrenheit] should be reported to the DON. In observations and interview with LVN A on 5/19/2022 at 3:03 PM the medication refrigerator on the north hallway displayed a temperature of 43 degrees Fahrenheit. Interior ambient air in the refrigerator and items in the refrigerator felt cool at this time. LVN A stated she did not know how long the temperature had been above 41, and the last time anyone would have been in the Medication Refrigerator North Hallway would have been before lunch [noon] trays were delivered when a resident received his scheduled liquid pain medication. This surveyor stayed in the area and did not observe anyone unlock the medication room door, go in or unlock to open the refrigerator. At 3:20 PM the medication refrigerator on the north hallway displayed a temperature of 44 degrees Fahrenheit. LVN A stated she would notify her boss for further instructions as she wasn't sure what to do about an elevated temperature. LVN A stated it was the responsibility of the overnight nurse to check the temperatures of the refrigerators and document the findings. In an interview on 05/19/22 at 03:51 PM the DON stated the ADON was responsible for reviewing temperature logs daily. The DON stated if the temperature readings are beyond the parameters for safety, the expectation was for the ADON to notify management, and remove items from that refrigerator, place an out of order sign on the refrigerator, and notify maintenance. The DON stated if medications were used that had been outside the parameters for safe temperatures, the resident could have adverse drug reactions or subtherapeutic effects of medications. The DON stated all items in the Medication Fridge North were disposed of and reordered when it was discovered they were out of parameters for safety. In an interview on 05/19/22 at 3:55 PM the ADON stated the temperature logs are reviewed every morning by her. She stated, if necessary, she will recheck temperatures if the log shows temperatures close to being out of range. On weekends or scheduled days off, this task was assigned to the weekend nurse. She stated the equipment would be placed out of order, items removed, and maintenance notified to service the refrigerator. .

Based on observations, interviews and record reviews, the facility failed to store food in accordance with professional standards for food safety in 1 of 1 refrigerator reviewed for food service safety. The facility failed to ensure Refrigerator #1 [Resident Snack Fridge North] maintained a safe storage temperature. This failure could place residents at risk for food-born illness and food contamination. The findings include: In a record review on 05/19/22 at 3:58 PM of Refrigerator Temperature logs for the north hallway were completed up to the current date; no missing entries, and no entries were outside of safe temperature ranges (36-41 degrees Fahrenheit). This log included the Medication, Specimen and Snack refrigerators on the north hallway. In a record review of food receiving and storage policy, undated, revealed in step #8, refrigerated foods must be stored below 41 degrees F[ahrenheit]. Further in step #11, monitored at designated intervals .and documented. Step #13, Food items and snacks kept on the nursing unit must be maintained as indicated below: 1. All food items to be kept below 41 degrees F[ahrenheit]; 3. Refrigerators must have working thermometers and be monitored for temperatures. In an observatio n on 5/19/2022 at 3:08 PM Refrigerator #1 [Resident Snack Fridge North] on the north hallway displayed a temperature of 50.2 degrees Fahrenheit. At 3:16 PM the resident snack refrigerator on the north hallway displayed a temperature of 52.0 degrees Fahrenheit. This refrigerator had individual serving packages of pudding, gelatin, juice, and milk containers in it. The interior ambient air was only slightly cooler than room temperature to the touch and the items did not feel refrigerated to the touch; items were not cold. In an interview and observation on 05/19/22 at 3:11 PM LVN A confirmed the temperature reading of 50.2 degrees Fahrenheit; LVN A adjusted the dial in the fridge to colder; LVN A stated she did not know if anyone had recently been in this refrigerator recently. This survey stayed in the area and did not observe any one open the refrigerator until at 3:22 PM when LVN A confirmed temperature reading at 52.0 degrees Fahrenheit. LVN A stated she would notify her boss for further instructions as she wasn't sure what to do about an elevated refrigerator temperature. LVN A stated it is the responsibility of the overnight nurse to check the temperatures of the refrigerators and document the findings. In an interview on 05/19/22 at 03:51 PM the DON stated the ADON was responsible for reviewing temperature logs daily. The DON stated if the temperature readings are beyond the parameters for safety, the expectation was for the ADON to notify management, and remove items from that refrigerator, place an out of order sign on the refrigerator, and notify maintenance. The DON stated if food items were consumed that had been outside the parameters for safe temperatures, the resident would be at risk for a food borne illness. The DON stated all items in the resident snack refrigerator were disposed of and reordered when it was discovered they were out of parameters for safety. In an interview on 05/19/22 at 3:55 PM the ADON stated the temperature logs are reviewed every morning by her. She stated, if necessary, she will recheck temperatures. On weekends or scheduled days off, this task was assigned to the weekend nurse. She stated the equipment would be placed out of order, items removed, and maintenance notified to service the refrigerator. .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices were put into place prevent accidents for 1 of 2 residents (Resident #34) reviewed for falls. The facility failed ensure Resident #34's fall mat was on the floor, next to her bed to prevent potential fall injury for 3 of 4 days. This failure could place the resident who require supervision assistance due at risk for falls with injuries, hospitalization , and a decreased quality of life. The findings were: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning) and [CONDITION(S)] (a mental health problem that causes people to perceive or interpret things differently from those around them) with hallucinations (an experience involving the apparent perception of something not present). Record review of Resident #34's Fall Risk Evaluation, dated 2/2/22, revealed the resident was at risk for falls. Record review of Resident #34's Fall Risk Evaluation, dated 3/18/22, revealed the resident was at risk for falls. Record review of Resident #34's nurse's note written by RN H, dated 3/18/22, revealed Resident #34 was found on the floor with a small skin tear to her left elbow. The nurse cleansed the wound and completed an assessment. Record review of Resident #34's care plan for the focus area of The resident is high risk for falls, initiated 1/21/22 and revised on 4/26/22 revealed under Interventions was Due to fall on 3/18 [2022] resident will have a floor [fall] matt [sic] when in bed with an initiation date of 3/18/22. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired, required total dependence of 1 staff member to physically assist with bed mobility, and had 1 fall with minor injury since the last assessment. Record review of the facility's Occurrence Report (Incident/Accident Log) from 11/18/21 to 5/17/22 revealed Resident #34's last fall occurred on 3/18/22. Observation on 5/17/22 at 10:03 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/17/22 at 2:56 p.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/18/22 at 10:57 revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/19/22 at 9:54 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. In an interview on 5/19/22 at 9:55 a.m., CNA F stated Resident #34 did not need a fall mat on the floor when she was in bed. CNA F stated Resident #34 required total assistance with her care and did not state if the resident needed assistance with repositioning. In an interview on 5/19/22 at 9:58 a.m., LVN G stated when Resident #34 was in bed the bed would be in the lowest position and thought there should be a fall mat on the floor in case the resident fell out of bed, but she was not sure. LVN G looked at Resident #34's care plan and stated the care plan indicated a floor (fall) mat should be on the floor when the resident was in bed. Observation on 5/19/22 at 10:05 a.m. with LVN G in Resident #34's room, LVN G stated there was no fall mat on the floor and verified there was no fall mat in the room. In an interview on 5/19/22 at 10:12 a.m., LVN G stated the risk of not having a fall mat on the floor when Resident #34 was in bed could result in skin tears and increase the resident's risk for injuries. In an interview on 5/19/22 from 12:01 p.m. to 12:35 p.m., the DON stated Resident #34 had 1 fall from her bed. The DON reviewed Resident #34's care plan and stated after the 3/18/22 fall, the facility implemented a mat on the floor when the resident was in bed to decrease her risk of injury. The DON stated Resident #34 was no longer at risk for falling out of bed as the resident did not move much in bed and relied on staff to reposition her. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated Resident #34 could get injured if she fell out of bed and there was no fall mat on the floor next to the bed. The Administrator stated the fall mat was to decrease the resident's risk for injury. Record review of the facility's undated policy Care Planning revealed An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs is developed for each resident. Further review of the policy revealed 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes .6. Identifying problem area and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making 8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on interview and record review, the facility failed to obtain the hospice election form and physician certification of terminal illness, most recent hopsice plan of care, hospice medication information for for 1 of 1 resident (Resident #34) reviewed for hospice services, in that: The facility failed to obtain Resident #34's most recent hospice Plan of care, hospice election form, physician certification of the terminal illness, hospice medication information and interdisciplinary documentation of the hospice staff that provided services. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's electronic consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and received hospice care. Record review of Resident #34's care plan initiated 1/24/22 revealed she received hospice services. Record review of Resident #34's electronic clinical record revealed there was no recent hospice plan of care, hospice election form, physician certification of the terminal illness, hospice medication information, or any other interdisciplinary documentation of the hospice staff that provided services from Hospice Company I. In an interview on 5/20/22 at 9:11 a.m., LVN A stated she thought Resident #34's hospice documents were scanned and put into the electronic clinical record. LVN A reviewed Resident #34's electronic clinical record and stated she could not find any documents from Hospice Company I. LVN A then looked around the nurse's station for a binder from Hospice Company I for Resident #34 and could not find one. LVN A stated Hospice Company I would visit Resident #34 three times a week and she did not know what documentation they would leave with the facility. In an interview on 5/20/22 at 12:43 p.m. the Administrator stated she had uploaded Resident #34's hospice records into the resident's electronic chart under the document section today (5/20/22) after the surveyor had requested the documents. The Administrator stated Resident #34's hospice records were in the hospice company's electronic chart system that a few people in the facility had access to and did not state who those people were beside the administrator when the surveyor inquired. When asked how nurses could view Resident #34's electronic clinical record that had not been uploaded in the document section before 5/20/22, the Administrator stated the hospice staff would communicate with the facility nurse when hospice was in the facility. In an interview on 5/20/22 at 3:36 p.m. the Administrator stated the Social Worker would coordinate care between the facility and hospice and was responsible for ensuring the hospice documents were in place. In an interview on 5/20/22 at 3:44 p.m. the Social Worker stated she would contact the hospice company chosen by the resident's family so the hospice company could assess the resident, but she was not responsible for ensuring the hospice documentation was in the facility. The social worker stated historically, the hospice documents would be kept in a binder at the nurse's stations. Record review of Hospice Company I's Hospice Service Agreement (contract) with the facility, dated 5/1/14, revealed under Section III. Services to be Furnished by the LTCF [Long-Term Care Facility] was B. LTCF Services .17. Ensure proper documentation of all services provided to Hospice Company I patients. Hold in strict confidence all patient records and Protected Health Information in accordance with applicable Federal and State laws and regulations and disclose Protected Health Information only to persons or entities authorized by law or written consent of the patient or the patient's representatives. Records shall be maintained for a period of five years from date of discharge or such other time period as required by applicable Law. LTCF shall take reasonable precautions to safeguard records against loss, destruction and unauthorized disclosure. Further review of the contract revealed under Section VIII. Compliance was Hospice Company I and LTCF hereby acknowledge that it is the full intent of both parties to comply with all Federal and State laws and regulations that apply to the provision of hospice care in long term care facilities. Record review of the facility's undated policy Hospice Services revealed the objective was To provide end of life care for residents. Under Responsibility: the Licensed Nursing Home Administrator, Nursing services and Social Services were listed. Under Guideline was 7. Hospice will be requested to provide documentation in the resident's clinical record. Record review of the facility's undated policy Clinical Records revealed the objective was To make certain that clinical records on each resident are maintained with accepted professional standards. Under Responsibility: the Licensed Nursing Home Administrator and Designee were listed. Under Guideline was 1. Clinical records will be: a. Complete; b Accurately documented; c. Readily accessible for resident care; and d. Systematically organized. 2. The Clinical record will contain an accurate and functional representation of the actual experience of the resident. 3. The Clinical record will contain enough information to show that The Health Center knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. 4. Documentation will provide a picture of the resident's progress, including response to treatment, change in condition and changes in treatmen .11. The clinical record will contain: Signed and dated clinical documentation from all health care practitioners involved in the resident's care

Based on interview and record review, the facility failed to conduct regular inspection of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment. The facility failed to have a maintenance progra to conduct regular inspections of the beds and bedrails to identify risks and problems. This failure could place residents with bed rails at risk of entrapment, injury, or death. The findings were: Observation on 5/18/22 at 8:50 a.m. revealed Resident #10's ¼ bed rail (assist/grab bar) on one side of the bed stuck away from the mattress about 4 inches, the other bed rail was flush with the mattress. Interview on 5/19/22 at 10:12 a.m. with LVN G revealed Resident #10's bed rail that was about 4 inches from the mattress, she stated the Supply Manager would service the bed rails (assist/grab bars). In an interview and observation on 5/19/22 at 10:13 a.m., the Supply Manager, stated he would inspect the bed rails on the residents' bed when informed by staff, did not have a set routine to inspect the bed rails and stated he would walk by the residents' room and look at the bed rails from the hallway. In a further interview on 5/19/22 at 1:33 p.m. the Supply Manager stated he did not have the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator stated the enabler bars (assist/grab bars/bed rails) should be pushed in so would be flushed with the mattress; if the enabler bar was more than 4 ¾ inches from the mattress then there was the potential the resident could get trapped between the mattress and the enabler bar. The Administrator did not state how the facility monitors the enabler bars (assist/grab bars/bed rails) to ensure they are correctly installed on the bed. Record review of an undated bed brochure provided by the facility from the bed manufacturer revealed the bed came with an assist device (assist bar/bed rail) and did not indicate how far away from the mattress it should be from the assist device. Record review of U.S. Department of Health and Human Services Food and Drug Administration (FDA) Center for Devices and Radiological Health's Guidance for Industry and FDA Staff Hospital Bed System Dimensional and assessment Guidance to Reduce Entrapment issued 3/10/2006, pages 13-17, revealed the space between the bed rail and mattress was a potential zone of entrapment. The FDA is recommending a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps withing the bed system are within the dimensions established by the FDA d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.).

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 12 residents (Resident #9) reviewed for accuracy of assessments. The facility failed to ensure Resident #9's Quarterly MDS assessment accurately reflected the resident received oxygen. This failure could place residents at risk of inadequate care. The findings were: Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's electronic consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's February 2022 TARs revealed it was checked the resident received oxygen daily from 2/1/22 to 2/28/22. Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed under Section O it was not checked the resident received oxygen. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Observation on 5/18/22 at 9:47 a.m. revealed Resident #9 received oxygen at 2 LPM via nasal cannula connected to an oxygen concentrator. In an interview on 5/18/22 at 10:15 a.m., Resident #9's Family Member E stated Resident #9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values) and he could not remember when she started to receive oxygen). In an interview on 5/19/22 at 11:46 a.m., after the MDS Nurse looked at Resident #9's oxygen order, stated the resident had received oxygen since December 2021. The MDS Nurse reviewed Resident #9's Quarterly MDS, dated [DATE] and said the MDS was not checked to indicate the resident received oxygen. The MDS Nurse stated he would look through the resident's clinical record to determine if the resident received oxygen and stated frankly, I missed that one. In an interview on 5/19/22 at 12:01 p.m., the DON stated to ensure accuracy of the MDS she would review residents' MDS and did not indicate how often they were reviewed. The DON stated if the MDS was not accurate, she did not see any direct risk to the resident other than it could affect the reimbursement rate from Medicare. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated she relied on the MDS Nurse and DON to ensure the residents' MDS were completed accurately and did not see any risk to the resident if the MDS was inaccurate. Record review of CMS's RAI Version 3.0 Manual, October 2019, Chapter 3 Section O, Page O-1 to O-3, revealed Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. Under Coding Instructions for Column 2 was Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. Under Oxygen therapy was Code [check] continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve [CONDITION(S)] [low blood oxygen level] in this item. Record review of the undated policy Certifying the Accuracy of the Resident Assessment revealed All personnel who complete any portion of the MDS assessment .must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment.

Based on observation, interviews, and record review, the facility failed to develop a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of one resident reviewed (Resident #132) reviewed for baseline care plans. Resident #132's baseline care plan did not include a wander guard. The failure placed all residents with behaviors at risk for not having their needs met. Findings include: Review of face sheet for Resident #132 reflected a [AGE] year-old male who was admitted on [DATE] with no documented diagnoses. Review of the Admission MDS for Resident #132, dated 10/30/19, reflected a BIMS of 9 indicating moderate cognitive deficit. Further review of MDS Section [NAME] reflected no wandering behaviors. Section G (sub section G0110) Activities of Daily Living (ADL) reflected resident can independently walk in room, corridor on unit and off unit. Section G (sub section G0400) Functional Limitation in Range of Motion reflected no impairment to upper and lower extremities. Further review of Section G (sub section G0600) Mobility Devices reflected no need for cane, walker or wheelchair. Review of the baseline care plan for Resident #132 dated 10/18/19 reflected interventions including independence with bed mobility, transfers ambulation, locomotion, dressing, eating, personal hygiene, toileting and no safety precautions with ADL's. Further review did not reflect Resident # 132 was an elopement risk nor were there interventions that included a wander guard. Review of Resident # 132's physician's orders [REDACTED]. Further review did not reflect wander guard was ordered. Observation on 10/29/19 at 1:36 PM revealed Resident # 132 sitting in a chair reading a book in his room and with a wander guard on left lower extremity. During an interview on 10/30/19 PM at 1:03 PM RN A stated the facility's procedure regarding wander guard placement was to notify Nurse Practitioner (NP) or Physician and DON, get a physician's orders [REDACTED]. RN A stated the family requested the wander guard placement on 10/19/19. When RN A was asked if he notified NP or Physician to request an order, RN A stated, I did not. During an interview on 10/30/19 at 11:32 AM Resident #132's son stated resident was resistive to transferring from independent living (IL) and in addition to the private sitter, he requested wander guard placement for additional safety. During an interview on 10/30/19 10:40 AM DON confirmed there was not a physician order [REDACTED]. During an interview on 10/30/19 at 4:57 PM ADM stated expectation for the use of wander guards are a physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biological's to meet the needs of one 1 (Resident #2) of ten 10 residents reviewed for pharmacy services. The facility failed to verify Resident #2's physician's orders [REDACTED].#2 only receiving 25mg of B12 daily. This deficient practice could affect 21 residents receiving prescribed medication by placing them at risk for not receiving the intended therapeutic value or benefits of the medication as ordered by the physician. Findings: Review of the Face Sheet for Resident #2 reflected an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Minimum Data Sheet (MDS) for Resident #2 dated 09/25/17 reflected the following: A Brief Interview for Mental Status (BIMS) score of 15 out of 15 with no cognitive deficiencies; Section I Active [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #2 dated 09/18/17 reflected the following: I am at moderate risk for falls related to: Decreased strength, endurance, balance, mobility and ability to transfer related to recent hospitalization for left femur/knee fracture with surgical repair and I am at risk for nutritional deficit related to status [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the consolidated physician's orders [REDACTED]. Observation of Medication Pass for Resident #2 on 10/11/17at 8:00 a.m. revealed the following: CMA A administered Resident #2 Ferrex Forte UD 150(mg)(Iron)- 25(mg)(B12) - 1(mg)(Folic Acid); one capsule was given by mouth. In an interview on 10/12/17 at 9:30 a.m., CMA A stated she did not see the B12 dosage difference and should have checked the label. In an interview on 10/12/17 at 9:40 a.m., LVN A stated the facility didn't check on the Ferrex dosage and should have, but the facility was probably only looking to make sure the iron part of the dosage was correct and didn't look up the rest of the compound, but stated they should have. In an interview on 10/12/17 at 11:30 a.m., the DON stated she expects staff to follow the five rights of medication administration for residents. The DON stated the facility needs to be checking the order when checking in the medications, to make sure the right dose is sent from the pharmacy, and she stated they didn't do that. In an interview on 10/12/17 at 3:00 p.m., the NP stated the Ferrex order came from the hospital discharge orders and the discharge orders usually only say Niferex 150 mg and don't have the other components. The NP stated instead of 60 mg B12 as ordered, the pharmacy sent 25 mg B12. The NP stated she didn't feel any harm was done to Resident #2 and there were no negative outcomes with her taking less than the prescribed amount. The NP stated they have now changed the order to 25 mg B12. Record review of the discharge orders from Seton Medical Center Austin for Resident #2 dated 09/11/17 reflected the following: Iron polysaccharide (Niferex - 150) 150 Milligram Take by mouth once a day. No other indication of the other compounds such as B12 or Zinc were noted. Record review of the undated Skilled Nursing Admission Checklist reflected the following: Put all orders in AOD as the following and leave orders pink - until patient arrives: (BRAND NAME, (generic name), dosage, Route of Administration; Frequency; Physician name; and DIAGNOSIS). Complete Admission Medication Review Form and Fax to the pharmacy (Scan to Chart - pharmacy). Record review of undated policy # of the Standards and Guidelines for Clinical Records reflected the following: Clinical records will be maintained according to the guidelines of the State of Texas. 1. Clinical records will be: a. Complete; b. Accurately documented. Record review of the undated Licensed Practical Nurse Position Description reflected the following: Reviews physician's orders [REDACTED]. Knowledgeable of common action, usual dosage and side effects. Record review of the undated Night Shift Nursing Duties reflected the following: 1. 24-Hour Check: Check orders recorded for the day, ensure medication is in and that the order is correct in AOD. Record review of the policy Preventing Medication Errors dated 2017 reflected the following: Medication Administration: 10. Review MAR indicated [REDACTED]. Compare medication source (bubble pack, vial, etc.) with MAR indicated [REDACTED]. According to the Administrator, 21 residents recieved perscribed medications.